Tuesday, March 20, 2012

The 2012 Family Medicine Match Results - Future of Family Medicine Match Day Coverage

Match Day is once again upon the world of medicine, and we are eager to outline and track updates to 2012 match results for Family Medicine. While the Family Medicine Match continues to increase for the 3rd year in a row, gains in the number of positions filled and the percentage fill rate are marginal this year.

NRMP Match Results: 2,611 of 2,764 Family Medicine PGY-1 positions were filled in the match, making for a 94.5% fill rate, which is 0.1% higher than last year's 94.4% match rate when 2,576 of the 2,730 available positions were filled. 48.3% of PGY-1 spots were filled by US medical graduates, marking a 0.1% increase from 2011.
2000-2012 NRMP Family Medicine Match Results (Source: AAFP)

Regarding the NRMP match, AAFP President Glen Stream commented in the AAFP News Now:
"Family medicine's 2012 Match numbers barely increased from 2011 numbers and certainly did not indicate enough growth in the specialty to keep up with America's increasing demand for family physicians. Family medicine is the foundation of improved health care in this country. We must continue to promote programs that generate and sustain student interest in the specialty."

The AAFP president identifies several priorities that need to be addressed to increase the family medicine match and ultimately sustain (and hopefully increase) access to health care services  across the nation: "Several things need to happen, including narrowing the income gap between primary care and other physician specialists, reforming the medical education infrastructure, changing the system that funds graduate medical education, and increasing support for programs such as the National Health Service Corps and health professions training programs."

Also read AAFP News Now coverage of Match Day at: Family Medicine Match Rate Increases Slightly.

The Osteopathic Match: Family medicine continues to be the largest matched specialty among osteopathic medical students which announced the results of the 2012 osteopathic match in mid-February. Family medicine saw a 16% increase from last year, and was the largest matched specialty with 433 positions filled. Last year family medicine also was the largest matched specialty with 373 positions filled. This represents an increase of 60 spots for 2012.

Last years family medicine match results: 2,576 family medicine positions were filled out of 2,730: a fill rate of 94.4% - impressive when taking into account that 100 more positions were available for family medicine vs. 2010. Of the 2,576 candidates who selected family medicine, 1,317 of them were U.S. medical school graduates - this as a result of 133 more US Grads choosing family medicine, or an increase of 8.4% in 2011.

See www.aafp.org/match for more detailed match analysis. Follow AAFP detailed analyses at: http://www.aafp.org/online/en/home/residents/match/summary.html also!

Saturday, March 10, 2012

Motivational Interviewing - a core competency or an elective skill?

This past Thursday, I attended a seminar on motivational interviewing. After 3.5 years of medical school focused primarily on the science of medicine, it was a refreshing change. As I progress through medical school, I've been increasingly frustrated by my inability to influence behavior changes in patients - most, if not all, of my patients know that smoking is bad, that fast foods lead to obesity, that exercise can help prevent cardiac disease... the list goes on. As clinicians, we sound like a droning tape recorder when we ask (once again) if our patients are exercising (they're not), if they're still drinking (they are) and if they're still smoking (they're still doing that too).

I've spent countless hours learning about things like Kreb's cycle, IL-1, APO-B and Fabry's Disease, all of which I am unlikely to ever use in my professional career. But, in my medical school training, I have not had a single hour devoted to behavioral change in patients.

Motivational interviewing is "a collaborative, person-centered form of guiding to elicit and strengthen motivation for change." It is a method of empowering our patients to take responsibility for their health and accompanying them on the journey towards that change. It is a method that views each patient as a person with a story and a background and not as the "diabetic in room 2" or "the non-compliant patient."

OARS is often used as an acronym in approaching motivational interviewing:
  • Open-ended questions
  • Affirmation
  • Reflection
  • Summarizing
Science tells us that prevention decreases morbidity, increases quality of life and decreases cost. Motivational interviewing provides a systematic approach to prevention.

To better serve our patients, medical schools and residencies across the country need to focus more on teaching the art of medicine, which includes behavioral change methods. Strategies like motivational interviewing should be listed as core clinical competencies and students need to be evaluated on these skills in addition to their clinical knowledge. Learning medicine is daunting - the continuously increasing body of knowledge requires that schools pick and choose what they can teach. But if schools continue to focus on teaching the science of medicine at the expense of the art of medicine, it can only be to the detriment of those we aim to serve.

Motivational Interviewing Resources:
"A 'Stages of Change' Approach to Helping Patients Change Behavior." http://www.aafp.org/afp/2000/0301/p1409.html

Saturday, March 3, 2012

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.