Postresidency Practice Setting and Clinical Care Features According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Pilot Study.

BACKGROUND AND OBJECTIVES: Factors associated with physician practice choice include residency location, training experiences, and financial incentives. How length of training affects practice setting and clinical care features postgraduation is unknown. METHODS: In this Length of Training Pilot (LoTP) study, we surveyed 366 graduates of 3-year (3YR) and 434 graduates of 4-year (4YR) programs 1 year after completion of training between 2013 and 2021. Variables assessed included reasons for practice setting choice, practice type, location, practice and community size, specialty mix, and clinical care delivery features (eg, integrated behavioral health, risk stratified care management). We compared different length of training models using χ2 or Fisher's exact tests for categorical variables and independent samples, and t test (unequal variances) for continuous variables. RESULTS: Response rates ranged from 50% to 88% for 3YR graduates and 68% to 95% for 4YR graduates. Scope of practice was a predominant reason for graduates choosing their eventual practice, and salary was a less likely reason for those completing 4 years versus 3 years of training (scope, 72% vs 55%, P=.001; salary, 15% vs 22%, P=.028). Community size, practice size, practice type, specialty mix, and practice in a federally designated underserved site did not differ between the two groups. We found no differences in patient-centered medical home features when comparing the practices of 3YR to 4YR graduates. CONCLUSIONS: Training length did not affect practice setting or practice features for graduates of LoTP programs. Future LoTP analyses will examine how length of training affects scope of practice and clinical preparedness, which may elucidate other elements associated with practice choice.

Measuring Clinical Preparedness After Residency Training: Development of a New Instrument.

BACKGROUND AND OBJECTIVES: Research on preparedness for independent clinical practice typically uses surveys of residents and program directors near graduation, which can be affected by several biases. We developed a novel approach to assess new graduates more objectively using physician and staff member assessors 3 months after graduates started their first job. METHODS: We conducted a literature review and key informant interviews with physicians from varying practice types and geographic regions in the United States to identify features that indicate a lack of preparedness for independent clinical practice. We then held a Clinical Preparedness Measurement Summit, engaging measurement experts and family medicine education leaders, to build consensus on key indicators of readiness for independent clinical practice and survey development strategies. The 2015 entrustable professional activities for family medicine end-of-residency training provided the framework for assessment of clinical preparedness by physician assessors. Sixteen published variables assessing interpersonal communication skills and processes of care delivery were identified for staff assessors. We assessed frequencies and compared survey findings between physician and staff assessors in 2016 to assist with survey validation. RESULTS: The assessment of frequencies demonstrated a range of responses, supporting the instrument's ability to distinguish readiness for independent practice of recent graduate hires. No statistical differences occurred between the physician and staff assessors for the same physician they were evaluating, indicating internal consistency. CONCLUSIONS: To learn about the possible impact of length of training, we developed a novel approach to assess preparedness for independent clinical practice of family medicine residency graduates.

Resident Visit Productivity and Attitudes About Continuity According to 3 Versus 4 Years of Training in Family Medicine: A Length of Training Study.

BACKGROUND AND OBJECTIVES: Training models in the Length of Training Pilot (LOTP) vary. How innovations in training length affect patient visits and resident perceptions of continuity is unknown. METHODS: We analyzed resident in-person patient encounters (2013-2014 through 2018-2019) for each postgraduate year (PGY) and total visits at graduation derived from the Accreditation Council for Graduate Medical Education reports for each LOTP program. We collected data on residents' perceptions of continuity from annual surveys (2015-2019). We analyzed continuous variables using independent samples t tests with unequal variance and categorical variables using χ2 tests in comparing 3-year (3YR) versus 4-year (4YR) programs. RESULTS: PGY-1 and PGY-2 residents in 4YR programs saw statistically more patients than their counterparts in 3YR programs. In PGY3, 3YR program residents had statistically higher visit volume compared to 4YR program residents. Visits conducted in PGY4 ranged from 832 to 884. The additional year of training resulted in approximately 1,000 more total patient visits. Most residents in 3YR and 4YR programs rated their continuity clinic experience as somewhat or very adequate (range 86.3% to 93.7%), which did not statistically differ according to length of training. CONCLUSIONS: Resident visits were significantly different at each PGY level when comparing 3YR and 4YR programs in the LOTP and the additional year of training resulted in about 1,000 more total visits. Resident perspectives on the adequacy of their continuity clinic experience appeared to not be affected by length of training. Future research should explore how the volume of patient visits performed in residency affects scope of practice and clinical preparedness.

