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!

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:
http://www.motivationalinterview.org/
http://motivationalinterview.net/clinical/interaction.html
"A 'Stages of Change' Approach to Helping Patients Change Behavior." http://www.aafp.org/afp/2000/0301/p1409.html

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?

A Call for Leadership

The modern physician is called to provide twenty-first century health care upon the foundation of a twentieth-century training. Long gone are the days of home house calls and the autonomy of the solo practitioner with an isolated patient population. Today's physician trainees enter a world of teamwork and collaboration in health care delivery. Evidence-based medicine and quality initiatives reinforce the fact that better outcomes and lower costs are driven by such a team-oriented approach. Complimenting these internal health care initiatives has been the strong response of policy reform and regulation. Together, new models for health delivery facilitate patient care under the joint banner of teamwork and communication. At every step of the journey, physicians accept the role of team leader, facilitator, and communicator.

The ability for future physician leaders to embrace the role of team leader can be best cultivated and enhanced through the response of medical educators. This next generation of physicians must be equipped to deal with an expanded skill set that goes beyond the approach to developing the traditional clinician. It must also relinquish the outdated belief that physician administrators are the only group in need of leadership training. Rather, all physicians must be prepared to be active leaders. The academic medical community can go a long way to develop this sort of physician leader, one that is prepared for the challenges and successes of twenty-first century health care.

This call for a new model of leadership development in the medical academic community was most recently emphasized in the November, 2011 issue of Academic Medicine,

“The full benefits of such a model will not be apparent for years. Early benefits, however, include reduced costs of care, increased availability of health care, improved quality, and a focus on wellness rather than disease management. Long-term benefits include increased involvement of physicians in all aspects of health care administration, with younger physicians leading changes in health care delivery.”(1)

Research suggests that there is a link between the engagement of doctors in leadership and quality improvement – with correlative improvements in patient care.(2) It has become evident that trained physician leaders are better able to both initiate positive change as well as respond to negative or unexpected diversions. This flexibility to interact with change is crucial to the maintenance of equitable and sustainable high quality patient care. With the continued mantra of placing the patient first in health care, investment in such leadership development should be a priority.

Meanwhile, contemporary legislative and regulatory output continues to interplay with systems development to drive the evolution of patient care around the foundation of team-based approaches. Health care systems continue to grow, and to further integrate the various levels of providers and practitioners, in an effort to find a cost-saving blend of quality care. The constant in all of these regulatory models remains that the physician is placed at the center of delivery and as the leader of a team. If the academic community does not strive to meet the demands of these evolving health care systems, perhaps other licensed providers will be offered the chance to step into the void. Physician leaders must be prepared to both interact with, as well as facilitate and lead, these future health care teams.

Finally, perhaps the most systemic influence on leadership development will be driven by financial incentives. Bundled reimbursements, value-based purchasing of health care resources, and pay-for-performance all indicate that providers will be rewarded in concert with team-based care. To complement this, several national societies, think-tanks and government bodies have suggested stratified incentives to academic institutions that engage medical core competencies to differing degrees. All of this is indicative of a likelihood that institutions and residency programs that address necessary competencies, such as leadership development, will likely see greater direct funding.

Some would argue that the movement towards leadership development in medicine is already upon us. To be fair, much discussion has taken place and early adoption has followed in, mostly, isolated settings. But, as a profession, we must still be doing something wrong. Physician burnout is at an all time high, with studies demonstrating that 1 in 3 physicians is experiencing such burnout at any given time. (3) Further studies show that 90% of professionals, who leave their profession, either voluntarily or involuntarily, leave not because of technical incompetence, but because of a non-technical shortcoming or difficulty. Meanwhile, the most commonly raised issues in both medical student and physician performance continue to be within the domain of the non-technical competencies. These areas of concern include professionalism, ethics, and perhaps most important - interpersonal skills. (4)

The time for leadership development in medicine is at our doorstep. It is quite clear that the business community tapped into the importance of recognizing and advancing these principles over three decades ago. In review of the literature on leadership development, it is evident that these topics have only just begun at earnest within the past five to ten years in the medical community. As a profession, physicians have likewise lagged behind – with only recent mutterings and support for the importance of structured and focused leadership in academic medicine. The necessity for developing a new generation of physician leaders is without question. The call for such leadership development is now loud and clear. However, the response of the academic community must be considered. As a profession, we cannot miss the opportunity to answer the door.

