Implementing radical curriculum change in a family medicine residency: the majors and masteries program.

BACKGROUND AND OBJECTIVES: There have been dramatic changes in the specialty of family medicine and the American health care system in the more than 40 years since the formation of the specialty. As a result, there is urgent need for experimentation and innovation in residency training to better prepare family physicians. METHODS: Waukesha Family Medicine Residency used a strategic planning process to identify four guiding concepts for a new model of residency education: intentional diversification; options for advanced training in a fourth year of residency; longitudinal, competency-based training; and strong fundamental background in family medicine skills. These concepts guided radical restructuring of the curriculum. RESULTS: The new Majors and Masteries curriculum begins with 19 months of training in core family medicine skills. Residents then elect to pursue a Major or Mastery in an area of interest. Majors are completed within 3 years, while Masteries are completed in 4 years and include advanced training (MPH, MBA, advanced obstetrics). Since implementation, residents have selected a broad range of Majors, three residents have elected advanced training in three different mastery areas, and resident recruitment has not been disrupted. CONCLUSIONS: The Majors and Masteries curriculum and the process used to implement it may benefit other residencies considering radical curriculum change.

Learner-directed intentional diversification: the experience of three P4 programs.

BACKGROUND: This paper presents early outcomes of three residency programs participating in Preparing the Personal Physician for Practice (P4), family medicine's innovative residency redesign initiative. The three programs allow learner-directed diversification and either allow or require extra time, up to 4 years of residency, to complete these experiences. Residents endorse the changes by two measures: they choose a wide variety of areas of concentration, and a significant minority (40%) of residents chose to extend their residency training to 4 years, a proportion that grew significantly from 2006 to 2008.

Using a simulated practice to improve practice management learning.

BACKGROUND AND OBJECTIVES: Practice management education is required in family medicine residencies, and requirements have recently been expanded. Surveys show that graduates feel unprepared to address practice management after graduation, so it is an aspect of training in need of improvement. METHODS: We substituted a "simulated practice" for part of an established didactic program in practice management. The curriculum included 20 modules with specific practice management tasks to be completed by the residents. An objective examination covering a broad range of practice management topics was created and given twice to residents, once early in their second year and again at the end of third year. One group of residents participated in the simulated practice curriculum, and a comparison group participated in a standard didactic curriculum. RESULTS: Our pre-test and post-test examinations each produced reliable data. Residents with simulated practice training had statistically significant increases in exam scores while the comparison group did not. The simulated practice group also increased scores on every subsection of the exam, while the comparison group increased scores on only half of the subsections. However, only one resident (in the intervention group) achieved >60% correct answers on the post-test examination. CONCLUSIONS: The increased learning demonstrated by improved test performance suggests that a simulated practice approach is more helpful than a standard didactic curriculum for teaching residents about practice management, but it still does not yield knowledge scores at an optimal level.

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.

Twenty questions in genetic medicine--an assessment of World Wide Web databases for genetics information at the point of care.

PURPOSE: The aim of this article was to determine the accuracy and efficiency of World Wide Web ("Web") resources to help nongeneticists answer four clinical questions about each of five common genetic conditions. METHODS: Correct answers were established by literature review. Two open-access genetics resources and seven general subscription resources were reviewed. Scoring criteria were established to define complete, partial, vague, inconsistent, not found, and wrong answers. The main outcome measures were number of answers found, accuracy, and completeness of answers. Efficiency (time per answer found) was a secondary measure. RESULTS: Overall, the databases contained complete answers 33.3% of the time but contained no information as frequently (33.9%). The best database had complete answers 70% of the time, whereas the worst contained no complete answers. Five of the seven subscription databases had a total of eight wrong answers. The other two subscription databases and the two open-access genetics databases had no wrong answers. Search time ranged from 3.2 to 18.3 minutes per complete answer. CONCLUSIONS: Nongeneticist providers do not have a Web resource that is accessible, accurate, and efficient to answer genetic questions that might arise in practice.

Screen-positive rates and agreement among six family history screening protocols for breast/ovarian cancer in a population-based cohort of 21- to 55-year-old women.

PURPOSE: Mutations in the BRCA1 and BRCA2 genes are responsible for approximately 2% of breast cancers by age 70 years. Professional and governmental groups recommend using family history protocols as an initial step in identifying women and families for mutation testing. We assess screen-positive rates and levels of agreement between these protocols. METHODS: We applied six family history screening protocols to a population-based cohort of 321 women, age 21 to 55 years, who reported their personal and family history of breast and ovarian cancer. RESULTS: The proportion of women and families identified as candidates for mutation testing ranged from 4.4% to 7.8%, depending on the protocol. The protocols had low or fair agreement (kappa <0.75 for 14 of 15 comparisons), but all identified six women (1.9%, 95% confidence interval 0.7%-4.0%) as screen positive. When the effect of missing ages of cancer onset was modeled, these rates increased (range 6.5%-11.5%), and nine women (2.8%) were screen positive by all protocols. CONCLUSION: Given limitations of family history as a screening test for hereditary cancer related to BRCA1/2 mutations, 1% to 2% of women in the general population should initially be identified for mutation testing. One way to achieve this would be to require that multiple screening protocols agree.