Sanchez-Menegayetal.. URI PATIENTSATISFACTION
434
REFERENCES 1. KomaroffAL. "Minor" illness symptoms: The magnitude of their burden and our ignorance. Arch Intern Med. 1990:150;1586-7. 2. Marsland DW, Wood M, Mayo F. A data bank for patient care, curriculum, and research in family practice: 526,196 patient problems. J Fam Pract. 1976;3(1):25-8. 3. Cowan PF. Patient satisfaction with an office visit for the common cold. J Faro Pract. 1987;24(4):412-3. 4. Gillam SJ. Sociocultural differences in patients' expectations at consultations for upper respiratory tract infection. J R Coll Gen Pract. 1987;37:205-6. 5. Ware JE Jr, Davies-Avery A, Steward AL. The measurement and meaning of patient satisfaction. Health Med Care Serv Rev. 1978;1(1):1-16. 6. Ware JE Jr, Snyder MK, Wright WR, Davies AR. Defining and measuring patient satisfaction with medical care. Eval Program
Plann. 1983;6:247-63. 7. Like R, Zyzanski SJ. Patient satisfaction with the clinical encounter: social psychological determinants. Soc Sci Med. 1987;24(4):351-7. 8. Like R, Zyzanski SJ. Patient requests in family practice: a focal point for clinical negotiations. Fam Pract. 1986; 3 (4): 216-28. 9. Gerace TM, Sangster JF. Factors determining patients' satisfaction in a family practice residency teaching center. J Med Educ. 1987;62:485-9. 10. Smith CK, Polls E. Hadac RR. Characteristics of the initial medical interview associated with patient satisfaction and understanding. J Fam Pract. 1981;12(2):283-8. 11. NguyenTD, AttkissonCC, StegnerBL.Assessmentofpatientsatisfaction: development and refinement of a service evaluation questionnaire. Eval Program Plann. 1983;6:299-314. 12. Zyzanski SJ, Hulka BS, Cassel JC. Scale for the measurement of "satisfaction" with medical care: modifications in content, format and scoring. Med Care. 1974;12(7):611-20.
Integrating General Medicine and Rheumatology Training in the Outpatient Setting: A Practice Model JANET B. HENRICH, MD, DANIEL W. RAHN, MD, NICHOLAS H. FIEBACH, MD The a u t h o r s describe a p r i m a r y care-based e d u c a t i o n a l a n d p r a c t i c e m o d e l that integrates g e n e r a l medicine resid e n t e d u c a t i o n in o u t p a t i e n t rbeumatology with specialty f e l l o w s h i p training. C o m p a r e d with the use o f t r a d i t i o n a l specialty clinics, the m o d e l p r o v i d e s better access a n d service to p a t i e n t s a n d m o r e a p p r o p r i a t e t r a i n i n g f o r residents. Revenues f r o m clinical service delivered by facultysupervised residents a n d f e l l o w s s u p p o r t 8096 o f the o p e r a t i n g costs a n d e d u c a t i o n a l activities o f the model The conceptual framework f o r the model reconciles the e d u c a t i o n a l goals a n d p r a c t i c e p h i l o s o p h i e s o f g e n i a l medicine a n d specialty t r a i n i n g a n d is applicable to traini n g in o t h e r p r e d o m i n a n t l y o u t p a t i e n t specialty areas. K e y words: e d u c a t i o n a l model; residents; specialty training. J GEN INTERN MED 1992;7:434-436.
