The Time Is Now: A Plan to Redesign Family Medicine Residency Education

A new graduate medical education program in family medicine is urgently needed now. We propose an innovative plan to develop community-based, community-owned family medicine residency programs. The plan is founded on five guiding principles in which residencies will (1) transition to independent, community-owned organizations; (2) sustain comprehensiveness and generalism; (3) emphasize collaborative learning and interprofessional education; (4) develop local educators with national guidance; and (5) share resources, responsibilities, and learning. We describe actionable steps to begin the process of transforming residencies and strengthening primary care. As community-based and locally-run organizations, residencies will gain self-determination in how time is allocated, budgets are spent, and teams function. Building on the momentum of the National Academy of Medicine’s 2021 primary care implementation plan and recommendations by family medicine organization leaders, we propose a Decade of Family Medicine Residency Transformation. We encourage individuals and organizations spanning disciplines, health care systems, and communities, to join forces to reimagine and recreate the preparation of outstanding personal physicians dedicated to individual and community health and well-being.

Letter to the Editor Concerning “Why is Palliative Care Training During the Portuguese Family Medicine Residency Program Not Mandatory?”

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Nonclinical Time for Family Medicine Residency Faculty: National Survey Results

Introduction: Recent changes to the Accreditation Council for Graduate Medical Education (ACGME) requirements eliminated minimum standards for protected nonclinical time for core faculty. Faculty perform many nonclinical tasks to maintain family medicine residencies. The objective of this study is to describe the landscape of nonclinical time for family medicine residency faculty. Methods: Program directors at ACGME-accredited family medicine residencies were electronically surveyed in August 2019 to describe nonclinical time of their faculty. Survey information requested included program demographics, the amount of nonclinical time allocated, and the estimated amount of nonclinical time spent per year completing their faculty duties. Results: A total 156 of 635 program directors (24.6%) returned the survey and 58 (9.1%) completed the entire survey for analysis inclusion. An average of 3,394 hours per year, per program were estimated to be spent on nonclinical activities. The greatest amount of time was spent on program administration (39%) and the least amount of time on curriculum development (5%). There was variation in the use of nonphysician faculty to complete these tasks. Allocated faculty time was comparable to estimated time spent performing nonclinical tasks. On average, a 24-resident program devoted 1.9 full-time equivalent faculty salary support to complete nonclinical activities. Conclusions: Family medicine residency faculty spend significant time completing nonclinical tasks required to meet ACGME requirements and need the protected time to complete these necessary tasks. Direct data on the use of faculty nonclinical time is needed to more accurately define its use.

Defining Essential Topics and Procedures for Korean Family Medicine Residency Training

Background: This study aims to create a comprehensive list of essential topics and procedural skills for family medicine residency training in Korea.Methods: Three e-mailed surveys were conducted. The first and second surveys were sent to all board-certified family physicians in the Korean Academy of Family Medicine (KAFM) database via e-mail. Participants were asked to rate each of the topics (117 in survey 1, 36 in survey 2) and procedures (65 in survey 1, 19 in survey 2) based on how necessary it was to teach it and personal experience of utilizing it in clinical practice. Agreement rates of the responses were calculated and then sent to the 32 KAFM board members in survey 3. Opinions on potential cut-off points to divide the items into three categories and the minimum achievement requirements needed to graduate for each category were solicited.Results: Of 6,588 physicians, 256 responded to the first survey (3.89% response rate), 209 out of 6,669 to the second survey (3.13%), and 100% responded to the third survey. The final list included 153 topics and 81 procedures, which were organized into three categories: mandatory, recommended, and optional (112/38/3, 27/33/21). For each category of topics and procedures, the minimum requirement for 3-year residency training was set at 90%/60%/30% and 80%/60%/30%, respectively.Conclusion: This national survey was the first investigation to define essential topics and procedures for residency training in Korean family medicine. The lists obtained represent the opinions of Korean family physicians and are expected to aid in the improvement of family medicine training programs in the new competency-based curriculum.