The Association Between Length of Training and Family Medicine Residents' Clinical Knowledge: A Report From the Length of Training Pilot Study.

BACKGROUND AND OBJECTIVE: The associations between training length and clinical knowledge are unknown. We compared family medicine in-training examination (ITE) scores among residents who trained in 3- versus 4-year programs and to national averages over time. METHODS: In this prospective case-control study, we compared the ITE scores of 318 consenting residents in 3-year programs to 243 who completed 4 years of training between 2013 through 2019. We obtained scores from the American Board of Family Medicine. The primary analyses involved comparing scores within each academic year according to length of training. We used multivariable linear mixed effects regression models adjusted for covariates. We performed simulation models to predict ITE scores after 4 years of training among residents who underwent only 3 years of training. RESULTS: At baseline postgraduate year-1 (PGY1), the estimated mean ITE scores were 408.5 for 4-year programs and 386.5 for 3-year programs, a 21.9 point difference (95% CI=10.1-33.8). At PGY2 and PGY3, 4-year programs scored 15.0 points higher and 15.6 points higher, respectively. When extrapolating an estimated mean ITE score for 3-year programs, 4-year programs would still score 29.4 points higher (95% CI=15.0-43.8). Our trend analysis revealed those in 4-year programs had a slightly lesser slope increase compared to 3-year programs in the first 2 years. Their drop-off in ITE scores is less steep in later years, though these differences were not statistically significant. CONCLUSIONS: While we found significantly higher absolute ITE scores in 4 versus 3-year programs, these increases in PGY2, PGY3 and PGY4 may be due to initial differences in PGY1 scores. Additional research is needed to support a decision to change the length of family medicine training.

An antidote to what's ailing healthcare workers: a new (old) way of relational leadership.

PURPOSE: The purpose of the study's mixed-methods evaluation was to examine the ways in which a relational leadership development intervention enhanced participants' abilities to apply relationship-oriented skills on their teams. DESIGN/METHODOLOGY/APPROACH: The authors evaluated five program cohorts from 2018-2021, involving 127 interprofessional participants. The study's convergent mixed-method approach analyzed post-course surveys for descriptive statistics and interpreted six-month post-course interviews using qualitative conventional content analysis. FINDINGS: All intervention features were rated as at least moderately impactful by at least 83% of participants. The sense of community, as well as psychological safety and trust created, were rated as impactful features of the course by at least 94% of participants. At six months post-intervention, participants identified benefits of greater self-awareness, deeper understanding of others and increased confidence in supporting others, building relationships and making positive changes on their teams. ORIGINALITY/VALUE: Relational leadership interventions may support participant skills for building connections, supporting others and optimizing teamwork. The high rate of skill application at six months post-course suggests that relational leadership development can be effective and sustainable in healthcare. As the COVID-19 pandemic and systemic crises continue to impact the psychological well-being of healthcare colleagues, relational leadership holds promise to address employee burnout, turnover and isolation on interprofessional care teams.

An Exploratory Mixed Methods Study of Experiences of Interprofessional Teams Who Received Coaching to Simultaneously Redesign Primary Care Education and Clinical Practice.

