EXPERIMENTATION AND INNOVATION IN FAMILY MEDICINE RESIDENCY EDUCATION: THE TIME IS NOW
From the Association of Family Medicine Residency Directors
By this time, most of you have heard or read about the joint initiative between the American Board of Family Medicine and the Association of Family Medicine Residency Directors called “Preparing the Personal Physician for Practice” or the P4 Initiative. As stated in the recent Call for Proposals,1 “The purpose of P4 is to learn how to improve the graduate medical education of family physicians such that they are prepared to be outstanding personal physicians, working in new models of practice. The innovations tested by P4 residencies are expected to inspire substantial changes in the content, structure and location of training family physicians and guide future revisions in accreditation and certification requirements.”
From the beginning, it was felt that the P4 Initiative would succeed or fail based on the creativity and tenacity of the folks in the trenches, ie, the residency program directors and their faculty. Therefore, prior to this yearâ€™s Program Director Workshop (PDW), input was solicited from directors on the current status of residency education. The magnitude of the response (over 200 directors offered input) and the thoughtfulness of the comments demonstrated to me a significant interest in this project and a readiness for change in our graduate medical education system. Following is a synopsis of the responses received from the directors, combined with opinions expressed during the discussion forum, which was held at the 2006 PDW. These comments capture the full range of ideas expressed by the directors and though not meant to be a formal analysis of the responses, I think the comments do offer insight into our directorsâ€™ thoughts and desires for the future.
In response to what important aspects of residency education need to change in the future, we received comments around the themes of decreased regulation, more curricular flexibility, more practical learning in “real-world” settings, guidance on how to adopt new technology, help in identifying new funding sources, help in developing a viable financial model for practices, and better ways to assess and assure the competency of our graduates.
In response to what important aspects of residency education need to be preserved, we received comments relating to continuity of care, breadth of training, intellectual curiosity, the personal, continuous doctor-patient relationship and the core, universal training that all residents receive, so thereâ€™s consistency across the spectrum of what all family physicians can do; ie, “training canâ€™t become totally variable.”
When asked to fast forward 5 years, after the residency experiments are completed, what must we know that we currently donâ€™t, we received comments relating to how we could use more technology to improve quality and outcomes, what teaching methods are actually effective, what educational outcome measures are meaningful, how to better assess and assure competency and that the New Model of Practice is financially viable and relevant. It was clear from the comments that we need to better understand what experiences during residency are most effective in training knowledgeable and skilled family physicians.
The comments regarding barriers to change were somewhat predictable. Directors saw the major impediments to change revolved around inadequate funding, lack of access to technology and an EHR, lack of faculty time and support, overregulation by our accrediting bodies such that it is “creativity stifling,” and increased service requirements by the sponsoring institution making educational innovation difficult. There was also the feeling that many programs have difficulty embracing the concept of change.
Lastly, we wanted the directors to portray what their ideal graduate would be in 2015. The responses hinged around the graduateâ€™s ability to use technology and systems to provide comprehensive, high-quality, evidence-based care to people of all backgrounds, to be an excellent communicator, and to be a competent, caring, and compassionate physician who provides personalized care to patients. I thought one response worth quoting (probably from a director who recently underwent a RRC site visit) was that the ideal graduate in 2015 will be “a walking testimonial to the ACGMEâ€™s 6 competencies.”
Regardless of what we learn at the end of this 5-year experiment, in many ways, I believe the P4 Initiative has already been a success. As seen in the above comments, there appears to be significant enthusiasm for change. The next few years offer an incredible opportunity to embrace change and look at all the possibilities afforded us through both TransforMEDâ€™s National Demonstration Project and the P4 Initiative. These are indeed exciting times and I look forward to seeing the outcomes of these experimental initiatives.
Samuel M. Jones, MD
1. P4 Initiative Call for Proposals. September 1, 2005. Available at: http://www.transformed.com/p4.cfm.