One more year? - Family Medicine Residency Training

A few weeks ago, the American Board of Family Medicine was approved to sponsor a pilot of 4-year family medicine residency programs. Leaders in family medicine organizations have been exploring moving family medicine training to 4 years for some time and, starting in July 2013, programs that apply and are accepted will have the opportunity to offer 4 years of residency.

Why this change now? In the 2011, for the second consecutive year in more than a decade, more students are choosing to enter family medicine (1). When this debate started, interest in family medicine had reached an all time low (2). Is this debate to extend residency training now irrelevant with re-emerging student interest? I would argue not. As organizations and leaders in family medicine, our goal is not primarily to promote our specialty but to best serve our patients and their health. So our question then is does a 4-year family medicine residency better serve our patients balancing quality of the physicians trained with the number of physicians and access to those physicians?

To date, only one family medicine residency program has moved to a mandatory 4-year curriculum. As part of the P4 innovation program, Middlesex FMR (in CT) switched in 2006 to a 4 year program and have found, based on preliminary results, that student application rates to the residency have increased, clinical outcomes from the clinic have improved, resident satisfaction rate has improved and financial success of the clinic has been enhanced (3). Other P4 programs have offered optional 4 year tracks but the number of residents who have selected these tracks to date has been too small to appropriately report results. Outside of the P4 programs, Oregon Health and Sciences University plans to move to a 4 year curriculum starting this July (4).

Proponents of the 4-year family medicine residency model advance multiple benefits of the additional year of training:

• Increasing complexity of health care:  Today's family physicians enter into an increasing complex medical system with increasing complex health needs. The average person is living longer with more chronic diseases and learning how to care for these problems will require more training. The scope of family physicians has been decreasing in recent years (5) and for residency graduates to feel confident in practicing comprehensive care, additional training would be beneficial. Furthermore, not only is the science of medicine growing more complex but the art of medicine is also expanding. Today's family physician must be trained in practice management/transformation, quality improvement, research, leadership skills, cultural competency and more - all of which currently sit on the back burner with so many competing medical curricular items.
• Potential for flexibility: A 4th year allows for more elective time and allows for residents to develop an "Area of Concentration." This could potentially reduce the need for fellowship training and reduce the artificial transition between residency and fellowship.
• New work rules: New work rules implemented in July 2011 again effectively reduce residency work hours and reduce residents' experience and training.
• Decreased preparation of interns: Many of suggested that today's interns are less prepared than those of a decade ago. Because of wide range of issues, an incoming resident today is less likely to have had adequate hands-on training.

There are significant concerns that need to be addressed though before family medicine dives headlong into 4 year residency training:

• Student interest: while I dismissed student interest earlier in favor of patient value, it remains an important issue. I brought this issue up at a recent AAFP commission meeting and it was suggested that I was being impertinent for considering the specialty's numbers above the needs of the nation's health needs. In reality though, it doesn't do any good if we have great training programs if we don't have any students and residents to fill those training programs. Family medicine leaders points to numbers that show that each year a growing number of students, residents and faculty support 4 year training programs. However, this number remains a minority (<50%) and the fact is a growing minority is still a minority whether or not it is growing.
• Law of diminishing returns: I learned this concept in health economics where I learned that more is not always better. Yes, an additional year of training is generally always better but what about a 5th year of training? Or a 6th? Each progressive year can add something in training and comprehesiveness but what we gain may not balance out the other disadvantages. Our northern neighbour, Canada, does FM residency training in 2 years - is there something we're missing?
• Workforce challenges: Will adding a year of training exacerbate workforce issues? First, there's the issue already discussed of student interest. But we also need to consider that there will be a transitional period when we are producing fewer residents because they are in training longer. Furthermore, there is the question of whether existing programs will accept smaller classes to accommodate the increased number of residents present overall. For example, Middlesex, the only 4-year program to date, went from being a 8-8-8 program to a 6-6-6-6 program.
• Logistical challenges - can residency programs get funding and accreditation?

I don't know if we should move to mandatory 4-year residency training in family medicine. Personally, as a medical student currently in the residency application process, I am seriously considering programs that offer 4 year training. But, I believe that serious and open-minded discussions and research must take place to decide if this is the best move for our specialty and, more importantly, for our patients. Discussions must take place with all stakeholders (family medicine organizations, faculty, residents, students and the general community/people we serve) and pilot projects with exemplary research methodology must take place. We have reached an important juncture and what we decide now may have significant reverberations for our patients and their health.

