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.

The American Board of Family Medicine: New Tools to Assist Program Directors and Graduates Achieve Success.

In this commentary we review the improvements in the pass rates for first-time American Board of Family Medicine (ABFM) Certification Examination test takers in the context of new tools and resources for program directors against the backdrop of a changing accreditation system and increased competition for a relatively fixed number of graduate medical education positions in family medicine. While causality cannot be established between the strategic initiatives of the ABFM and higher pass rates, we can all celebrate the new tools and resources provided to residents and program directors, and the improved performance of family medicine graduates on the certification examination.

Residency Training in Family Medicine: A History of Innovation and Program Support.

BACKGROUND: Residency programs have been integral to the development, expansion and progression of family medicine as a discipline. Three reports formed the foundation for graduate medical education in family medicine: Meeting the Challenge of Family Practice, The Graduate Education of Physicians, and Health is a Community Affair. In addition, the original core concepts of comprehensiveness, coordination, continuity, and patient centeredness continue to serve as the foundation for residency training in family medicine. While the Residency Review Committee for Family Medicine of the Accreditation Council for Graduate Medical Education has provided the requirements for training throughout the years, key organizations including the Society of Teachers of Family Medicine, the American Academy of Family Physicians, the Association of Family Medicine Residency Directors, and the American Board of Family Medicine have provided resources for and supported innovation in programs. Residency Program Solutions, National Institute for Program Director Development, and Family Medicine Residency Curriculum Resource are several of the resources developed by these organizations. The future of family medicine residency training should continue the emphasis on innovation and development of resources to enhance the training of residents. Areas for further development include leadership and health care systems training that allows residents to assume leadership of multidisciplinary health care teams and increase focus on the family medicine practice population as the main unit for resident education.

Responses to Medical Students' Frequently Asked Questions About Family Medicine.

This article provides answers to many of the common questions that medical students ask about the specialty of family medicine. It describes the crucial role that family physicians have in the evolving health care environment, the scope of practice, the diverse career opportunities available, the education and training of family physicians, the economic realities of a career in family medicine, why the future is so bright for family medicine, and why family physicians are passionate about their work.

Program Director Participation in a Leadership and Management Skills Fellowship and Characteristics of Program Quality.

BACKGROUND AND OBJECTIVES: The association between a residency program director completing a leadership and management skills fellowship and characteristics of quality and innovation of his/her residency program has not been studied. Therefore, the aim of this study is to examine the association between a residency program director's completion of a specific fellowship addressing these skills (National Institute for Program Director Development or NIPDD) and characteristics of quality and innovation of the program they direct. METHODS: Using information from the American Academy of Family Physicians (AAFP), National Resident Matching Program (NRMP) and FREIDA® program characteristics were obtained. Descriptive statistics were used to summarize the data. The relationship between programs with a NIPDD graduate as director and program quality measures and indicators of innovation was analyzed using both chi square and logistic regression. RESULTS: Initial analyses showed significant associations between the NIPDD graduate status of a program director and regional location, mean years of program director tenure, and the program's 5-year aggregate ABFM board pass rate from 2007--2011. After grouping the programs into tertiles, the regression model showed significant positive associations with programs offering international experiences and being a NIPDD graduate. CONCLUSIONS: Program director participation in a fellowship addressing leadership and management skills (ie, NIPDD) was found to be associated with higher pass rates of new graduates on a Board certification examination and predictive of programs being in the upper tertile of programs in terms of Board pass rates.

Transforming Training to Build the Family Physician Workforce Our Country Needs.

BACKGROUND AND OBJECTIVES: The Affordable Care Act has spurred significant change in the US health care system, including expansion of Medicaid and private insurance coverage to millions of Americans. As a result, the need for the medical education continuum to produce a family physician workforce that is sizable enough and highly skilled is significant. These two interdependent goals have emerged as top priorities for Family Medicine for America's Health, a new, 5-year, $21 million collaborative strategic effort of the eight US family medicine organizations to lead continued change in the US health care system. To achieve these important goals, reforms are needed across the entire educational continuum, including how we recruit, train, and help practicing family physicians refresh their skills. Such reforms must provide opportunities to acquire skills needed in new practice and payment environments, to incorporate new educational standards that reflect the public's expectations of family physicians, to collaborate with our primary care colleagues to develop effective interprofessional training, and to design educational programs that are socially accountable to the patients, families, and communities we serve. Through Family Medicine for America's Health, the discipline is well positioned to emerge as a leader in primary care workforce development and educational quality.

