Background/Purpose: Models of residency education in the United States are evolving nationwide to limit conflicting care responsibilities and enhance the outpatient internal medicine resident experience. One newer model of training is known as the X+Y model with X (inpatient) weeks to Y (ambulatory clinic) weeks (e.g. 4 inpatient weeks followed by 1 outpatient week) repeated in a continuous cycle over the course of residency. [1] Despite the increasing adoption of an X+Y training model, little is known about how it impacts subspecialty rheumatology elective time and resident rheumatology education needs. This needs assessment sought to determine how residents at The George Washington University (GWU) felt rheumatology education was impacted in the new X+Y structure.

Methods: Two surveys, were conducted utilizing Survey Monkey in March of 2015 and again in June of 2016. [2] Surveys consisted of 9-10 questions with responses via Likert scale or multiple choice with section for free text response.

Results:   27/98 (27%) of residents responded to the March 2015 survey conducted in the first year of the 4+1 residency structure, 19/27 (69%) of residents reported extreme or moderate dissatisfaction with rheumatology exposure in the 4+1 residency structure. 0/27 (0%) felt they had adequate time for electives in the new structure. 18/27 (66%) rated themselves as likely or definite in their plans to seek rheumatology elective. 16/27 (59%) resident respondents reported decreased opportunity for rheumatology exposure in a 4+1 structure. To achieve rheumatology education, the requested models for education included addition of a rheumatology half day clinic to their +1 week (9/27 (33%)) with the second most popular choice being the addition of more rheumatology noon conference lectures (7/27 (25%)), however 12/27 (44%) felt noon conference was not an effective training method. 17/25 (68%) third year residents responded to the 2016 follow up survey. 4/17 (24%) of residents found subspecialty elective time decreased in the newer residency model with majority of residents 13/17 (64%) noting elective time the same or increasing. 8/17 (47%) of residents felt satisfied with the amount of rheumatology exposure they receive in the new 4+1 structure with 9/17 (53%) feeling dissatisfied or unsure if they had sufficient exposure. 6/17 (35%) reported an educational half-day within their +Y week would best meet their rheumatology education needs. 6/17 (35%) cited more morning report cases as the optimal rheumatology learning format. Only 3/17 (18%) felt rheumatology elective time would best satisfy their learning needs. 

Conclusion: Dissatisfaction with degree of rheumatology training and exposure were evident in both surveys. Traditional rheumatology elective was not cited as a popular way for residents to meet their rheumatology education needs. Rheumatology educators need to consider novel ways of adopting internal medicine resident rheumatology education to evolving residency structures.  

1. Mariotti, J.L., M. Shalaby, and J.P. Fitzgibbons, The 4ratio1 schedule: a novel template for internal medicine residencies. J Grad Med Educ, 2010. 2(4): p. 541-7.

2. Monkey, S.; Available from: https://www.surveymonkey.com/home/.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/rheumatology-elective-time-in-a-41-residency-structure-evaluating-impact-of-a-novel-residency-schedule-structure-on-rheumatology-resident-education/