Impact of a Residency Family Systems Curriculum on the Postresidency Practice of Family Physicians.

BACKGROUND AND OBJECTIVES: Training residents in family systems and family-oriented care holds the potential to increase empathy for patients and to grow self-awareness of how one's own family of origin affects clinical practice. Little has been studied about how training residents in family systems affects their clinical practice after they graduate residency. METHODS: We surveyed all the residency graduates (N=60) who completed the longitudinal family systems curriculum during their third year of residency, from 2016 to 2021. The former residents were emailed a survey and asked to respond to Likert-scale and qualitative questions regarding the effects of the family systems curriculum on their clinical practice. RESULTS: Thirty-five graduates (58.3%) returned completed surveys. Overall, 26 of 35 (74.3%) respondents felt that the family systems curriculum had helped them a fair amount or a great deal in the care of their patients. In particular, 29 of 35 (82.9%) felt that the curriculum helped them a fair amount or a great deal in maintaining empathy. Compared to other longitudinal courses, 32 of 35 (91.4%) respondents indicated that they liked the curriculum somewhat or a great deal.  Conclusions: More than half the respondents found all elements of the curriculum helpful in their clinical practice, especially in the areas of caring for patients and maintaining empathy. The responses will be used as a baseline for comparison to improve the training. Continued research, perhaps in the form of randomized controlled trials using several residencies, could help in developing elements for more standardized curriculum in family-oriented care training.

Residency Education Redesign: The Interplay of Innovation and Standardization.

Tensions have always existed between innovation and standardization in family medicine, due to the need for rapid responses to changing health issues while ensuring proficiency. For innovation in residency training to be successful, standardization of milestones and frameworks as well as outcomes of residency education are needed and must be clear and rely on measurable effectiveness standards. Standardization without innovation can cause educational stasis, failure to adapt to change, and/or lack of evidence-guided education. Here, we examine possible options for creating the right balance, review what the evidence shows, and make recommendations for the future, including (1) adoption and study of clear, actionable entrustable professional activities (EPAs) as educational standards for residency graduates; (2) core faculty be required to engage in faculty development that includes competency-based medical education using the EPA framework, advanced curriculum development, program evaluation, objective learner assessments aligned with individualized learning plans, and increased opportunities for program directors to gain additional training in the educational sciences; (3) 30% of protected time for core faculty to design, administer, and assess the educational program; (4) required participation in educational collaboratives that rigorously study innovation; (5) required scholarly work that supports program development both clinically and educationally. Taken together, these recommendations represent a vital interplay between cutting-edge innovation and thoughtful standardization using collaboration to graduate residents ready to provide optimal care in their communities, both now and into the future. All stakeholders in the discipline must undertake strategic and deliberate planning designed to adjust direct and indirect costs of residency training to support these recommendations.

Financing the Fourth Year: Experiences of Required 4-Year Family Medicine Residency Programs.

The optimal length of family medicine training has been debated since the specialty's inception. Currently there are four residency programs in the United States that require 4 years of training for all residents through participation in the Accreditation Council for Graduate Medical Education Length of Training Pilot. Financing the additional year of training has been perceived as a barrier to broader dissemination of this educational innovation. Utilizing varied approaches, the family medicine residency programs at Middlesex Health, Greater Lawrence Health Center, Oregon Health and Science University, and MidMichigan Medical Center all demonstrated successful implementation of a required 4-year curricular model. Total resident complement increased in all programs, and the number of residents per class increased in half of the programs. All programs maintained or improved their contribution margins to their sponsoring institutions through additional revenue generation from sources including endowment funding, family medicine center professional fees, institutional collaborations, and Health Resources and Services Administration Teaching Health Center funding. Operating expense per resident remained stable or decreased. These findings demonstrate that extension of training in family medicine to 4 years is financially feasible, and can be funded through a variety of models.

Effects of Clinic First Educational Interventions on Resident Wellness and Engagement.