INTRODUCTION/OBJECTIVES: Coaching is emerging as a form of facilitation in health professions education. Most studies focus on one-on-one coaching rather than team coaching. We assessed the experiences of interprofessional teams coached to simultaneously improve primary care residency training and interprofessional practice. METHODS: This three-year exploratory mixed methods study included transformational assistance from 9 interprofessional coaches, one assigned to each of 9 interprofessional primary care teams that included family medicine, internal medicine, pediatrics, nursing, pharmacy and behavioral health. Coaches interacted with teams during 2 in-person training sessions, an in-person site visit, and then as requested by their teams. Surveys administered at 1 year and end study assessed the coaching relationship and process. RESULTS: The majority of participants (82% at end of Year 1 and 76.6% at end study) agreed or strongly agreed that their coach developed a positive working relationship with their team. Participants indicated coaches helped them: (1) develop as teams, (2) stay on task, and (3) respond to local context issues, with between 54.3% and 69.2% agreeing or strongly agreeing that their coaches were helpful in these areas. Cronbach's alpha for the 15 coaching survey items was 0.965. Challenges included aligning the coach's expertise with the team's needs. CONCLUSIONS: While team coaching was well received by interprofessional teams of primary care professionals undertaking educational and clinical redesign, the 3 primary care disciplines have much to learn from each other regarding how to improve inter- and intra-professional collaborative practice among clinicians and staff as well as with interprofessional learners rotating through their outpatient clinics.

Financial Considerations Associated With a Fourth Year of Residency Training in Family Medicine: Findings From the Length of Training Pilot Study.

BACKGROUND AND OBJECTIVES: The feasibility of funding an additional year of residency training is unknown, as are perspectives of residents regarding related financial considerations. We examined these issues in the Family Medicine Length of Training Pilot. METHODS: Between 2013 and 2019, we collected data on matched 3-year and 4-year programs using annual surveys, focus groups, and in-person and telephone interviews. We analyzed survey quantitative data using descriptive statistics, independent samples t test, Fisher's Exact Test and χ2. Qualitative analyses involved identifying emergent themes, defining them and presenting exemplars. RESULTS: Postgraduate year (PGY)-4 residents in 4-year programs were more likely to moonlight to supplement their resident salaries compared to PGY-3 residents in three-year programs (41.6% vs 23.0%; P=.002), though their student debt load was similar. We found no differences in enrollment in loan repayment programs or pretax income. Programs' descriptions of financing a fourth year as reported by the program director were limited and budget numbers could not be obtained. However, programs that required a fourth year typically reported extensive planning to determine how to fund the additional year. Programs with an optional fourth year were budget neutral because few residents chose to undertake an additional year of training. Resources needed for a required fourth year included resident salaries for the fourth year, one additional faculty, and one staff member to assist with more complex scheduling. Residents' concerns about financial issues varied widely. CONCLUSIONS: Adding a fourth year of training was financially feasible but details are local and programs could not be compared directly. For programs that had a required rather than optional fourth year much more financial planning was needed.

Conditions Influencing Collaboration Among the Primary Care Disciplines as They Prepare the Future Primary Care Physician Workforce.

BACKGROUND AND OBJECTIVES: Much can be gained by the three primary care disciplines collaborating on efforts to transform residency training toward interprofessional collaborative practice. We describe findings from a study designed to align primary care disciplines toward implementing interprofessional education. METHODS: In this mixed methods study, we included faculty, residents and other interprofessional learners in family medicine, internal medicine, and pediatrics from nine institutions across the United States. We administered a web-based survey in April/May of 2018 and used qualitative analyses of field notes to study resident exposure to team-based care during training, estimates of career choice in programs that are innovating, and supportive and challenging conditions that influence collaboration among the three disciplines. Complete data capture was attained for 96.3% of participants. RESULTS: Among family medicine resident graduates, an estimated 87.1% chose to go into primary care compared to 12.4% of internal medicine, and 36.5% of pediatric resident graduates. Qualitative themes found to positively influence cross-disciplinary collaboration included relationship development, communication of shared goals, alignment with health system/other institutional initiatives, and professional identity as primary care physicians. Challenges included expressed concerns by participants that by working together, the disciplines would experience a loss of identity and would be indistinguishable from one another. Another qualitative finding was that overwhelming stressors plague primary care training programs in the current health care climate-a great concern. These include competing demands, disruptive transitions, and lack of resources. CONCLUSIONS: Uniting the primary care disciplines toward educational and clinical transformation toward interprofessional collaborative practice is challenging to accomplish.