ATTEMPTSTO RESTRUCTUREtraditional specialty clinics to focus on resident training are often hindered by: a lack of educational goals and curriculum specific for generalists in training; adequate exposure to patients
Received from the Section of General Medicine, Yale University School of Medicine. New Haven, Connecticut (JBH, NHF); and the Department of Medicine, Medical College of Georgia, Augusta, Georgia (DWR). Address correspondence and reprint requests to Dr. Henrich: Primary Care Center, Yale- New Haven Hospital, 20 York Street, New Haven, CT 06504.
with specialty problems that represent the full range of clinical skills and knowledge required of general internists; and limited financial resources to subsidize faculty for the time required to teach residents and supervise the care o f disenfranchised patients whose medical care has traditionally been within the purview of resid e n c y training programs. 1-s To address these problems the sections of general medicine and rheumatology at Yale University School of Medicine d e v e l o p e d an educational and practice model that integrates resident education in outpatient rheumatology with a fellowadministered consultation practice. This report describes the model that resulted from this collaboration.
STRUCTURE OF THE PROGRAM In July 1988, w e replaced the traditional rheumatology outpatient clinic elective for medical residents with a rheumatology consultation clinic located in the primary care practice setting at Yale. The consultation clinic is managed jointly by the general medicine and rheumatology sections and serves as the primary outpatient rheumatology specialty training site for residents. It meets one half-day a week and is staffed by the clinical rheumatology fellows and medical residents on am-
JOURNALOF GENERALINTERNALMEDICINE, Volume 7
bulatory rotation. Their activities are supervised by a dedicated full-time rheumatology faculty attending physician and a voluntary community-based rheumatologist whose responsibilities are exclusively teaching and the supervision of patient care. Patients are referred to the consultation clinic from community physicians or from the hospital emergency department and primary care practice. Patients with private health insurance are registered and billed through our faculty practice plan. The remainder, a mix of Medicare, Medicaid, and self-pay patients, are registered and billed separately by the hospital. The rheumatology fellows, under the supervision of the rheumatology faculty, have primary responsibility for patient management and coverage of the clinic. The medical residents participate in the consultation practice during scheduled ambulatory rotations over three years of training. They evaluate new patients and provide follow-up care during the rotation. Patients who require long-term medical care are incorporated into the residents' panel of patients when appropriate. This arrangement allows the residents to become the primary provider to patients with a broad spectrum of musculoskeletal disorders and teaches them how to work with consultants in the long-term management of patients with both general medical and specialized problems. The clinical teaching is primarily patient-based, with emphasis on fundamental rheumatologic skills needed by generalists in practice. Common rheumatologic problems are discussed in the context of patients' presentations and issues that arise in their management. Didactic lectures on common rheumatologic disorders are presented at weekly preclinic conferences. Over three years of training, the residents become familiar with the diagnosis and management of common rheumatologic problems and become proficient in the diagnostic skills and procedural techniques required to manage these problems in general medical practice.
(July/August),
1992
435
Diffuse Connective Tissue Disease
Other Neuropathic Disorders Spondylitis
Degenerative Joint Disease
Crystal-Induced Arthritis
Nonarticular Rheumatism FIGURE 1. Proportions of patient visits to the rheumatology consuItation clinic attributed to primary rheumatologic diagnoses (based on 398 visits by 207 patients between July 1990 and April 1991 ). Patients' ages ranged from 16 to 86 years, with a mean age of 48. The high proportion of visits for connective tissue diseases was due primarily to rheumatoid arthritis, systemic lupus, and early, or as yet unidentified, inflammatoryjoint disease. Polymyalgia rheumatica and erythema nodosum contributed a small number of visits to this category, Degenerative joint disease and nonarticular rheumatism, including regional and general pain disorders, accounted for 37% of all patient visits. Gout, ankylosing spondylitis, and compression neuropathies, such as spinal stenosis and carpal tunnel syndrome, accounted for 17% of total visits. The remainder were related to arthritis associated with infectious agents, including Lyme disease, and symptoms related to trauma.
random sample of 207 patient charts. Figure 1 shows the proportions of patient visits attributed to the major rheumatologic diagnostic categories. 9 Compared with the casemix of traditional specialty clinics, where highly select patients are referred to faculty with specific clinical and research interests, the diagnoses represented by the patients seen in this clinic span the spectrum of common rheumatologic disorders seen in general medical practice.