Five Key Leadership Actions Needed to Redesign Family Medicine Residencies.

BACKGROUND: New skills are needed to properly prepare the next generation of physicians and health professionals to practice in medical homes. Transforming residency training to address these new skills requires strong leadership. OBJECTIVE: We sought to increase the understanding of leadership skills useful in residency programs that plan to undertake meaningful change. METHODS: The Preparing the Personal Physician for Practice (P4) project (2007-2014) was a comparative case study of 14 family medicine residencies that engaged in innovative training redesign, including altering the scope, content, sequence, length, and location of training to align resident education with requirements of the patient-centered medical home. In 2012, each P4 residency team submitted a final summary report of innovations implemented, overall insights, and dissemination activities during the study. Six investigators conducted independent narrative analyses of these reports. A consensus meeting held in September 2012 was used to identify key leadership actions associated with successful educational redesign. RESULTS: Five leadership actions were associated with successful implementation of innovations and residency transformation: (1) manage change; (2) develop financial acumen; (3) adapt best evidence educational strategies to the local environment; (4) create and sustain a vision that engages stakeholders; and (5) demonstrate courage and resilience. CONCLUSIONS: Residency programs are expected to change to better prepare their graduates for a changing delivery system. Insights about effective leadership skills can provide guidance for faculty to develop the skills needed to face practical realities while guiding transformation.

Transforming primary care residency training: a collaborative faculty development initiative among family medicine, internal medicine, and pediatric residencies.

PROBLEM: The scope and scale of developments in health care redesign have not been sufficiently adopted in primary care residency programs. APPROACH: The interdisciplinary Primary Care Faculty Development Initiative was created to teach faculty how to accelerate revisions in primary care residency training. The program focused on skill development in teamwork, change management, leadership, population management, clinical microsystems, and competency assessment. The 2013 pilot program involved 36 family medicine, internal medicine, and pediatric faculty members from 12 residencies in four locations. OUTCOMES: The percentage of participants rating intention to implement what was learned as "very likely to" or "absolutely will" was 16/32 (50%) for leadership, 24/33 (72.7%) for change management, 23/33 (69.7%) for systems thinking, 25/32 (75.8%) for population management, 28/33 (84.9%) for teamwork, 29/33 (87.8%) for competency assessment, and 30/31 (96.7%) for patient centeredness.Content analysis revealed five key themes: leadership skills are key drivers of change, but program faculty face big challenges in changing culture and engaging stakeholders; access to data from electronic health records for population management is a universal challenge; readiness to change varies among the three disciplines and among residencies within each discipline; focusing on patients and their needs galvanizes collaborative efforts across disciplines and within residencies; and collaboration among disciplines to develop and use shared measures of residency programs and learner outcomes can guide and inspire program changes and urgently needed educational research. NEXT STEPS: Revise and reevaluate this rapidly evolving program toward widespread engagement with family medicine, internal medicine, and pediatric residencies.

Health is primary: Family medicine for America's health.

PURPOSE: More than a decade ago the American Academy of Family Physicians, American Academy of Family Physicians Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine came together in the Future of Family Medicine (FFM) to launch a series of strategic efforts to "renew the specialty to meet the needs of people and society," some of which bore important fruit. Family Medicine for America's Health was launched in 2013 to revisit the role of family medicine in view of these changes and to position family medicine with new strategic and communication plans to create better health, better health care, and lower cost for patients and communities (the Triple Aim). METHODS: Family Medicine for America's Health was preceded and guided by the development of a family physician role definition. A consulting group facilitated systematic strategic plan development over 9 months that included key informant interviews, formal stakeholder surveys, future scenario testing, a retreat for family medicine organizations and stakeholder representatives to review strategy options, further strategy refinement, and finally a formal strategic plan with draft tactics and design for an implementation plan. A second communications consulting group surveyed diverse stakeholders in coordination with strategic planning to develop a communication plan. The American College of Osteopathic Family Physicians joined the effort, and students, residents, and young physicians were included. RESULTS: The core strategies identified include working to ensure broad access to sustained, primary care relationships; accountability for increasing primary care value in terms of cost and quality; a commitment to helping reduce health care disparities; moving to comprehensive payment and away from fee-for-service; transformation of training; technology to support effective care; improving research underpinning primary care; and actively engaging patients, policy makers, and payers to develop an understanding of the value of primary care. The communications plan, called Health is Primary, will complement these strategies. Eight family medicine organizations have pledged nearly $20 million and committed representatives to a multiyear implementation team that will coordinate these plans in a much more systematic way than occurred with FFM. CONCLUSIONS: Family Medicine for America's Health is a new commitment by 8 family medicine organizations to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim. It is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective.

