Table 4.

Interventions residents’ opinions of rotation’s educational strengths and weaknesses (qualitative interviews)

Theme	Subthemes	Representative quotations
Educational strengths
Learned about system-wide factors (previously unaware of)	“Big picture” regarding PCMH Practice committees (operations, PCMH, etc) Practice policies	“I think all of us will leave with a general understanding of, you know, how to move a practice along, how to work with our chronic care patients, and I see it as a huge benefit to our training” “it is easy to complain like this is not working. You know, but then to actually see what goes into making changes is - that was kind of enlightening.”
Learned that change is possible	Opportunities to make an impact Concrete mechanisms for change Change can take time	“Opportunity to recognize areas that needed change and then to actually do something active to make those changes” “[I] learned change can take a long time […] but also see that change can happen fairly quickly”
Learned how to work with interdisciplinary team on systems	Interdisciplinary PCMH rounds Committees (operations and PCMH) Improved communications	“I did not even know they [operations committee] met once a month […] really valuable […] because it does give you insight into how things work and how things change and what the barriers are”
Learned specific skills not learned elsewhere in residency	PDSA cycles, registries, GMVs, chart audits, etc Tracking high-risk patients Impacting practice policies	“I learned some specific tips about patient policies. We looked at the violent patient policy, the geriatric policy for nursing homes […]. so, that was the only time I did that” “[…] so while I find some of that kind of annoying, I also think that it is important to actually have objective measures […] track different things […] like how many people have you talked about smoking cessation with”
Educational weaknesses
Inadequate time to see impact of many changes	Mixture of understanding and frustration	“I know that whatever we did […] I wouldn’t see any fruits from it. So I did the work, but kind of left it more for the second and first years, as they were the ones more likely to see change” “I think it is nice to analyze things and find out that there are ways that could be better. I think it didn’t necessarily give me hope though”.
Lack of adequate resources – residents felt they were doing “secretarial” work (specifically re: hospital transitions of care)	Few saw no benefit and were frustrated Many saw benefit but remained concerned Few saw benefit and were not frustrated	“It [the rotation] is all about tracking” “the transitions of care piece is a frustrating piece for the residents, but it is also a very important piece and something that needs improvement” “[…] satisfaction out of being like okay I found one [hospitalized PCMH patient], and now I am going to tell the PCP and just feeling like I was contributing to continuity of care, and not any people get lost”
Nursing home patient acute visits did not seem to “fit” in PCMH rotation	Several did not see relationship Few understood population management of elderly	“So you have a lot of like those nursing home responsibilities that are keeping you from doing like your PCMH responsibilities or PCMH responsibilities that are keeping you doing your nursing home responsibilities”
Unclear roles and responsibilities	More prominent earlier in year A work in progress	“I did not know what my - [what] the expectations were for the rotation in the beginning.” “I am glad it is in place, and I think there is a lot of improvements that have already happened, and I think continuing to improve it will be good.”

Abbreviations: GMV, group medical visit; PCMH, patient-centered medical home; PDSA, Plan Do Study Act; PCP, primary care physician.