A Comparison of Residency Applications and Match Performance in 3-Year vs 4-Year Family Medicine Training Programs.

BACKGROUND AND OBJECTIVES: The optimal length of residency training in family medicine is under debate. This study compared applicant type, number of applicants, match positions filled, matched applicant type, and ranks to fill between 3-year (3YR) and 4-year (4YR) residencies. METHODS: The Length of Training Pilot (LOTP) is a case-control study comparing 3YR (seven residencies) and 4YR (six residencies) training models. We collected applicant and match data from LOTP programs from 2012 to 2018 and compared data between 3YR and 4YR programs. National data provided descriptive comparisons. An annual resident survey captured resident perspectives on training program selection. Summary statistics and corresponding t-tests and χ2 tests of independence were performed to assess differences between groups. We used a linear mixed model to account for repeated measures over time within programs. RESULTS: There were no differences in the mean number of US MD, US DO, and international medical graduate applicants between 3YR and 4YR programs. Both the 3YR and 4YR programs had a substantially higher number of US MD and DO applicants compared to national averages. The percentages of positions filled in the match and positions filled by US MDs, DOs and IMGs were not different between groups. The percentage of residents in 4YR programs who think training in family medicine requires a fourth year varied significantly during the study period, from 35% to 25% (P<.001). The predominant reasons for pursuing training in a 4YR program was a desire for more flexibility in training and a desire to learn additional skills beyond clinical skills. CONCLUSIONS: The applicant pool and match performance of the residencies in the LOTP was not affected by length of training. Questions yet to be addressed include length of training's impact on medical knowledge, scope of practice, and clinical preparedness.

Concerning trends in allopathic medical school faculty rank for Indigenous people: 2014-2016.

BACKGROUND: Trends in faculty rank according to racial and ethnic composition have not been reviewed in over a decade. OBJECTIVE:  To study trends in faculty rank according to racial and ethnicity with a specific focus on Indigenous faculty, which has been understudied. METHODS: Data from the Association of American Medical Colleges' Faculty Administrative Management Online User System was used to study trends in race/ethnicity faculty composition and rank between 2014 and 2016, which included information on 481,753 faculty members from 141 US allopathic medical schools. RESULTS: The majority of medical school faculty were White, 62.4% (n = 300,642). Asian composition represented 14.7% (n = 70,647). Hispanic, Latino, or of Spanish Origin; Multiple Race-Hispanic; Multiple Race-Non-Hispanic; and Black/African American faculty represented 2.2%, 2.3%, 3.0%, and 3.0%, respectively. Indigenous faculty members, defined as American Indian/Alaska Native (AIAN), Native Hawaiian or Other Pacific Islander (NHPI), represented the smallest percentage of faculty at 0.11% and 0.18%, respectively. White faculty predominated the full professor rank at 27.5% in 2016 with a slight decrease between 2014 and 2016. Indigenous faculty represented the lowest percent of full professor faculty at 5.2% in 2016 for AIAN faculty and a decline from 4.6% to 1.6% between 2014 and 2016 for NHPI faculty (p < 0.001). CONCLUSIONS: While US medical school faculty are becoming more racially and ethnically diverse, representation of AIAN faculty is not improving and is decreasing significantly among NHPI faculty. Little progress has been made in eliminating health disparities among Indigenous people. Diversifying the medical workforce could better meet the needs of communities that historically and currently experience a disproportionate disease burden.

Redesigning Residency Training: Summary Findings From the Preparing the Personal Physician for Practice (P4) Project.