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.

Resident time in continuity practice.

BACKGROUND AND OBJECTIVES: Family medicine residents are required to maintain a continuity practice in an approved family medicine center (FMC) and achieve minimum targets for patient encounters. In the past, minimum periods of time in the FMC were defined in the program requirements, but these have now been replaced with target numbers of patient encounters. As residency programs come under increasing pressure to address service needs on patient care services, some program directors face requests by hospital administration to benchmark their requirements for resident schedules in the FMC against national standards. Since no such standards presently exist, the authors decided to determine the average frequency with which residents are currently scheduled in their FMC continuity practices in order to meet accreditation requirements. METHODS: Using the data set from the 2011 American Academy of Family Physicians (AAFP) annual residency census and residency directory questionnaire, the frequency of reported resident scheduling in the FMC continuity practice was extracted. Although the census itself achieves a 100% response rate, not all programs respond to all of the residency directory questions. In this case, for reported time in the FMC, an 84% (380 out of 450 programs) response rate was achieved. RESULTS: Family medicine residency programs currently schedule residents in their FMC continuity practice substantially more often than previously required. CONCLUSIONS: To meet current accreditation requirements, family medicine residency programs schedule residents in their FMC continuity practices more than previously required minimums.

Residency program solutions: making a difference in quality residency education.

BACKGROUND: Residency Program Solutions (RPS) consultants assist family medicine residency programs in solving issues perceived as limiting quality resident education. Residencies ask RPS to assist in preparing for accreditation site visits by the Residency Review Committee-Family Medicine (RC-FM). The RPS Criteria for Excellence in Family Medicine Education (RPS Criteria) may have influenced the accreditation standards of the RC-FM. RPS consultations also may affect accreditation visit cycle length and number of RC-FM citations. METHODS: The authors reviewed the RC-FM Program Requirements for Family Medicine Residency Education and the RPS Criteria from 1978 to 2007, comparing statements between the two documents for "nearly verbatim" and equivalent "must" or "should" requirements. The average number of citations and cycle length for programs seeking a Comprehensive Accreditation Program (CAP) Consultation from 2004--2010 were compared to cohort programs evaluated at the same RC-FM meeting using an independent samples t test. RESULTS: The strongest relationship between the RC-FM requirements and the RPS criteria occurred in 1983--1984. Nine "nearly verbatim" statements, 15 "must-should" or "must-must" statements, and 11 "should-should" statements existed. Over time, additional concurrences between organizational statements occurred. Residency programs with CAP consultations benefited significantly by both a decrease in number of citations and an increase in the length of accreditation cycle. CONCLUSIONS: The RPS Criteria have positively impacted iterations of RC-FM requirements. Family medicine residency programs concerned about successful accreditation by the RC-FM will likely benefit from RPS CAP consultations by increased length of accreditation cycle and/or a decreased number of citations.

A sustainable family medicine academic workforce: a study of Pennsylvania residency faculty.

BACKGROUND AND OBJECTIVES: This study determined the demographic and practice characteristics of current Pennsylvania family medicine residency faculty. METHODS: Surveys were sent electronically to program directors to distribute to their faculty members. Participants were surveyed for age, race, gender, current and completed residency training program, fellowship completion, practice track, and current practice characteristics. RESULTS: Survey response rate represented 35.3% of residency faculty in Pennsylvania. The majority represented full-time faculty (83.7%), were male (53.8%), were Caucasian (84.8%), did not enter their faculty position following residency (65.9%), had completed their residency training in Pennsylvania (57.9%), and did not complete a fellowship. While most faculty have continued inpatient and outpatient care, less than half participate in other surveyed elements of comprehensive family medicine care. CONCLUSIONS: The environment within academic family medicine and changing cultures have created a shift that the future of academic practice may need to depend on new graduates. Current demographics suggest a poorly diverse faculty with private practice experience and limited full-spectrum mentors that may have contributed to family medicine's difficulties within the academic marketplace. Creating a strong primary care workforce demands ensuring a sustainable faculty.

