Hello from Kingsport, TN!



Our team for the clinic first collaborative consisted of: Gary Michael, Chief Medical Officer for the Department of Family Medicine, Billy Buselmeier, Assistant Program Director, and Kelly Kahle, one of our chief residents who is now faculty at the program.

Our aims for entering the Clinic First collaborative were two-fold. 

  • First, to improve our resident numbers as in the last few years we have had increasing difficulty reaching our required 1650 outpatient visits. This was placing undue burden on our soon to be graduating third year residents and created a stressful, volume focused atmosphere at the end of the year.
  • Second, to improve the general morale of our residents in the clinic, which some may say was approaching dangerously low levels.

The collaborative meeting in February was excellent.  Not only because we got to brainstorm solutions to common problems with other programs, but we were also given time to focus on our unique challenges.   After the collaborative, we left with specific goals applicable to our program.


  • Increase overall resident comfort level and time assigned to clinic
  • Have more consistent resident presence in clinic to minimize long stretches of absences
  • Minimize tension between inpatient/outpatient roles and responsibilities
  • Increase meaningfulness of our clinic teams

Methods we pursued to accomplish these goals:

  • Redesign the current block schedule
  • Redefine clinic time commitments while on inpatient services
  • Reorganize our current clinic teams


Block Schedule Redesign

Our previous block schedule was made from scratch every year taking into consideration resident preference while looking back at how many hospital and clinic rotations they have had in the past.  Obviously, this was extremely challenging and often resulted in residents having varying amounts of dedicated ambulatory vs. inpatient training time.  By redesigning the schedule, we hoped to have all three years planned out in advance to make it predictable, more consistent for residents, and significantly decrease the annual planning burden on staff. 

 Original Schedule Features

  • 3-4 resident hospital day team
  • Month long rotations for all residents on hospital service
  • Roughly equal number of hospital rotations in first, second, and third year.

 Revised Schedule Features

  • 3 resident hospital team
  • Intern still on for one month, seniors now on for two weeks at a time
  • Progressively less hospital in 2nd and 3rd year
  • Fewer electives in first and second year

 In order to increase ambulatory rotations, residents have fewer hospital service and elective rotations overall.  Additionally, seniors were shifted to a two week hospital service to minimize the extended period of lower clinic volume.

 By making a standardized block schedule, we were also able to open our clinic schedules 6 months in advance.  We are hoping to eventually expand it to 12 months in advance.

 New on-boarding for the R1s in July including a scavenger hunt designed for them to get to know the clinic and its staff. We dedicated the last full week of orientation to work one-on-one with the R1s to learn clinic processes, see patients, have IT on-site to help with EMR, and scheduled extended time with preceptor to review case and presentation.


Changing Clinic Responsibilities during hospital rotations

 Original Clinic Responsibilities

  • One clinic afternoon each week while on hospital service
  • Night float was two weeks without any clinic

Revised Clinic Responsibilities

  • Both hospital and night float residents have one clinic afternoon a week with just two patient slots at the end of the day


We thought that be shortening the hospital week clinic day, this would hopefully minimize inpatient outpatient tension while still meeting ACGME requirements for residents being in clinic.   And by adding the two clinic slots while on night float, residents don’t feel as removed from the clinic after being gone for weeks.


Clinic Team Restructuring

- Our previous team structure was four teams, each containing attending physicians, nurses, and resident physicians.  Other staff and providers such as clinical pharmacists, behavioral health, and management were also assigned to the teams.  These distinctions were not really used except for resident task oversight.  When one resident was gone, the others on their team watched their task list. 

 We wanted the changes to promote…

  • Patient-Physician continuity
  • Nurse-Physician continuity
  • Ease of patient redistribution after graduation

 As we have a 6-6-6 program, we decided to make 6 separate teams containing an R1, R2, R3, attending physician, and a nurse.  Front office staff was trained if patient’s PCP was not available, to first always look and see if another resident on the team was.  When the R3 graduates, the patients will be redistributed among the residents of that team to promote continuity with the same nurse and same team of physicians.  


What are we doing now and what are our next steps?


  • We are tracking proportion of resident time spent in the clinic and more closely following patient numbers.
    • In the first 4 months (July-October) we increased the number of patients seen by 22.4%!
  • We expanded our clinic first team in August to include additional faculty and new resident representatives to keep the committee thriving.
  • We are polling our current and past residents’ attitudes towards outpatient medicine and the clinic learning environment to look at whether our changes have any meaningful impact on resident opinion.
  • We are currently working on making our teams more meaningful by moving our faculty advisor and resident pairs to match their assigned clinic team. Additionally, we are brainstorming how we can shift to residents developing their required QI projects within the teams as well.



1 Comment
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Clinic First blog post

January 14, 2020 10:19 AM by Kathleen Ingraham Marshall

Wow! You all have done some great work -- thanks so much for sharing!

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Hello from Kingsport, TN!