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.

"Have you thought about med-peds?"

It is not uncommon for medical students who express interest in primary care to be asked: "have you thought about med-peds?" Not only are these programs popular for medical students but, over the past decade or two, there has also been a plethora of new and expanding med-peds programs. So, you may ask, what exactly is a med-peds program? An internal medicine-pediatrics combined residency program is a 4-year long program with 2 years spent doing pediatrics and 2 years spent doing internal medicine with the end result that residency graduates are board eligible for both pediatrics and internal medicine.

These programs have become increasingly popular with US medical students. In 2011, there were 77 med-peds programs in the US with 365 slots of which 84.7% were filled by US medical graduates. In contrast, there were 453 family medicine programs in the US with 2708 slots of which 48.0% were filled by US medical graduates (1).

Sounds great, right? Isn't this the new solution for primary care?

Well, there are several problems with this point of view:

1. Only approximately 50% of med-peds graduates end up practicing primary care (2). The other residency graduates end up entering internal med or pediatric fellowships to sub-specialize.
   
2. FM residents spend significantly more time in outpatient primary care work than med-peds residents during residency training. As a result, FM residents become more confident in outpatient work and are more likely to practice primary care when they leave residency.
   
3. Family medicine residency training encompasses (in most cases) a holistic perspective of families, looking at children, pregnant women and adults together. There may be specific adult and pediatric medicine rotations but these are more or less integrated into a holistic training vision. Meanwhile, med-peds residents spend 50% of their time with the peds dept and 50% of their time with the internal medicine dept. If not done appropriately, this training has the potential to become fragmented.
4. Med-peds doctors are not trained in maternity care or surgical care. Okay - I realize most family docs don't end up doing maternity or surgical care anyways but the training helps keep the broader, comprehensive perspective in mind, makes family docs more competent in basic procedures, and makes family docs a better fit in rural areas where they may be the only doctor.
   

Med-peds as residency training programs and as a specialty have existed for decades now and do serve important roles in patient care. For example, those with chronic diseases diagnosed with childhood, such as cystic fibrosis or congenital heart disease, can often be best served by a med-peds subspecialist who can bridge the continuity gap often found between the pediatric specialist and the adult specialist. Furthermore, students unsure if they want to practice primary care or subspecialize often choose med-peds. Med-peds programs are also appropriate for students who are interested in primary care but want to spend a significant portion of their time providing care to children (the argument being that med-peds residents spend 50% doing pediatrics while FM residents spend significantly less time... although this can be changed by pediatric tracks or electives depending on the program).

I argue not that med-peds doctors cannot do primary care. I only ask that before diving straight into med-peds, students consider the pros and cons of the two specialties and honestly evaluate what type of training they are seeking from residency and what they want to practice in the future. If your school doesn't have a family medicine rotation or has a weak family medicine presence, seek out an elective at another school to see how family medicine is practiced elsewhere in the country.

With its holistic and comprehensive vision of caring for patients, family medicine is naturally the specialty for primary care. Is med-peds also? With only 50% of med-peds grads vs. virtually all FM grads choosing to practice primary care, it doesn't quite seem so.

The real question then is: "have you thought about family medicine?"

(1) National Resident Matching Program. "Results and Data. 2011 Main Residency Match." www.nrmp.org
(2) Freed GL, Fant KE, Nahra TA, Wheeler JR. Internal medicine-pediatrics physicians: their care of children versus care of adults. Academic Medicine. 2005;80:858-64.

Redesigning Residency... the pilots

12 + 4 + 4 + 3 = 23 years. From grade school through college and medical school to residency, that's how long it takes to become a family medicine doctor right now. How about changing the 3 at the end to a 4? Asking that question to various classmates interested in family medicine, I've received a range of answers from "WHAT! No way!" to "ah, 1 more year, what's that in the long scheme of things?" to "That's a great idea!"

A 4 year residency program is just one of the 14 different innovations considered by the P4 project (Preparing the Personal Physician for Practice). P4 is a 6-year pilot project started in 2007 in which 14 family medicine residencies across the country are participating. These residency programs range from university-based to community-based and urban to rural. Each residency program is experimenting with some new innovation to improve family medicine training with the goal of preparing residents with real life skills for practice.

Okay - great, so let's get down to the nitty gritty. What are these innovations that are being considered? As I first mentioned, a number of programs are experimenting with either a mandatory or an optional fourth year of training. These programs generally encourage or require residents to choose a "track" or a "focus" that is either incorporated throughout the four years or is focused upon during the fourth year. For example, Middlesex FMRP in Connecticut requires each resident to complete four years while JPS in Texas and Waukesha in Wisconsin have optional 4th year tracks.