Faculty development needs in residency redesign for practice in patient-centered medical homes: a P4 report.

OBJECTIVES: The study's objective was to describe faculty development skills needed for residency redesign in 14 family medicine residencies associated with the Preparing the Personal Physician for Practice (P4) project. METHODS: We used self-administered surveys to assess ratings of existing faculty development efforts and resident attitudes about faculty teaching between 2007 and 2011. Telephone interviews were conducted to assess faculty development activities and needs at baseline. Early project faculty development needs were addressed using tailored sessions delivered during site visits. We conducted a detailed content analysis of 14 site-specific comprehensive reports to characterize ongoing faculty development needs and faculty themes related to residency redesign. RESULTS: Early in the P4 project, faculty needs included skills in using the electronic health record (EHR) in teaching, change management, curriculum design, evaluation, learning portfolios and individualized learning plans, career coaching, qualitative research, competency-based assessment, and leadership. As the project progressed, the need for a "learning together" approach when training residents in transformed practices emerged. Using the EHR more effectively, evaluation and competency-based assessment skills, individualized curriculum design, better career coaching skills, shared leadership, and team-based care skills were consistent faculty development needs. Redesign strategies included having a committed core faculty group, faculty retreats, curricular change process management, intra-residency collaboration, and providing adequate support for key individuals. CONCLUSIONS: Faculty attempting to redesign residencies to train residents in patient-centered medical homes need new skills, and understanding these needs can inform faculty development programs nationally to achieve the crucial mission of training the workforce to accomplish this transformation.

Results of the 2011 National Resident Matching Program: family medicine.

The results of the 2011 National Resident Matching Program (NRMP) reflect another small but promising increased level of student interest in family medicine residency training in the United States. Compared with the 2010 Match, family medicine residency programs filled 172 more positions (with 133 more US seniors) through the NRMP in 2011. In other primary care fields, 26 more primary care internal medicine positions filled (10 more US seniors), one more position in pediatrics-primary care (two fewer US seniors), and seven more positions in internal medicine-pediatrics programs (10 more US seniors). The 2011 NRMP results suggest a small increase in choosing primary care careers for the second year in a row; however, students continue to show an overall preference for subspecialty careers. Multiple forces continue to influence medical student career choices. Despite matching the highest number of US seniors into family medicine residencies since 2002, the production of family physicians remains insufficient to meet the current and anticipated need to support the nation's primary care infrastructure.

Entry of US medical school graduates into family medicine residencies: 2010-2011 and 3-year summary.

This is the 30th report prepared by the American Academy of Family Physicians (AAFP) on the percentage of each US medical school's graduates entering family medicine residency programs. This retrospective analysis based on data reported to the AAFP from medical schools and family medicine residency programs shows approximately 8.0% of the 17,081 graduates of US medical schools between July 2009 and June 2010 were first-year family medicine residents in 2010, compared to 7.5% in 2009 and 8.2% in 2008. Medical school graduates from publicly funded medical schools were more likely to be first-year family medicine residents in October 2010 than were residents from privately funded schools (9.6% versus 5.4%). The Mountain and West North Central regions reported the highest percentage of medical school graduates who were first-year residents in family medicine programs in October 2010 (14.3% and 11.3%, respectively); the New England and Middle Atlantic regions reported the lowest percentages (5.6% and 5.3%, respectively). Approximately four in 10 of the medical school graduates (40.3%) entering a family medicine residency program as first-year residents entered a program in the same state where they graduated from medical school. The percentages for each medical school have varied substantially from year to year since the AAFP began reporting this information. This article reports the 3-year average percentage from each medical school of graduates entering family medicine residencies and the number and percentage of graduates from colleges of osteopathic medicine who entered Accreditation Council for Graduate Medical Education-accredited family medicine residency programs in 2010.