BACKGROUND AND OBJECTIVES: Tensions between clinical and hospital training, along with dysfunctional family medicine training clinics, have resulted in continuity clinic being the least favorite part of training for some residents. These factors are all contributors to burnout. We hypothesized that following Clinic First action steps to prioritize and enhance outpatient clinic would positively affect resident wellness and clinic engagement. This study describes our interventions and their effects within the Oregon Health & Science University (OHSU) Family Medicine 4-year Portland residency program. METHODS: In July 2017 the Oregon Health & Science University Family Medicine Portland residency program implemented scheduling and curricular interventions inspired by the Clinic First model. We conducted a mixed-methods cross-sectional study using focus groups and surveys to understand the effects of these interventions on resident wellness and engagement. RESULTS: Clinic First-inspired interventions, particularly a 2+2 scheduling model, decreased transitions within the day, and a clinic immersion month were associated with improved residents' perception of wellness. These interventions had variable effects on clinic engagement. Eighty-eight percent of interns surveyed about the month-long clinic orientation in the beginning of residency reported that they felt prepared managing continuity patients in the clinic setting and their upcoming rotations. CONCLUSIONS: This study demonstrates that Clinic First-inspired structural changes can be associated with improvement in resident perceptions of wellness and aspects of clinic engagement. This can give educators a sense of hope as well as tangible steps to take to improve these difficult and important issues.

Impact of Residency Training Redesign on Residents' Clinical Knowledge.

BACKGROUND AND OBJECTIVES: The In-training Examination (ITE) is a frequently used method to evaluate family medicine residents' clinical knowledge. We compared family medicine ITE scores among residents who trained in the 14 programs that participated in the Preparing the Personal Physician for Practice (P4) Project to national averages over time, and according to educational innovations. METHODS: The ITE scores of 802 consenting P4 residents who trained in 2007 through 2011 were obtained from the American Board of Family Medicine. The primary analysis involved comparing scores within each academic year (2007 through 2011), according to program year (PGY) for P4 residents to all residents nationally. A secondary analysis compared ITE scores among residents in programs that experimented with length of training and compared scores among residents in programs that offered individualized education options with those that did not. RESULTS: Release of ITE scores was consented to by 95.5% of residents for this study. Scores of P4 residents were higher compared to national scores in each year. For example, in 2011, the mean P4 score for PGY1 was 401.2, compared to the national average of 386. For PGY2, the mean P4 score was 443.1, compared to the national average of 427, and for PGY3, the mean P4 score was 477.0, compared to the national PGY3 score of 456. Scores of residents in programs that experimented with length of training were similar to those in programs that did not. Scores were also similar between residents in programs with and without individualized education options. CONCLUSIONS: Family medicine residency programs undergoing substantial educational changes, including experiments in length of training and individualized education, did not appear to experience a negative effect on resident's clinical knowledge, as measured by ITE scores. Further research is needed to study the effect of a wide range of residency training innovations on ITE scores over time.

Long-term Effects of a Health Literacy Curriculum for Family Medicine Residents.

INTRODUCTION: Improving education about health literacy for health care professionals has been recommended, and many US family medicine residency programs have developed such curricula. Few studies have evaluated the effectiveness of health literacy curricula for health care professionals. This pilot study aimed to determine whether a longitudinal health literacy curriculum for family medicine residents could achieve long-term sustained improvements in health literacy knowledge and clear communication practices. METHODS: Self-reported pre- and postassessments were conducted for a series of four health literacy didactic and experiential trainings over 11 months with a cohort of 12 first-year family medicine residents (study adequately powered for cohort of 10 or more). RESULTS: Five out of five health literacy knowledge items showed sustained significant improvement immediately after the initial didactic training. Two out of eight clear communication behaviors (eliciting patients' questions through an open-ended approach, and using a teach-back method to check for patients' understanding) showed sustained significant improvements in the 11-month follow-up period. The remaining six behaviors demonstrated a saw-tooth pattern, wherein each training session produced improvements in planned behaviors, which were, however, not maintained at subsequent follow-up assessments. CONCLUSIONS: These data suggest that residents learned the cognitive material related to health literacy and clear communication easily, but had difficulty integrating many trained skills into clinical practice, despite the use of experiential learning techniques. Future studies should use an observational design to assess clear communication behaviors, and should include assessment of potential barriers to implementing clear communication skills in clinical practice.

Health Literacy Teaching in U.S. Family Medicine Residency Programs: A National Survey.

Health care providers, including medical residents, often lack adequate knowledge and skills to work effectively with patients who have limited health literacy. Little is known about the degree to which medical residents are trained to communicate effectively with people who have limited health literacy. This study aimed to assess the status of health literacy training for physicians in U.S. family medicine residency programs. We conducted an online survey of residency directors at 444 U.S. family medicine residencies. Among 138 respondents (31% response rate), 58 programs (42%) reported teaching residents about health literacy as part of the required curriculum. Most instruction occurred during the 1st year of training. Hours of instruction ranged from 2 to 5 during Years 1 through 3. Skills-based training (e.g., plain language techniques) was taught by most programs. Not having access to a faculty authority on health literacy was strongly associated with lack of a required health literacy curriculum. Respondents overwhelmingly agreed that increasing health literacy training for medical students and residents would help improve residents' clinical skills. This study provides a baseline snapshot of health literacy curricula in U.S. family medicine residencies and likely overestimates the prevalence of such curricula. Additional studies are needed to determine the quality of health literacy instruction in U.S. family medicine residencies and the most effective methods for teaching residents about health literacy.