RESULTS
DISCUSSION
There has been steady growth in the number of patient visits to the consultation practice. Currently, up to 25 patients are seen during each weekly session. Twenty-six percent of all patient visits are new patient evaluations. Faculty practice-registered patients account for 30% of all new patient evaluations and 21% of return visits. Direct revenue from the consultation clinic offsets approximately 80% of the total costs of the practice. These costs, excluding resident and fellow salaries, include the operating costs of the clinic and the equivalent of a 0.1 full-time faculty salary in rheumatology. To assess whether the practice provides an appropriate casemix for residents in training, we reviewed a
This model is successful for several reasons. First, the training of residents and fellows was moved out of the specialty clinics and into the general medicine setting. In contrast to training in specialty clinics, where patients are referred with the presumption of significant illness and often for highly selective diseases, training in a general medicine-based consultation clinic allows residents to evaluate patients not previously screened and to develop broad experience in the diagnosis and management of common rheumatologic disorders. Second, the clinical rheumatology fellows obtain valuable clinical experience in the longterm management of patients with common outpatient rheumatologic problems, training that is not otherwise
436
Henrich etaL, GENERALMEDICINEAND SPECIALTYTRAININGMODEL
a v a i l a b l e to t h e m d u r i n g i n p a t i e n t c o n s u l t a t i o n activities i n a t e r t i a r y care setting. T h e y d e v e l o p a c l o s e w o r k i n g r e l a t i o n s h i p w i t h t h e p r i m a r y care staff and, as consultants, are a v a l u a b l e s o u r c e of e x p e r t i s e . T h i r d , t h e c o l l a b o r a t i v e r e l a t i o n s h i p b e t w e e n t h e s e c t i o n s o f general m e d i c i n e a n d r h e u m a t o l o g y a n d j o i n t m a n a g e m e n t o f the p r a c t i c e a l l o w t h e g e n e r a l m e d i c i n e s e c t i o n to i n f l u e n c e s u b s t a n t i a l l y t h e n a t u r e of t h e p r a c t i c e as w e l l as t h e s p e c i a l t y c u r r i c u l u m for r e s i d e n t s . I n addit i o n , the p r e s e n c e of the r h e u m a t o l o g y a t t e n d i n g phys i c i a n s a n d f e l l o w s i n t h e p r i m a r y care p r a c t i c e has f o c u s e d a t t e n t i o n o n t h e i m p o r t a n t role o f s p e c i a l i s t s as t e a c h e r s i n t h e a m b u l a t o r y setting. 4 F o u r t h , the g e n e r a l m e d i c i n e l o c a t i o n of t h e m o d e l h e l p s address t h e p r o b l e m o f p a y i n g for s p e c i a l t y e d u c a t i o n i n t h e o u t p a t i e n t setting. 1o.14 R e v e n u e g e n e r a t e d f r o m an a p p r o p r i a t e m i x of f a c u l t y a n d h o s p i t a l - b i l l e d c l i n i c a l a c t i v i t y s u p p o r t s a p p r o x i m a t e l y 80% o f t h e costs of t h e p r a c t i c e , i n c l u d i n g f u l l - t i m e f a c u l t y t i m e . I n a d d i t i o n , t h e p r i m a r y care p r a c t i c e serves b o t h as a m a j o r referral s o u r c e of p a t i e n t s to t h e c o n s u l t a t i o n c l i n i c as w e l l as a s o u r c e o f care for p a t i e n t s w i t h r h e u matologic disorders w h o require ongoing general medical care. T h e hospital, i n t u r n , is c r e d i t e d for t h e pat i e n t a c t i v i t y a n d a n c i l l a r y services g e n e r a t e d b y t h e clinic. Finally, t h e greatest b e n e f i c i a r i e s of this m o d e l are t h e patients. Patients r e f e r r e d f r o m t h e p r i m a r y care p r a c t i c e r e c e i v e t h e i r care i n o n e s e t t i n g w i t h easy access to n e e d e d a n c i l l a r y services. P a t i e n t s r e f e r r e d f r o m o t h e r s o u r c e s have r e a d y access to s p e c i a l t y c o n s u l t a tion in a setting where general, long-term medical n e e d s c a n also b e addressed. A l t h o u g h t h e s u c c e s s of t h e p r a c t i c e m a y b e specific to o u r i n s t i t u t i o n , t h e phil o s o p h y a n d c o n c e p t u a l f r a m e w o r k o f t h e m o d e l are a p p l i c a b l e to o t h e r s p e c i a l t y areas a n d i n s t i t u t i o n s ) 5
The authors thank Barbara L. Israel for her assistance with data management and the preparation of the manuscript.