BACKGROUND AND OBJECTIVES: The Preparing the Personal Physician for Practice (P4) project (2007 to 2014) involved a comparative case study of experiments conducted by 14 selected family medicine programs designed to evaluate new models of residency education that aligned with the patient-centered medical home (PCMH). Changes in length, structure, content, and location of training were studied. METHODS: We conducted both a critical review of P4 published Evaluation Center and site-specific papers and a qualitative narrative analysis of process reports compiled throughout the project. We mapped key findings from P4 to results obtained from a survey of program directors on their top 10 "need to know" areas in family medicine education. RESULTS: Collectively, 830 unique residents took part in P4, which explored 80 hypotheses regarding 44 innovations. To date, 39 papers have resulted from P4 work, with the P4 Evaluation Center producing 17 manuscripts and faculty at individual sites producing 22 manuscripts. P4 investigators delivered 21 presentations and faculty from P4 participating programs delivered 133 presentations at national meetings. For brevity, we present findings derived from the analyses of project findings according to the following categories: (1) how residency training aligned with PCMH; (2) educational redesign and assessment; (3) methods of financing new residency experiences; (4) length of training; (5) scope of practice; and (6) setting standards for conducting multisite educational research. CONCLUSIONS: The P4 project was a successful model for multisite graduate medical education research. Insights gained from the P4 project could help family medicine educators with future residency program redesign.

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.

Rural Curricular Guidelines Based on Practice Scope of Recent Residency Graduates Practicing in Small Communities.

BACKGROUND AND OBJECTIVES: The optimal curriculum for training family physicians for rural practice within a traditional urban-based residency is not defined. We used the scope of practice among recent family medicine graduates of residencies associated with Preparing the Personal Physician for Practice (P4), practicing in small communities, to identify rural curriculum components. METHODS: We surveyed graduates 18 months after residency between 2007 and 2014. The survey measured self-reported practice characteristics, including community size, and scope of practice. We compared the subgroups according to practice community size. RESULTS: Compared to graduates in larger communities, those practicing in small communities were more likely to report a broader scope of clinical practice including: adult hospital care (59% vs 35%), vaginal deliveries (23% vs 12%), C sections as primary surgeon (14% vs 5%) and assistant (21% vs 8%), newborn hospital care (45% vs 24%), and procedures such as endometrial biopsy (46% vs 33%), joint injections and aspirations (89% vs 79%), and fracture care (58% vs 42%). Graduates in small communities were also more often engaged in assessing community health needs (78% vs 64%) and developing community interventions (67% vs 51%) compared to graduates in larger communities. In contrast, graduates in small communities were less likely to have integrated behavioral health (26% vs 46%) and case management support (37% vs 52%). CONCLUSIONS: A rural practice curriculum should include training toward a broad medical scope of practice as well as skills in community-oriented primary care and integrated behavioral health.

Scope of Practice Among Recent Family Medicine Residency Graduates.

BACKGROUND AND OBJECTIVES: The scope of practice among primary care providers varies, and studies have shown that family physicians' scope may be shrinking. We studied the scope of practice among graduates of residencies associated with Preparing the Personal Physician for Practice (P4) and how length of training and individualized education innovations may influence scope. METHODS: We surveyed graduates 18 months after residency between 2008 and 2014. The survey measured self-reported practice characteristics, scope of practice and career satisfaction. We assessed scope using individual practice components (25 clinical activities, 30 procedures) and a scaled score (P4-SOP) that measured breadth of practice scope. We conducted subgroup analyses according to exposure to innovations over the project period and exposure to specific innovations. RESULTS: No significant differences were found in mean P4-SOP scores between the Pre and Full P4 groups. Compared to national data, P4 graduates reported higher rates for vaginal deliveries (19.3% vs 9.2%), adult inpatient care (48.5% vs 33.7%) and nursing home care (25.4 vs 11.7%) in practice. Graduates exposed to innovations that lengthened training, compared to standard training length, were more likely to include adult hospital care (58.2% vs 38.5%, P=0.002), adult ICU care (30.6% vs 19.2%, P=0.047) and newborn resuscitation (25.6% vs 14%, P=0.028) in their practice and performed 19/30 procedures at higher rates. Graduates of programs with individualized training innovations reported no significant differences in scope compared to graduates without this innovation. CONCLUSIONS: Graduates of residencies engaged in significant educational redesign report a broad scope of practice. Innovations around the length of training may broaden scope and individualized education appears not to constrict scope.