Innovating within the ACGME regulatory environment is not an oxymoron.

BACKGROUND AND OBJECTIVES: The aim of this study was to describe the analysis of program citations and cycle length for reaccreditation in the 14 family medicine residencies participating in the P4 project. METHODS: An exploratory narrative analysis was conducted on all actions taken by the Review Committee for Family Medicine (RC-FM) between 2003 and 2012. The analysis included cycle length and types of citations associated with accreditation actions. Several validation steps were undertaken to confirm findings reported. RESULTS: Mean cycle length for all P4 programs was 4.0 before P4 (2007) and did not change significantly during P4. The average number of citations per program before P4 was 6.2, and during P4 the average was 6.8. The P4 averages were similar to national norms during the project period. The citations that most commonly decreased during the P4 project were: Continuity of Patient Care/Inpatient, FMC Patient Population/Patient Volume, Orthopedics or Sports Medicine Curriculum, Resident Final Evaluation, Resident Workload/Duty Hours, and Resident Attrition. The citations that most commonly increased during the P4 project were FMC Patient Population/Demographics, Certifying Exam Scores, and Management of Health Systems Curriculum. CONCLUSIONS: Innovation and redesign of residency training in the P4 programs appears not to have affected the average cycle length or number of citations per program. The current regulatory environment in family medicine residency education appears to allow for innovation and experimentation.

Financing Residency Training Redesign.

BACKGROUND: Redesign in the health care delivery system creates a need to reorganize resident education. How residency programs fund these redesign efforts is not known. METHODS: Family medicine residency program directors participating in the Preparing Personal Physicians for Practice (P(4)) project were surveyed between 2006 and 2011 on revenues and expenses associated with training redesign. RESULTS: A total of 6 university-based programs in the study collectively received $5,240,516 over the entire study period, compared with $4,718,943 received by 8 community-based programs. Most of the funding for both settings came from grants, which accounted for 57.8% and 86.9% of funding for each setting, respectively. Department revenue represented 3.4% of university-based support and 13.1% of community-based support. The total average revenue (all years combined) per program for university-based programs was just under $875,000, and the average was nearly $590,000 for community programs. The vast majority of funds were dedicated to salary support (64.8% in university settings versus 79.3% in community-based settings). Based on the estimated ratio of new funding relative to the annual costs of training using national data for a 3-year program with 7 residents per year, training redesign added 3% to budgets for university-based programs and about 2% to budgets for community-based programs. CONCLUSIONS: Residencies undergoing training redesign used a variety of approaches to fund these changes. The costs of innovations marginally increased the estimated costs of training. Federal and local funding sources were most common, and costs were primarily salary related. More research is needed on the costs of transforming residency training.

A review of video review: new processes for the 21st century.

Reviewing with resident physicians their preciously recorded video of patient encounters is an effective method for teaching not only communications and interpersonal skills but also such subjects as agenda negotiation, visit efficiency, shared decision making, and overall medical care. Video allows for effective coaching while minimizing observer effect. Many residency programs use video review processes for evaluation and coaching, yet there is paucity of literature on the subject, and no consensus on best processes or equipment. Recent advances in the design of digital media devices has made it easier to conduct video review in everyday medical settings, but also creates new challenges in ensuring security and confidentiality. In this article, we have outlined the infrastructure and process needed to design and implement such a program as well as possible pitfalls that should be attended to in order to ensure patient confidentiality as well as resident safety.

Challenges to depression care documentation in an EHR.

BACKGROUND AND OBJECTIVES: Patients with depression most frequently present in primary care. Electronic health records (EHR) have the potential to improve depression care through improved clinical documentation and information exchange. This report provides an example of how an EHR can fail to capture important information regarding depression care. METHODS: A 6-month baseline period in 2009 was defined to identify ambulatory patients age 18 or older in the EHR with an ICD-9 coded new depression diagnosis. Data was abstracted electronically, and charts were reviewed by hand for patient demographics and to assess the clinical documentation of depression screening, diagnosis, and treatment practices among four community-based family medicine clinics. RESULTS: Electronic abstraction of baseline data identified 200 adult patients with a documented new diagnosis of depression. Review of charts by hand was required to obtain clinical documentation of screening (9% of patients), use of diagnostic tools (73%), discussion of treatment options (83%), medication treatment (71%), and follow-up characteristics (75%). CONCLUSIONS: Despite having a robust EHR, we encountered significant challenges finding documentation of depression care, which also made it difficult to track and evaluate the implementation of evidence-based treatment. Clinical documentation in the EHR needs to be simplified and standardized if data extraction and exporting processes of clinician performance data are to become efficient and routine practice.

