The 3+1 Model
The UVA Internal Medicine Residency Program transitioned in 2014 to a 3+1 model. This change came about after much thoughtful planning by several generations of chiefs and the X+Y system is a model that has continued to spread throughout Internal Medicine programs across the country. 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”). This separates your inpatient and outpatient time, such that you can have dedicated time for each.
During the three-week inpatient rotations, residents rotate through General Medicine, the Medical Intensive Care Unit, Hematology/Oncology, Acute Cardiology, and the 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. As a result, inpatient resident education is improved because more residents are available to attend afternoon teaching sessions with their attendings and teach their interns and students. For categorical interns, one of the thirteen 3-week blocks is available for elective time, while the remainder are spent on inpatient time. For PGY2s and PGY3s, four to five of the 3-week blocks are used for elective rotations each year, while the remainder of the thirteen 3-week blocks are inpatient rotations.
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. After the education block, time is set aside for the plus-one groups to get lunch together before heading back for afternoon clinic. 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. 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.