The Primary Care Exception Rule in Internal Medicine Residency Clinic: Benefits, Disadvantages, Best Practices, and Recommendations for Reform.

The outpatient continuity clinic experience is a crucial component of internal medicine residency training. While in many contexts the teaching physician must be physically present for key parts of the patient encounter, some outpatient environments qualify for use of the Primary Care Exception Rule (PCER), which allows indirect supervision of residents for low-complexity visits. Despite pervasive use of the PCER in resident continuity clinics, the literature regarding its effects on various stakeholders is limited. We are a working group of representatives from the Society of General Internal Medicine's Education and Clinical Practice Committees and Medical Resident Clinic Directors Interest Group. In this Perspective, we discuss the benefits and disadvantages of the PCER for patients, residents, attendings, and health systems. We also suggest best practices for its use: to wit, we advise against using the PCER when the history and/or physical exam is critical to the diagnosis and/or management of the patient's chief concern, and advocate for competency-based, rather than time-based, benchmarks for resident supervision under it. We make recommendations for PCER reform, most importantly expanding the PCER to moderate-complexity visits once competency-based assessments have been instituted. We conclude with future directions for research to improve application of the PCER.