Factors Associated With Interest in Pursuing a Fourth Year of Family Medicine Residency Training.

BACKGROUND AND OBJECTIVES: The optimal length of residency training in family medicine, as with emergency medicine, is an ongoing debate due to several factors, but perceptions of graduating residents are missing from this debate. METHODS: We used data from 3,054 family medicine residents who registered for the American Board of Family Medicine certification examination in 2014. A practice demographic questionnaire was a mandatory component of registration. The survey included the question, "If another year of training were available in your residency program, how likely would you be to pursue that?" We examined several factors potentially associated with interest in additional training. RESULTS: The sample was predominantly female (53.9%), white (65.7%), and non-Hispanic (91.7%), with a mean age of 32.5 years. Overall, 52.8% of respondents reported being not at all likely to pursue additional training if available, 26.4% reported being somewhat likely, and 21.4% reported being moderately or extremely likely to do so. Male respondents were more likely than females to express no interest in an additional year of training (57.7% versus 48.1%). As educational debt increased, the likelihood of interest in additional training decreased. Anticipated practice settings, planned scope of practice, and intention to perform specific procedures also influenced interest in pursuing additional training. CONCLUSION: Slightly less than half of graduating family medicine residents expressed interest in a fourth year of training. Interest in a fourth year was associated with several characteristics that may help the discipline decide on the optimal length of training.

Team Training in Family Medicine Residency Programs and Its Impact on Team-Based Practice Post-Graduation.

OBJECTIVE: Our objective was to examine perceptions of adequacy in team-based care training during residency and whether this influences practice choice post- residency training. METHODS: We analyzed self-administered survey data from recent residency graduates collected as part of the Preparing Personal Physicians for Practice (P4) Project to characterize residents' perceptions of adequacy of training they received on team-based care. Multivariable logistic regression was used to assess the association between adequacy of team-based care training and joining practices that use team-based care after residency graduation, adjusting for differences in demographics. RESULTS: A total of 241 residency graduates were included in these analyses with response rates to surveys of 80.8%-98.1%. They reported practicing in 31 different US states or districts and four other countries. Over 82% of residency graduates reported being adequately trained in team-based care, 9.5% reported being overtrained, and 7.9% reported receiving no team-based care training over the study period. Seventy-six percent of P4 graduates joined practices that used team-based care in 2011, which increased to 86% (81/94) in 2013. The adjusted odds of practicing in settings with team-based care was 5.7 times higher for residents who reported being adequately prepared for team-based care compared to those who reported receiving no team-based care training and was 12.5 times higher for those who reported being over-prepared compared to those who reported no training/under-prepared. CONCLUSIONS: The majority of residency graduates perceive they were well trained in team-based care, which is significantly associated with joining practices that use team-based care post graduation.

Varied Rates of Implementation of Patient-Centered Medical Home Features and Residents' Perceptions of Their Importance Based on Practice Experience.

BACKGROUND AND OBJECTIVES: Little is known about how the patient-centered medical home (PCMH) is being implemented in residency practices. We describe both the trends in implementation of PCMH features and the influence that working with PCMH features has on resident attitudes toward their importance in 14 family medicine residencies associated with the P4 Project. METHODS: We assessed 24 residency continuity clinics annually between 2007-2011 on presence or absence of PCMH features. Annual resident surveys (n=690) assessed perceptions of importance of PCMH features using a 4-point scale (not at all important to very important). We used generalized estimating equations logistic regression to assess trends and ordinal-response proportional odds regression models to determine if resident ratings of importance were associated with working with those features during training. RESULTS: Implementation of electronic health record (EHR) features increased significantly from 2007-2011, such as email communication with patients (33% to 67%), preventive services registries (23% to 64%), chronic disease registries (63% to 82%), and population-based quality assurance (46% to 79%). Team-based care was the only process of care feature to change significantly (54% to 93%). Residents with any exposure to EHR-based features had higher odds of rating the features more important compared to those with no exposure. We observed consistently lower odds of the resident rating process of care features as more important with any exposure compared to no exposure. CONCLUSIONS: Residencies engaged in educational transformation were more successful in implementing EHR-based PCMH features, and exposure during training appears to positively influence resident ratings of importance, while exposure to process of care features are slower to implement with less influence on importance ratings.