REFERENCES
1. Eisenberg JM. Curricula and organization of primary care residencies in internal medicine. J Med Educ. 1980;55:345-53. 2. Branch WTJr. Teaching models in an ambulatory program. J Gen Intern Med. 1990;5 (J/F suppl):S15-S26. 3. Schroeder SA, Showstack JA, Gerbert B. Residency training in internal medicine: time for a change? Ann Intern Med. 1986; 104:554-61. 4. The Task Force on the Future Internist, American Board of Internal Medicine. The future internist. Ann Intern Med. 1988; 108:139-41. 5. Halperin AK, Kaufman A. Ambulatory medical education: a reconsideration of sites and teachers. J Gen Intern Med. 1990;5 (J/F suppl) :S35-S44. 6. Gamble P, RamsdellJW. Subspecialty rotations: teaching ambulatory internal medicine. SGIMNews. 1989; 12:1, 4. 7. Lurie N, Yergan J. Teaching residents to care for vulnerable populations in the outpatient setting. J Gen Intern Med. 1990;5 (J/F suppl) :S27-S34. 8. Rieselbach RE, Jackson TC. In support of a linkage between the funding of graduate medical education and care of the indigent. N EnglJ Med. 1986;314:32-5. 9. Schumacher HR, Klippel JH, Robinson DR (eds). Primer on the rheumatic diseases, 9th ed. Atlanta, GA: The Arthritis Foundation, 1988;81-3. 10. KosecoffJ, Brook RH, Fink A, et al. Providing primary general medical care in university hospitals: efficiency and cost. Ann Intern Med. 1987;107:399-405. 11. Perkoff GT. Teaching clinical medicine in the ambulatory setting. An idea whose time may have finally come. N Engl J Med. 1986;314:27-31. 12. Eisenberg JM. Financing ambulatory care education in internal medicine. J Gen Intern Med. 1990;5 (J/F suppl):STO-SSO. 13. Delbanco TL, Calkins DR. The costs and financing of ambulatory medical education. J Gen Intern Med. 1988;3(M/A suppl) :$34-S43. 14. Goodson JD, Goroll AH, BarskyAJ, et al. The training of physicians outside the hospital. Arch Intern Med. 1986; 146:1805-9. 15. Lavizzo-MoureyR, Beck LH, Diserens D, et al. Integrating residency training in geriatrics into existing outpatient curricula. J Gen Intern Med. 1990;5:126-31.
