Implementation of the Community Outpatient Practice Experience in a large pediatric residency program

To determine the feasibility of implementing the Community Outpatient Practice Experience (COPE), a community-based continuity program, in a large, tertiary-care-oriented pediatric residency; to assess the impact of the continuity program on pediatric residents' experience; and to compare the experience in a variety of community practice settings.

Continuity clinic settings included a hospital-based residents' group practice (RGP) clinic (1989 through 1991) and a community-based program in which each resident was paired with a practicing pediatrician in the community (1991 through 1993). Community practice types included publicly funded clinics (n = 9), private practices (n = 38), and managed-care practices (n = 14). In all settings, residents spent half a day per week in continuity activity.

Measures of resident's experience (patient encounters, patient age distribution, and diagnostic mix) were compared in both settings and among community practice types. RGP data were derived from a patient scheduling database, and COPE data were obtained from patient encounter records submitted by each resident.

Residents in RGP (108.5 resident years) had 5294-encounters with 1568 patients. In COPE (102.5 resident years), 21,978 encounters with 19,235 patients occurred. COPE residents saw significantly more patients per session (6.2 vs 1.7) than residents in RGP. The mean patient age in COPE was significantly higher than RGP (5.3 vs 2.6 years). A greater proportion of encounters in RGP were for health supervision (61% vs 30%), but a greater number of health supervision encounters per resident occurred in COPE. There was a higher proportion of patients with chronic disease in RGP (38% vs 7%), but a greater number of patients with chronic disease was seen per resident in COPE. Analysis of COPE data by practice type showed fewer patient encounters per session and a younger patient age in publicly funded sites than in private- or managed-care practices. The proportion of health supervision encounters was greatest in publicly funded sites, but the greatest number of health supervision encounters per resident occurred in managed-care practices.

We successfully integrated a large-scale community-based continuity experience into a large, tertiary-care-oriented pediatric residency program. We present COPE as an alternative to the hospital-based continuity clinic and suggest it as a model for improving residents' primary-care experience.