Intervisit care, the asynchronous care provided between visits, is essential to the provision of all medical care, especially ambulatory care. It encompasses a wide range of tasks that include follow-up of diagnostic testing, care team collaboration, medication management, and responding to patient messages. In recent years, intervisit care has received attention from physicians and health systems nationwide due to increases in the use of patient messaging and the association of this increased volume of messages with burnout.1,2,3 While the uptake of patient portals has significant opportunity for improved patient-physician communication, it is crucial for physicians to have strong intervisit management skills to balance effective intervisit patient communication with increasing intervisit care workload and its associated burnout.
Even though intervisit care is a fundamental aspect of patient care and a core aspect of several Internal Medicine Accreditation Council for Graduate Medical Education (ACGME) 2.0 milestones, many residents do not get formalized training in intervisit care.4 In addition, literature regarding teaching methods for intervisit care remains scarce.
We developed a pilot intervisit curriculum during the 2022-23 academic year in our large academic internal medicine residency program at the University of Utah with an aim to improve knowledge and comfort of intervisit care for internal medicine residents. The objectives of our intervisit curriculum included:
1. recognizing intervisit care as a clinical skill set distinct from traditional face-to-face care;
2. determining appropriate use of resources and care team members; and
3. employing a novel medical decision-making framework for applying intervisit care.
We delivered our intervisit care educational sessions via a 3-part noon conference series for all internal medicine residents and gave more in-depth workshops to a small sub-set of ambulatory focused residents. Our sessions included case-based discussions of common intervisit care scenarios with a focus on developing actionable care plans and next steps. These sessions employed multiple educational techniques including cased-based discussion, real-time polling, and gamification.
To evaluate our intervisit curricular intervention, residents completed electronic pre- and post-surveys. These surveys asked residents if they were confident in managing intervisit care and if they felt intervisit care was important using a Likert scale from strongly disagree (1) to strongly agree (5). We received 51 pre- and 63 post-didactic responses to the survey. We found that residents’ median confidence in managing intervisit care was low prior to the curriculum for both the small- and large-group settings (median 2, IQR 1 and median 3, IQR 2, respectively). However, their confidence improved after the curriculum in both the small- and large-group settings (median 4, IQR 1 and median 4, IQR 1). Although residents agreed that intervisit care was an important aspect of patient care prior to the curriculum (median 4, IQR 1), they agreed more strongly that intervisit care was an important aspect of patient care after the curriculum (median 5, IQR 0). We also asked residents about factors that negatively affect their ability to perform intervisit care on a Likert Scale from no impact (0) to severely negatively impact (10), and residents’ identified time as the biggest barrier to performing intervisit care (median of 7, IQR 2), followed by system factors (median 6, IQR 2), medical knowledge (median 5, IQR 3), and care team support (median 4, IQR 3).
On review of our curriculum, residents’ perceived baseline confidence in managing intervisit care was initially low, but brief educational interventions yielded a significant increase in both their perception of intervisit care’s importance and their confidence in managing intervisit care. This combination—low resident baseline confidence with high perception of intervisit care’s importance—highlights the necessity of intentional intervisit education, which aligns with prior findings suggesting a need for explicit teaching of indirect patient care activities such as intervisit care.5
This was a small pilot curricular change and, although successful, leaves an opportunity to determine the ideal curricular delivery of this content. We believe that partnering with residents to improve confidence in managing intervisit care is a necessary first step, and we continue to work to optimize future iterations of this curriculum. Areas that need ongoing attention include the development of well-established metrics for assessing intervisit care. The lack of metrics limits our evaluation of the curricular impact on clinical outcomes, intervisit efficiency, and physician burnout. SGIM members can assist in improving intervisit care by creating and disseminating metrics of intervisit care used across their health systems.
Residents identified time and system factors as major barriers to the management of intervisit care—it is crucial that these are addressed in intervisit education. We believe that intentional education on intervisit care can reduce time as a barrier through improved intervisit knowledge and skills and explicit acknowledgement of time as a limited resource for physicians. Though our large-group curriculum broadly addressed system-based factors, we were unable to address nuanced site-level resources due to the nature of our multi-clinical site residency program—this is better addressed in smaller group settings. We also acknowledged the overall ongoing system limitations through open and dynamic conversations; this transparency helps trainees identify current opportunities and increase preparation as they transition to independent practices.
There are also unique challenges for intervisit care in residency, including prolonged time away from clinic and competing inpatient and outpatient demands. To combat these factors, it is imperative that intervisit education be combined with residency- and clinic-specific policies that support residents in providing this essential aspect of clinical care.
In conclusion, our pilot showed that the introduction of a novel intervisit curriculum for internal medicine residents, in both small- and large-group settings, increased resident confidence in managing intervisit care and recognition of its importance in medical care. However, more work is needed to further refine our intervisit curriculum to identify best practices for delivery as well as develop metrics for assessment to ultimately achieve increased efficiency and improved patient care. SGIM members should begin (or continue) to intentionally teach trainees intervisit care at their respective institutions and disseminate lessons learned, best practices, and metrics for assessment. This will improve intervisit education for trainees and intervisit care for all internists. Given the impact on inbox messages and physician burnout, effective intervisit care skills will be crucial to the longevity of the physician workforce.
- Adler-Milstein J, Zhao W, Willard-Grace R, et al. Electronic health records and burnout: Time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians. J Am Med Inform Assoc. Apr 01 2020;27(4):531-538. doi:10.1093/jamia/ocz220.
- Nath B, Williams B, Jeffery MM, et al. Trends in electronic health record inbox messaging during the COVID-19 pandemic in an ambulatory practice network in New England. JAMA Netw Open. Oct 01 2021;4(10):e2131490. doi:10.1001/jamanetworkopen. 2021.31490.
- Tai-Seale M, Dillon EC, Yang Y, et al. Physicians’ well-being linked to in-basket messages generated by algorithms in electronic health records. Health Aff (Millwood). Jul 2019;38(7):1073-1078. doi:10.1377/hlthaff.2018.05509.
- Accreditation Council for Graduate Medical Education. Internal Medicine Milestones. https://www.acgme.org/globalassets/PDFs/Milestones/sInternalMedicineMilestones2.0.pdf. Second Revision, November 2020. Accessed December 15, 2023.
- O’Toole D, Sadik M, Inglis G, et al. Optimising the educational value of indirect patient care. Med Educ. Dec 2022;56(12):1214-1222. doi:10.1111/medu.14921.
Clinical Care Redesign, Medical Education, SGIM
Dr. Mulligan (firstname.lastname@example.org) is an assistant professor in the Division of General Internal Medicine at the Spencer Fox Eccles School of Medicine at the University of Utah. Dr. Stenehjem (Karen.Stenehjem@cuanschutz.edu) is an assistant professor of medicine in the Division of General Internal Medicine at the University of Colorado Anschutz Medical Campus and Rocky Mountain Regional VA Medical Center. Dr. Cioletti (email@example.com) is an associate professor and the Associate Chief of Ambulatory Operations in the Division of General Internal Medicine at the Spencer Fox Eccles School of Medicine at the University of Utah.
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