434
REFERENCES 1. KomaroffAL. "Minor" illness symptoms: The magnitude of their burden and our ignorance. Arch Intern Med. 1990:150;1586-7. 2. Marsland DW, Wood M, Mayo F. A data bank for patient care, curriculum, and research in family practice: 526,196 patient problems. J Fam Pract. 1976;3(1):25-8. 3. Cowan PF. Patient satisfaction with an office visit for the common cold. J Faro Pract. 1987;24(4):412-3. 4. Gillam SJ. Sociocultural differences in patients' expectations at consultations for upper respiratory tract infection. J R Coll Gen Pract. 1987;37:205-6. 5. Ware JE Jr, Davies-Avery A, Steward AL. The measurement and meaning of patient satisfaction. Health Med Care Serv Rev. 1978;1(1):1-16. 6. Ware JE Jr, Snyder MK, Wright WR, Davies AR. Defining and measuring patient satisfaction with medical care. Eval Program
Plann. 1983;6:247-63. 7. Like R, Zyzanski SJ. Patient satisfaction with the clinical encounter: social psychological determinants. Soc Sci Med. 1987;24(4):351-7. 8. Like R, Zyzanski SJ. Patient requests in family practice: a focal point for clinical negotiations. Fam Pract. 1986; 3 (4): 216-28. 9. Gerace TM, Sangster JF. Factors determining patients' satisfaction in a family practice residency teaching center. J Med Educ. 1987;62:485-9. 10. Smith CK, Polls E. Hadac RR. Characteristics of the initial medical interview associated with patient satisfaction and understanding. J Fam Pract. 1981;12(2):283-8. 11. NguyenTD, AttkissonCC, StegnerBL.Assessmentofpatientsatisfaction: development and refinement of a service evaluation questionnaire. Eval Program Plann. 1983;6:299-314. 12. Zyzanski SJ, Hulka BS, Cassel JC. Scale for the measurement of "satisfaction" with medical care: modifications in content, format and scoring. Med Care. 1974;12(7):611-20.
Integrating General Medicine and Rheumatology Training in the Outpatient Setting: A Practice Model JANET B. HENRICH, MD, DANIEL W. RAHN, MD, NICHOLAS H. FIEBACH, MD The a u t h o r s describe a p r i m a r y care-based e d u c a t i o n a l a n d p r a c t i c e m o d e l that integrates g e n e r a l medicine resid e n t e d u c a t i o n in o u t p a t i e n t rbeumatology with specialty f e l l o w s h i p training. C o m p a r e d with the use o f t r a d i t i o n a l specialty clinics, the m o d e l p r o v i d e s better access a n d service to p a t i e n t s a n d m o r e a p p r o p r i a t e t r a i n i n g f o r residents. Revenues f r o m clinical service delivered by facultysupervised residents a n d f e l l o w s s u p p o r t 8096 o f the o p e r a t i n g costs a n d e d u c a t i o n a l activities o f the model The conceptual framework f o r the model reconciles the e d u c a t i o n a l goals a n d p r a c t i c e p h i l o s o p h i e s o f g e n i a l medicine a n d specialty t r a i n i n g a n d is applicable to traini n g in o t h e r p r e d o m i n a n t l y o u t p a t i e n t specialty areas. K e y words: e d u c a t i o n a l model; residents; specialty training. J GEN INTERN MED 1992;7:434-436.
ATTEMPTSTO RESTRUCTUREtraditional specialty clinics to focus on resident training are often hindered by: a lack of educational goals and curriculum specific for generalists in training; adequate exposure to patients
Received from the Section of General Medicine, Yale University School of Medicine. New Haven, Connecticut (JBH, NHF); and the Department of Medicine, Medical College of Georgia, Augusta, Georgia (DWR). Address correspondence and reprint requests to Dr. Henrich: Primary Care Center, Yale- New Haven Hospital, 20 York Street, New Haven, CT 06504.
with specialty problems that represent the full range of clinical skills and knowledge required of general internists; and limited financial resources to subsidize faculty for the time required to teach residents and supervise the care o f disenfranchised patients whose medical care has traditionally been within the purview of resid e n c y training programs. 1-s To address these problems the sections of general medicine and rheumatology at Yale University School of Medicine d e v e l o p e d an educational and practice model that integrates resident education in outpatient rheumatology with a fellowadministered consultation practice. This report describes the model that resulted from this collaboration.
