INFLUENCE OF AMBULATORY CARE ROTATIONS ON GATEKEEPING REFERRAL PATTERNS OF CATEGORICAL MEDICAL RESIDENTS

Purpose. To determine whether a required ambulatory care block rotatio n for categorical medicine residents improved their ambulatory care sk ills and altered their outpatient gatekeeping referral patterns. Metho d. In 1991-92 a prospective cohort study was conducted of 39 categoric al medicine residents at the University of California, San Francisco, and their continuity clinic patients. Before and after the residents p articipated in an ambulatory care block rotation, the residents were s urveyed about their ambulatory care skills, and the frequencies and in dications for referral of their continuity clinic patients were obtain ed. Statistical methods consisted of Student's t-test, the Wilcoxon ra nk-sum test, and Mantel-Haenszel analysis. Results. The 39 residents r eported significant improvement in ambulatory care skills. Yet the pro portions of the residents' 4,276 patients referred before and after th e intervention were 14.2% and 12.4%, respectively (adjusted odds ratio 1.02, p > .9). One-fourth of the referrals were for procedures both b efore and after the intervention (adjusted odds ratio 1.06, p > .5). C onclusion. Despite improvements in the ambulatory care skills of the c ategorical medicine residents, the residents' gatekeeping referral pat terns remained unchanged. Ambulatory care curriculum changes need to b e evaluated from the perspective of the trainee and from the perspecti ve of whether these changes influence patient care.