Simple Curriculum and Inbox Fix Helps Doctors-in-Training Master Test Results

Most people picture a doctor’s visit as a conversation in an exam room, but a large share of modern medical care now happens between visits. Laboratory results arrive, imaging studies need interpretation, and patient messages pile up in electronic inboxes while the clinic is dark. This inter-visit care, or IVC, has become a core part of ambulatory practice, yet residency programs have long struggled to teach it, supervise it, and measure it. A new study published in the Journal of General Internal Medicine suggests that a carefully designed combination of structural change and targeted education can transform how doctors-in-training handle this invisible workload, with striking results for both learning and patient safety.

The research, led by Dr. Jacqueline F. Birnbaum of the University of Washington School of Medicine with colleagues from McGovern Medical School at UTHealth Houston, Emory University, and the UTHealth Institute for Clinical Research and Learning Health Care, examined an intervention implemented in an academic internal medicine continuity clinic during the 2023–2024 academic year. Thirty-two residents participated in the multimethod evaluation, which combined a retrospective pre-post survey of educational outcomes with a chart review of matched resident cohorts before and after implementation. The findings offer a rare, integrated look at how educational objectives and clinical systems can be aligned to improve a domain that has often been treated as an afterthought in graduate medical education.

Inter-visit care encompasses two main activities: the management of test results and asynchronous communication with patients through electronic health record inboxes. Prior research has documented that physicians now split their time roughly evenly between seeing patients and what researchers call desktop medicine, and that electronic health record workload has been steadily increasing among academic primary care physicians. Studies have also linked excessive inbox activity to burnout and lower patient satisfaction, while a systematic review found that failure to follow up ambulatory test results remains a persistent and dangerous problem across care settings. Despite these stakes, a national survey of internal medicine program directors revealed that inbox management is inconsistently taught and supervised in residency programs.

Previous attempts to address this gap have generally tackled either the educational side or the structural side of the problem in isolation. Curricular interventions have taught residents about inter-visit clinical reasoning, but without changing the underlying systems that determine who actually sees which results and when. Structural interventions, such as cross-coverage models, have improved timeliness of result management, but without explicitly building residents’ skills or professional identity. The new study was designed to test whether an integrated approach, addressing both dimensions simultaneously, could produce improvements that neither could achieve alone.

The intervention had two tightly connected components. The first was a firm-based inbox coverage system, modeled on the firm system long used in inpatient medicine, which organized residents into stable teams with shared faculty oversight. This structure ensured continuity of test result follow-up and guaranteed that every result had a designated, supervised owner, even when the primary resident was off service or unavailable. The second component was a longitudinal inter-visit care curriculum delivered across the academic year, addressing electronic health record efficiency, clinical reasoning in inter-visit decision-making, and professional responsibility. Crucially, the educational sessions were aligned with clinical supervision through shared faculty oversight and dedicated inbox office hours, so that what residents learned in the classroom was reinforced in the very systems where they practiced.

The results were dramatic. Clinic-wide, the proportion of test results communicated to patients increased from 57 percent to 76 percent, a statistically significant improvement. Even more striking, the mean time to communication dropped from 18.7 days to 8.5 days, meaning patients learned about their results more than twice as fast on average. These clinic-level gains represent a substantial improvement in a domain where delays can mean missed diagnoses, delayed treatment, and preventable harm. The improvements were achieved not by adding more faculty or extending clinic hours, but by reorganizing existing resources and aligning them with explicit educational goals.

At the resident level, the picture was more nuanced. The researchers analyzed changes across baseline communication tertiles and training levels, finding variable patterns of improvement. Some residents, particularly those starting from lower baseline performance, showed the largest gains, while others plateaued or improved more modestly. This variability is itself informative, suggesting that a one-size-fits-all approach may not fully capture how different learners respond to structural change, and that individualized coaching or differentiated supervision may be needed to close remaining gaps. The authors note that these patterns support treating inter-visit care as a multidimensional clinical domain rather than a single skill.

The educational outcomes were equally encouraging. Residents’ self-reported confidence in inter-visit care skills improved across all measured domains, including electronic health record efficiency, clinical reasoning about asynchronous results, and professional responsibility for between-visit tasks. This subjective improvement, paired with objective clinical gains, suggests that the intervention succeeded on both fronts simultaneously. The alignment between educational objectives and clinical systems appears to have been key: residents were not merely taught about inter-visit care in the abstract, but were embedded in a structure where the right thing to do was also the easy thing to do, with faculty supervision reinforcing good habits in real time.

The study’s implications extend well beyond a single residency clinic. As ambulatory practice becomes increasingly digital, the skills required for effective inter-visit care, including efficient inbox management, sound clinical judgment about asynchronous information, and a sense of professional ownership over results, will only grow in importance. The Accreditation Council for Graduate Medical Education’s Internal Medicine Milestones 2.0 already expects residents to demonstrate competence in systems-based practice and care coordination, yet many programs lack the structures to support this learning. The new findings suggest that residency programs should treat inter-visit care as a core clinical domain that benefits from deliberate alignment between what is taught and how care is organized, rather than as a task to be delegated or ignored.

For patients, the message is perhaps the most compelling of all. Faster and more complete communication of test results is not an abstract educational goal; it is a concrete improvement in the experience of care, reducing anxiety, enabling earlier treatment decisions, and potentially preventing serious harm. The study demonstrates that when teaching hospitals invest in the systems and skills that govern the invisible half of medicine, everyone benefits: residents learn more effectively, faculty supervise more meaningfully, and patients receive the timely answers they deserve. As health systems everywhere grapple with electronic health record burden and the challenge of training the next generation of physicians, this integrated model offers a practical, evidence-based blueprint for turning the inbox from a source of burnout into a site of learning and high-quality care.

Subject of Research: A Structural and Educational Intervention to Improve Inter-Visit Care in an Internal Medicine Residency Clinic: A Multimethod Evaluation

Article Title: A Structural and Educational Intervention to Improve Inter-Visit Care in an Internal Medicine Residency Clinic: A Multimethod Evaluation

Article References: Birnbaum, J. F., Urquidi, J., Chen, B., Bravo, R., Gandhi, P. B., & Swails, J. L. (2026). A Structural and Educational Intervention to Improve Inter-Visit Care in an Internal Medicine Residency Clinic: A Multimethod Evaluation. Journal of General Internal Medicine. https://doi.org/10.1007/s11606-026-10690-2

Image Credits: AI Generated

DOI: 10.1007/s11606-026-10690-2

Keywords: Structural, Educational, Intervention, Improve, Inter-Visit, Care, Internal, Medicine, Residency, Clinic, Multimethod, Evaluation