STRUCTURE OF THE PROGRAM In July 1988, w e replaced the traditional rheumatology outpatient clinic elective for medical residents with a rheumatology consultation clinic located in the primary care practice setting at Yale. The consultation clinic is managed jointly by the general medicine and rheumatology sections and serves as the primary outpatient rheumatology specialty training site for residents. It meets one half-day a week and is staffed by the clinical rheumatology fellows and medical residents on am-
JOURNALOF GENERALINTERNALMEDICINE, Volume 7
bulatory rotation. Their activities are supervised by a dedicated full-time rheumatology faculty attending physician and a voluntary community-based rheumatologist whose responsibilities are exclusively teaching and the supervision of patient care. Patients are referred to the consultation clinic from community physicians or from the hospital emergency department and primary care practice. Patients with private health insurance are registered and billed through our faculty practice plan. The remainder, a mix of Medicare, Medicaid, and self-pay patients, are registered and billed separately by the hospital. The rheumatology fellows, under the supervision of the rheumatology faculty, have primary responsibility for patient management and coverage of the clinic. The medical residents participate in the consultation practice during scheduled ambulatory rotations over three years of training. They evaluate new patients and provide follow-up care during the rotation. Patients who require long-term medical care are incorporated into the residents' panel of patients when appropriate. This arrangement allows the residents to become the primary provider to patients with a broad spectrum of musculoskeletal disorders and teaches them how to work with consultants in the long-term management of patients with both general medical and specialized problems. The clinical teaching is primarily patient-based, with emphasis on fundamental rheumatologic skills needed by generalists in practice. Common rheumatologic problems are discussed in the context of patients' presentations and issues that arise in their management. Didactic lectures on common rheumatologic disorders are presented at weekly preclinic conferences. Over three years of training, the residents become familiar with the diagnosis and management of common rheumatologic problems and become proficient in the diagnostic skills and procedural techniques required to manage these problems in general medical practice.
(July/August),
1992
435
Diffuse Connective Tissue Disease
Other Neuropathic Disorders Spondylitis
Degenerative Joint Disease
Crystal-Induced Arthritis
Nonarticular Rheumatism FIGURE 1. Proportions of patient visits to the rheumatology consuItation clinic attributed to primary rheumatologic diagnoses (based on 398 visits by 207 patients between July 1990 and April 1991 ). Patients' ages ranged from 16 to 86 years, with a mean age of 48. The high proportion of visits for connective tissue diseases was due primarily to rheumatoid arthritis, systemic lupus, and early, or as yet unidentified, inflammatoryjoint disease. Polymyalgia rheumatica and erythema nodosum contributed a small number of visits to this category, Degenerative joint disease and nonarticular rheumatism, including regional and general pain disorders, accounted for 37% of all patient visits. Gout, ankylosing spondylitis, and compression neuropathies, such as spinal stenosis and carpal tunnel syndrome, accounted for 17% of total visits. The remainder were related to arthritis associated with infectious agents, including Lyme disease, and symptoms related to trauma.
random sample of 207 patient charts. Figure 1 shows the proportions of patient visits attributed to the major rheumatologic diagnostic categories. 9 Compared with the casemix of traditional specialty clinics, where highly select patients are referred to faculty with specific clinical and research interests, the diagnoses represented by the patients seen in this clinic span the spectrum of common rheumatologic disorders seen in general medical practice.