1. Snyderman, Carl. Eibling, David. (2011). The Physician as Team Leader: New Job Skills are Required”. Academic Medicine. 86(11): p 1348.

2. Ferlie, Ewan B.Shortell. Stephen M.(2001). Improving the Quality of Health Care in the United Kingdom and the United States: A Framework for Change. The Milbank Quarterly: A Journal of Public Health and Healthcare Policy. 79(2): p 281-315.

3. Shanafelt, Tait D. (2009). “Enhancing Meaning in Work: A Prescription for Preventing Physician Burnout and Promoting Patient-Centered Care.” Journal of the American Medical Association. 302(12). p 1338-1340.

4. Eva KW, Rosenfeld J. (2004). “An Admissions OSCE: the Multiple-Mini Interview.” Medical Education. 38 p. 31-326

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!

Should we Occupy Medical Schools to Effectively Occupy Healthcare?

Kevin Bernstein, MD, MMS
Co-Founder, Future of Family Medicine Blog

A social media movement is happening before our eyes with action starting to take shape.  The #occupyhealthcare movement has begun within to the blogosphere and through various areas of social media by storm, including a recent demonstration on the streets of Boston.

What does the #occupyhealthcare movement mean to me?  By now, readers of this blog may notice that my main focus in advocacy for family medicine is the production of an adequate primary care workforce distributed adequately to best serve our country.  Those close to me also know that the current climate of health care access, quality and cost in the civilian world is one of my main reasons for pursuing a medical career in the military. What does that have anything to do with occupying healthcare?

First, we must occupy healthcare to produce the primary care workforce that our country needs.  There are a number of ways that this needs to be accomplished.  We must quit investing money into procedures and interventions that provide no decrease in morbidity and mortality for patients.  We need to shift our investments towards cognitive evaluation and management of patients in an effort to prevent diseases from occurring in the first place.  If they are already present, we need to invest in the cognitive efforts that are most proven to help our patients prolong or stop the progression of disease.  By doing so, we will attract the best and brightest medical and other professional students towards professions within patient-centered medical homes.  Our patients deserve nothing less than the best to provide ongoing, life-long, multidisciplinary care.

Second, we must occupy healthcare to decrease bureaucracy within medical schools.  This starts with how medical schools are "ranked" and funded.  Consider how much emphasis is put on NIH funding for research towards rank and prestige.  When looking at funding for research, most of the research done at these institutes are within tertiary care centers, where less than 1% of our population actually receives care.  This funding needs to be shifted towards research within our communities, to best represent the needs of the 99% of those who never make it to the ivory tower, academic tertiary care centers; to the 99% who would be better served by research that actually addresses the problems that they face.

There is no incentive for schools to produce the primary care workforce necessary for our country.

Do not get fooled by "The Dean's Lie," where medical schools count all students choosing internal medicine, family medicine, and pediatrics without accounting for the 80-90% of them that will eventually specialize and never practice true primary care.  In any other profession, this would be considered fraud.  How can we let them get away with this type of misrepresentation regarding how they contribute to our primary care workforce?

Should we incentivize NIH funding in proportion to primary care workforce production?  

Medical schools argue that their main job is to educate and train future physicians and that the choices of students is out of their hands.  Is it?  How many family physicians teach core competencies, including anatomy and pathology, during the first two years of medical school?  Are they stuck teaching clinical skills?  Is primary care valued at these schools - does the school have a family medicine department?  Does the admissions committee have primary care physicians involved in the selection of potential students?  Do other departments value primary care or do they tell medical students that they are "too smart" for primary care?

Without an adequate primary care workforce, not many people are going to have access to the patient-centered care necessary to screen and/or manage the many diseases that our country suffers from, most which could be prevented with high quality primary care.  This starts with our workforce and ends with how we value services provided by our system.  We pay more to keep people sick and less to keep people healthy.  In turn, we attract more medical students to pursue careers in areas that keep people sicker and longer rather than careers in primary care where we can make the biggest impact on people's lives with the lowest cost to our healthcare system.

The current climate forces those interested in keeping their jobs to make good business decisions in return for one of the worst healthcare systems among developed nations.  What a shame.  Let's #occupyhealthcare to allow those in charge (or those who will be in charge) to make the good business decisions necessary to create a system that everybody can be a part of.