An assessment of family medicine residency networks in the United States.

INTRODUCTION: Residency networks, comprising groups of residency programs organized as collaborative ventures or consortia, have existed in the United States for more than 30 years. At the same time, there have been no comparative assessments of their structures and functions. OBJECTIVES: We conducted a survey of residency networks to assess their organizational structures and activities. METHODS: We identified 9 residency networks and designed a survey to specifically assess their organizational structures and activities. This survey was sent electronically to network leadership and all respective program directors in each residency network. The survey contained 6 areas of focus: (1) network history and administration; (2) network funding; (3) resource sharing and communication within the network; (4) network activities; (5) research within the network; and (6) strengths and weaknesses of the network. RESULTS: Of the 9 networks, 5 provided data, with 32 of a possible 51 residency programs (62.8%) responding. Respondents reported predominantly functioning as affiliated networks (76.3%) rather than collaborative ventures or consortia. The networks have a variety of funding streams and share resources. CONCLUSIONS: A major function of residency networks is the sharing of resources, particularly in the area of faculty development, with 97.1% of respondents sharing faculty development resources. In addition, all residency networks were actively involved in research, and they participated in political advocacy and in enhancing the engagement of medical students. Networks have been successful at obtaining grants to support their infrastructure.

A p4 report: effect of curriculum innovation on residency applications and match performance.

BACKGROUND AND OBJECTIVES: Family medicine is actively engaged in residency redesign, but it is unclear how curricular innovation and restructuring of residency programs will affect their performance in the National Resident Matching Program (NRMP). METHODS: The Preparing the Personal Physician for Practice (P4) Project is a residency redesign initiative of 14 family medicine residency programs. Applicant and Match data provided by P4 programs were analyzed to determine if Match performance improved between the pre- (2006--2007) and post- (2008--2010) P4 program years and were compared to national applicant and Match data obtained from Electronic Residency Application System (ERAS) data and the NRMP. RESULTS: The mean number of US MD senior applicants per program increased from 53 before P4 to 81 after P4 implementation. The mean number of applicants interviewed per program increased nearly 40% in the post-P4 period. The mean percent of positions filled in the Match increased from 72.6% before P4 to 86.8% post-P4. Programs that implemented individualized training significantly improved the percent of positions filled in the Match compared to those that did not, 90% versus 83. CONCLUSIONS: In the family medicine P4 programs, innovations in residency curriculum, especially those with individualized training, appear to have a positive influence on student interest and program performance in the Match.

A model for a standardized national family medicine graduate survey.

BACKGROUND AND OBJECTIVES: Accreditation requirements mandate that family medicine residency programs perform surveys of graduates. As part of the Preparing the Personal Physician for Practice (P4) Project, we developed a model for a standardized national graduate survey to be used to assess practice characteristics of graduates, including the implementation of features of the Patient-centered Medical Home (PCMH). METHODS: We conducted a content analysis of residency graduate surveys from the 14 programs involved in the P4 project to identify common elements of importance to residencies. We then designed a new graduate survey as a core measure of the P4 Project. It included practice characteristics, assessment of training, and the status of features of the PCMH. RESULTS: Categories of variables common to the graduate surveys of the P4 programs included physician and practice characteristics, work load, scope of practice, career satisfaction, and assessment of training. We found variability among programs in the number of procedures and residency content areas listed on any individual program survey, with the number of procedure ranging from 0--21, and the number of content areas ranging from 0-61. The only PCMH feature included on any P4 program survey was the status of an electronic medical record. CONCLUSIONS: Graduate surveys from individual residency programs vary widely. Using a standardized national survey instrument would provide important information to understand the national practice characteristics and scope of practice in family medicine as well as to track the implementation of PCMH features among residency graduates.

Are major bleeding events from falls more likely in patients on warfarin?

There is no evidence of increased risk for major bleeding as a result of falls in hospitalized patients taking warfarin (strength of recommendation [SOR]: B, based on retrospective cohort studies). In the average patient taking warfarin for atrial fibrillation, the risk of intracranial hemorrhage from a fall is much smaller than the benefit gained from reducing risk of stroke (SOR: A, based on decision analysis of systematic reviews with sensitivity analysis).