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The New 3+1 Model

The UVA Internal Medicine Residency Program has recently changed to a 3+1 model. This change came about after much thoughtful planning by several generations of chiefs. Our academic year is divided into 13 four-week blocks: each resident has a three-week block rotation (either an inpatient ward/ICU rotation or a three-week elective) followed by an ambulatory week (the “+1 week”). All residents are split up into 4 groups, and each group rotates on to a rotation in a staggered fashion, one week at a time. Thus, one of the four groups is on their “+1 week” at any given time. The intern and resident rotate on and off a service on different days to ensure that someone always knows the patients well. The block schedule is also designed to improve workflow in the inpatient setting, where residents no longer need to leave to go to their continuity clinic and are more available for inpatient education. It is also designed to improve patient continuity at continuity clinic as well as continuity with supervising faculty at clinic.

During the three-week inpatient rotations, residents rotate through General Medicine, Medical Intensive Care Unit, Digestive Health, Hematology/Oncology, Acute Cardiology, and Coronary Care Unit. Our second year residents also do an Emergency Medicine rotation. As above, the time spent on an inpatient service is completely devoted to the inpatient service without interruption for clinics in the afternoons. Likewise, inpatient resident education is improved because more residents are available to attend afternoon teaching sessions with their attendings and teach their interns and students. In addition to the three-week inpatient blocks, each upper level resident has 4-5 three-week outpatient rotations per year.

Ambulatory Week

Every fourth week is the ambulatory +1 week, which consists of the internal medicine continuity clinic, a subspecialty clinic, and an ambulatory education session. The goal during this week is to focus on learning the principles of outpatient care. Each resident spends 4-5 half-days per week in their own continuity clinic at University Medical Associates (UMA). Residents also spend four half-days per week in a subspecialty clinic of their choosing to augment exposure to outpatient subspecialty medicine. Wednesday morning is devoted to ambulatory education, where we review a fundamental concept in primary care (such as cervical cancer screening or lipid management) and focus on quality improvement projects. The +1 week is a nice break from the hustle and bustle of the inpatient service and allows residents to be more focused on their clinic patients and education rather than the tension of going to clinic in the afternoon of a busy inpatient day. We also hope to see greater continuity for residents with their patients due to a more easily predictable clinic schedule. At the end of the +1 week, every resident has a guaranteed “golden” weekend where there are no obligations or responsibilities.

Our goal with the 3+1 system is to allow our residents to be 100% devoted to the task at hand, whether in the inpatient or ambulatory setting, and to optimize the educational experience. We also have eliminated cross-coverage on other residents’ teams, improved efficiency, and enhanced patient care. Feedback from the residents has been very positive and we are excited about the direction our program is taking under this new structure change.