(1) AAFP News Today. 2011 Match Results Again Spotlight Family Medicine Gains. March 17, 2011.
(2) Saultz JW. Is it time for a 4-year family medicine residency? Family Medicine 2004;36(5):363-6.
(3) Douglass AB et al. Implementation and Preliminary Outcomes of the Nation's First Comprehensive 4-year Residency in Family Medicine. Family Medicine 2011;43(7):510-3.
(4) OHSU Family Medicine Residency Program. Website
(5) Upcoming JABFM policy brief series on care for children, maternity care and care for women's health by family physicians.

Too Many Docs in the Kitchen? Careful Redundancy or Unnecessary Overcomplication?

I have just had the privilege of sitting in on a Patient Centered Medical Home meeting for the family medicine practice with which I am currently rotating. As I sat around with 16 health providers over the course of a 90 minute conference, two conflicting thoughts struck me:

1) Isn't it GREAT that we are able to have this coalescence for the good of patient care?
2) Is it really beneficial to have all these people in on the conversation?

I quickly did the rough mental math on 16 providers spending 90 minutes in a conference. It is certainly costly, and it additionally takes away from what could be a full 24 hours of one-on-one patient care.

The goal of this particular meeting was to analyze and discuss patients that are on the high end of the cost curve - those that are outliers in terms of readmission rates, ER visits, and other concerns of overutilization. From a cost-reduction and care standpoint, this was likely a productive meeting. Less than a dozen patients were targeted and discussed over the course of the 90 minute session. For those patients, the value for the extra time and concern for there care is immeasurable.

Simultaneously, I believe there was another current at work here - the adherence to the vision of the team-oriented approach in the Medical Home model. Bringing these providers together in one room allowed for a team-oriented discussion. However, at the same time, I witnessed a majority of bored faces, yawns, and disinterest. One person spoke at a time and, it seemed, the rest were more or less varyingly engaged.

Yet the box was checked. The meeting was held. But was the value and vision of the PCMH met?

Bringing 16 providers into a room sounds great. Then, why not make it 20, or 30, or 50 at a time? At what point do we sacrifice the general good of overarching patient care, to take the time to "check the box".

These are just some thoughts that crept through my mind over the course of this afternoon. My only intention in my criticism is in the opportunity for self-reflection and advancement. Ultimately, I am certain this model is far superior to the isolated islands of care of yesteryear, most prominently for the dozen or so patients discussed.

Are we truly moving forward or are we just taking baby steps while posturing?

Life as a Family Medicine Intern and Social Media Burnout

Rewind to November.

This blog had its best month ever, getting almost 4000 hits with several recent posts generating buzz.  Promotion of the blog was at its tipping point - it would either explode or continue on in its current state. 

Along came my month in ICU, an intern without a senior resident managing a census that not many of my peers have had during their ICU experience.  With this we bring in the idea of new work hour rules for interns, working 6 days per week, 12-16 hours per shift, 8-12 hours off between with a 24 hour hiatus known as a day off.  One day during the rotation I checked out my Klout score to notice that it had plummeted many points.  I also checked out the blog to notice that there were no new posts and that traffic dipped by about half.  And oh, by the way, my twitter account had my auto-generated #FMRevolution news daily as its only tweets for at least 15 days.  Several months prior to this I probably would have went into manic mode to try and recover from lost involvement in the health care and social media community.  Instead, I took a deep breath in and thought about how much I did not want to put energy into social media.  What was going on?

Next up was a month on night float: midnight to noon, 6 nights per week over the holiday break and through the New Year.  At my residency program, night float consists of an intern and senior along with another upper year resident on-call: 3 residents to cover codes, ICU, med/surg ward, ER admissions, and OB.  There were plenty of times that we were not busy though I knew social media involvement at the early hours in the morning was not going to be very effective, especially when I would be sleeping during the times at which my involvement could possibly make a difference.  I did not want to admit it and was in denial the entire time over it.  "Burnout" was not something in my vocabulary.  I could not bring myself to admit that I was burnt out from all my involvement in social media.

Well, after much debate and trying to figure out how to say it, here it is: I am officially burnt out from social media.  Is it intern year?  Is it everything I am involved with within my residency program and/or nationally with the AAFP?  Were my expectations too high in the current stage of my medical career?  Was I expecting more and not seeing the results I was hoping for?  These are just some of the questions I have yet to find the exact answers for.  

We learn all about life balance and making sure to have good skills in time management.  Is it possible to balance everything that goes into being an intern and be effective with social media?  

Over the next month I am setting a few goals that I will hopefully be able to achieve given that I have finally admitted to my social media burnout.

1. I am going to write one blog post within the month and try to generate more posts from other authors on the blog.
2. I will find one interesting article published in the news within the past 24 hours about family medicine or primary care and tweet this article at some point every day.
3. I will participate in one twitter chat this month, topic TBD (#mdchat, #hcsm, #meded?)

It will be interesting to see how this goes.  Hopefully I will be able to figure out a good balancing act to make it work!