Association Between Patient- Centered Medical Home Features and Satisfaction With Family Medicine Residency Training in the US.

BACKGROUND AND OBJECTIVES: Primary care residencies are undergoing dramatic changes because of changing health care systems and evolving demands for updated training models. We examined the relationships between residents' exposures to patient-centered medical home (PCMH) features in their assigned continuity clinics and their satisfaction with training. METHODS: Longitudinal surveys were collected annually from residents evaluating satisfaction with training using a 5-point Likert-type scale (1=very unsatisfied to 5=very satisfied) from 2007 through 2011, and the presence or absence of PCMH features were collected from 24 continuity clinics during the same time period. Odds ratios on residents' overall satisfaction were compared according to whether they had no exposure to PCMH features, some exposure (1-2 years), or full exposure (all 3 or more years). RESULTS: Fourteen programs and 690 unique residents provided data to this study. Resident satisfaction with training was highest with full exposure for integrated case management compared to no exposure, which occurred in 2010 (OR=2.85, 95% CI=1.40, 5.80). Resident satisfaction was consistently statistically lower with any or full exposure (versus none) to expanded clinic hours in 2007 and 2009 (eg, OR for some exposure in 2009 was 0.31 95% CI=0.19, 0.51, and OR for full exposure 0.28 95% CI=0.16, 0.49). Resident satisfaction for many electronic health record (EHR)-based features tended to be significantly lower with any exposure (some or full) versus no exposure over the study period. For example, the odds ratio for resident satisfaction was significantly lower with any exposure to electronic health records in continuity practice in 2008, 2009, and 2010 (OR for some exposure in 2008 was 0.36; 95% CI=0.19, 0.70, with comparable results in 2009, 2010). CONCLUSIONS: Resident satisfaction with training was inconsistently correlated with exposure to features of PCMH. No correlation between PCMH exposure and resident satisfaction was sustained over time.

The Importance of and the Complexities Associated With Measuring Continuity of Care During Resident Training: Possible Solutions Do Exist.

BACKGROUND AND OBJECTIVES: Evolutions in care delivery toward the patient-centered medical home have influenced important aspects of care continuity. Primary responsibility for a panel of continuity patients is a foundational requirement in family medicine residencies. In this paper we characterize challenges in measuring continuity of care in residency training in this new era of primary care. METHODS: We synthesized the literature and analyzed information from key informant interviews and group discussions with residency faculty and staff to identify the challenges and possible solutions for measuring continuity of care during family medicine training. We specifically focused on measuring interpersonal continuity at the patient level, resident level, and health care team level. RESULTS: Challenges identified in accurately measuring interpersonal continuity of care during residency training include: (1) variability in empanelment approaches for all patients, (2) scheduling complexity in different types of visits, (3) variability in ability to attain continuity counts at the level of the resident, and (4) shifting make-up of health care teams, especially in residency training. Possible solutions for each challenge are presented. Philosophical issues related to continuity are discussed, including whether true continuity can be achieved during residency training and whether qualitative rather than quantitative measures of continuity are better suited to residencies. CONCLUSIONS: Measuring continuity of care in residency training is challenging but possible, though improvements in precision and assessment of the comprehensive nature of the relationships are needed. Definitions of continuity during training and the role continuity measurement plays in residency need further study.