RESULTS
DISCUSSION
There has been steady growth in the number of patient visits to the consultation practice. Currently, up to 25 patients are seen during each weekly session. Twenty-six percent of all patient visits are new patient evaluations. Faculty practice-registered patients account for 30% of all new patient evaluations and 21% of return visits. Direct revenue from the consultation clinic offsets approximately 80% of the total costs of the practice. These costs, excluding resident and fellow salaries, include the operating costs of the clinic and the equivalent of a 0.1 full-time faculty salary in rheumatology. To assess whether the practice provides an appropriate casemix for residents in training, we reviewed a
This model is successful for several reasons. First, the training of residents and fellows was moved out of the specialty clinics and into the general medicine setting. In contrast to training in specialty clinics, where patients are referred with the presumption of significant illness and often for highly selective diseases, training in a general medicine-based consultation clinic allows residents to evaluate patients not previously screened and to develop broad experience in the diagnosis and management of common rheumatologic disorders. Second, the clinical rheumatology fellows obtain valuable clinical experience in the longterm management of patients with common outpatient rheumatologic problems, training that is not otherwise
436
Henrich etaL, GENERALMEDICINEAND SPECIALTYTRAININGMODEL
a v a i l a b l e to t h e m d u r i n g i n p a t i e n t c o n s u l t a t i o n activities i n a t e r t i a r y care setting. T h e y d e v e l o p a c l o s e w o r k i n g r e l a t i o n s h i p w i t h t h e p r i m a r y care staff and, as consultants, are a v a l u a b l e s o u r c e of e x p e r t i s e . T h i r d , t h e c o l l a b o r a t i v e r e l a t i o n s h i p b e t w e e n t h e s e c t i o n s o f general m e d i c i n e a n d r h e u m a t o l o g y a n d j o i n t m a n a g e m e n t o f the p r a c t i c e a l l o w t h e g e n e r a l m e d i c i n e s e c t i o n to i n f l u e n c e s u b s t a n t i a l l y t h e n a t u r e of t h e p r a c t i c e as w e l l as t h e s p e c i a l t y c u r r i c u l u m for r e s i d e n t s . I n addit i o n , the p r e s e n c e of the r h e u m a t o l o g y a t t e n d i n g phys i c i a n s a n d f e l l o w s i n t h e p r i m a r y care p r a c t i c e has f o c u s e d a t t e n t i o n o n t h e i m p o r t a n t role o f s p e c i a l i s t s as t e a c h e r s i n t h e a m b u l a t o r y setting. 4 F o u r t h , the g e n e r a l m e d i c i n e l o c a t i o n of t h e m o d e l h e l p s address t h e p r o b l e m o f p a y i n g for s p e c i a l t y e d u c a t i o n i n t h e o u t p a t i e n t setting. 1o.14 R e v e n u e g e n e r a t e d f r o m an a p p r o p r i a t e m i x of f a c u l t y a n d h o s p i t a l - b i l l e d c l i n i c a l a c t i v i t y s u p p o r t s a p p r o x i m a t e l y 80% o f t h e costs of t h e p r a c t i c e , i n c l u d i n g f u l l - t i m e f a c u l t y t i m e . I n a d d i t i o n , t h e p r i m a r y care p r a c t i c e serves b o t h as a m a j o r referral s o u r c e of p a t i e n t s to t h e c o n s u l t a t i o n c l i n i c as w e l l as a s o u r c e o f care for p a t i e n t s w i t h r h e u matologic disorders w h o require ongoing general medical care. T h e hospital, i n t u r n , is c r e d i t e d for t h e pat i e n t a c t i v i t y a n d a n c i l l a r y services g e n e r a t e d b y t h e clinic. Finally, t h e greatest b e n e f i c i a r i e s of this m o d e l are t h e patients. Patients r e f e r r e d f r o m t h e p r i m a r y care p r a c t i c e r e c e i v e t h e i r care i n o n e s e t t i n g w i t h easy access to n e e d e d a n c i l l a r y services. P a t i e n t s r e f e r r e d f r o m o t h e r s o u r c e s have r e a d y access to s p e c i a l t y c o n s u l t a tion in a setting where general, long-term medical n e e d s c a n also b e addressed. A l t h o u g h t h e s u c c e s s of t h e p r a c t i c e m a y b e specific to o u r i n s t i t u t i o n , t h e phil o s o p h y a n d c o n c e p t u a l f r a m e w o r k o f t h e m o d e l are a p p l i c a b l e to o t h e r s p e c i a l t y areas a n d i n s t i t u t i o n s ) 5
The authors thank Barbara L. Israel for her assistance with data management and the preparation of the manuscript.
REFERENCES
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