Tufts, on the other hand, is focusing on training its residents predominantly in the outpatient setting, since that's where the majority of family medicine actually practice. Meanwhile, University of Colorado is focusing explicitly on teaching its family medicine residents about the Patient Centered Medical Home. University of Missouri-Columbia is allowing 4th year students at its school who are decided on family medicine to start intern-like rotations, because, honestly speaking, the 4th year of medical school (unless really intentionally designed not to be by self-motivation) is generally speaking a waste of time. That's just to name a few of the 14 innovations (not selected by any favoritism but randomly).

We are now more than half way through the 6 year innovation period. The question is then: what are we doing with this P4 information? Do we want all family medicine programs to be 4 years long? Or do we want to start eliminating the 4th year of medical school? Or do we want to be more intentional about where are residents are training and what they are learning?

These are all questions that are being studied and analyzed. This month's issue of Family Medicine, STFM's academic peer-reviewed journal, focuses specifically on these questions. As we approach another RC review (the committee that determines residency guidelines), what changes do we want to make as the future of family medicine so that we can better train physicians to be prepared to serve their future patients? Better yet, what can we as family physicians do to advocate to the ACGME and to the American public about the needs of family medicine training?

GME Funding for Family Medicine Residencies Must Be Preserved.. Now!

In a letter from the ACGME to the American Board of Medical Specialties, American Hospital Association, American Medical Association, Association of American Medical Colleges, and Council of Medical Specialty Societies, the ACGME warns of consequences that could occur due to proposed cuts in Medicare Graduate Medical Education (GME) funding. GME funding is the main source of financial stability for residency programs that train this country's medical interns and residents - the pipeline of production for physicians.

These cuts would threaten:

• The availability of residency positions to produce new physicians
• Access to care for the Medicare population
• Access to care for the underserved, underinsured, and uninsured
• Community-based primary care residency programs which produce primary care physicians that typically serve in rural and other underserved areas
• The distribution of primary care residency slots in multi-specialty institutions towards more lucrative sub-specialty training which reimburse the institution more for procedural rather than preventive care
• Residency training in general with the possibility of support from industry (insurance companies, pharma, etc) and/or implementation of tuition for residency training
• Entering clinical practice after one year of internship to repay student debt resulting in the undereducation of practicing physicians

The Association of American Medical Colleges provides a variety of resources explaining the importance of GME funding, including their advocacy to increase the amount of funding for GME in order to prevent/slow down a shortage of physicians. This includes a letter to President Obama sent on 5 July 2011 urging the President to preserve GME funding.

The American Association of Colleges of Osteopathic Medicine took it a step further by initiating a member-driven action alert. This alert allows members and non-members to submit emails and letters to their representatives in an effort to generate more than the usual auto-generated email response from our elected officials.  The AACOM also submitted a joint letter with the American Osteopathic Association to Congress opposing cuts to GME.

The American Academy of Family Physicians focus in on primary care, asking its members to take action on its Speak Out Grassroots Advocacy site by contacting legislators to specifically preserve primary care.

"The deficit reduction conversations continue. Lawmakers are re-thinking Medicare’s Graduate Medical Education (GME), and at this critical time, they should be reminded of primary care’s importance. Our representatives have an opportunity to change this program so that it encourages the innovations in primary care training that will help build a workforce our communities can count on."

So, where is the American Medical Association and the American Academy of Pediatrics?

Currently on the homepage of the AMA, they are worrying about the Independent Payment Advisory Board (IPAB) as well as a decrease in Medicare payments for diagnostic imaging.   It seems like CMS is starting to do the work that the RUC should be doing to decrease overvalued services?  Apparently this is more important than worrying about cuts to GME.  The AAP does not seem to be worrying about much of anything.  The ACP has submitted a letter to the President and Congress urging for a debt ceiling agreement which addresses GME, but nothing really focused on GME.

The AOA had no problem leading the way as one of the first medical organizations to take action.  The ACP continues its support for primary care, though it is easy to tell they do so very cautiously to keep its medicine sub-specialty members content.  Will the AMA step up at the sake of losing support from its specialty members to help save funding for primary care?  Or will they issue a blanket statement asking to preserve GME funding in general while still knowing that the preservation of GME funding does not necessarily mean the preservation of primary care training.  It may mean the shifting of more training towards specialties that get paid more for procedures...  who funds the RUC again?  Who makes money off of coding books with codes for procedures for which the RUC makes recommendations to CMS for reimbursement rates?  I digress...

Any cuts to GME that do not preserve funding specifically for primary care could be catastrophic, especially for programs that can barely get by with the current level of funding.  GME cuts that do not preserve or increase primary care residency funding will continue the current shift in our physician workforce that favors specialization and does not value primary care.  It is at times like these when I am most thankful for choosing a family medicine residency in the military - a health care system that actually appreciates and values primary care as its foundation for health care delivery.