Maternity Care Tracks at US Family Medicine Residency Programs

Background and Objectives: The number of family physicians providing maternity care continues to decline, jeopardizing access to needed care for underserved populations. Accreditation changes in 2014 provided an opportunity to create family medicine residency maternity care tracks, providing comprehensive maternity care training only for interested residents. We examined the relationship between maternity care tracks and residents’ educational experiences and postgraduate practice. Methods: We included questions on maternity care tracks in an omnibus survey of family medicine residency program directors (PDs). We divided respondent programs into three categories: “Track,” “No Track Needed,” and “No Track.” We compared these program types by their characteristics, number of resident deliveries, and number of graduates practicing maternity care. Results: The survey response rate was 40%. Of the responding PDs, 79 (32%) represented Track programs, 55 (22%) No Track Needed programs, and 94 (38%) No Track programs. Residents in a track attended more deliveries than those not in a track (at Track programs) and those at No Track Needed and No Track programs. No Track Needed programs reported the highest proportion of graduates accepting positions providing inpatient maternity care in 2019 (21%), followed by Track programs (17%) and No Track programs (5%; P<.001). Conclusions: Where universal robust maternity care education is not feasible, maternity care tracks are an excellent alternative to provide maternity care training and produce graduates who will practice maternity care. Programs that cannot offer adequate experience to achieve competence in inpatient maternity care may consider instituting a maternity care track.

Implementing an Anonymous Closed-Loop Feedback Process and Associations With ACGME Annual Survey Scores in a Family Medicine Residency

Background and Objectives: The annual Accreditation Council for Graduate Medical Education (ACGME) survey evaluates numerous variables, including resident satisfaction with the training program. We postulated that an anonymous system allowing residents to regularly express and discuss concerns would result in higher ACGME survey scores in areas pertaining to program satisfaction. Methods: One family medicine residency program implemented a process of quarterly anonymous closed-loop resident feedback and discussion in academic year 2012-2013. Data were tracked longitudinally from the 2011-2019 annual ACGME resident surveys, using academic year 2011-2012 as a baseline control. Results: For the survey item “Satisfied that evaluations of program are confidential,” years 2013-2014, 2014-2015, and 2018-2019 showed a significantly higher change from baseline. For “Satisfied that program uses evaluations to improve,” year 2018-2019 had a significantly higher percentage change from baseline. For “Satisfied with process to deal with problems and concerns,” year 2018-2019 showed significantly higher change. For “Residents can raise concerns without fear,” years 2013-2014 and 2018-2019 saw significantly higher changes. Conclusions: These results suggest that this feedback process is perceived by residents as both confidential and promoting a culture of safety in providing feedback. Smaller changes were seen in residents’ belief that the program uses evaluations to improve, and in satisfaction with the process to deal with problems and concerns.

Diversity and Facing Discrimination in Family Medicine Residencies: A CERA Survey of Program Directors

Background and Objectives: Increasing the number of underrepresented minorities in medicine (URM) has the potential to improve access and quality of care and reduce health inequities for diverse populations. Having a diverse workforce in residency programs necessitates structures in place for support, training, and addressing racism and discrimination. This study examines reports of discrimination and training initiatives to increase diversity and address discrimination and unconscious bias in family medicine residency programs nationally. Methods: This survey was part of the Council of Academic Family Medicine Educational Research Alliance (CERA) 2018 national survey of family medicine residency program directors. Questions addressed the presence of reported discrimination, residency program training about discrimination and bias, and admissions practices concerning physician workforce diversity. We performed univariate and bivariate analyses on CERA survey response data. Results: We received 272 responses to the diversity survey items within the CERA program director survey from 522 possible residency director respondents, yielding a response rate of 52.1%. The majority of residency programs (78%) offer training for faculty and/or residents in unconscious/implicit bias and systemic/institutional racism. A minority of program directors report discrimination in the residency environment, most often reported by patients (13.2%) and staff (7.2%) and least often by faculty (3.3%), with most common reasons for discrimination noted as language or race/skin color. Conclusions: Most family medicine residency program directors report initiatives to address diversity in the workforce. Research is needed to develop best practices to ensure continued improvement in workforce diversity and racial climate that will enhance the quality of care and access for underserved populations.

Deprescribing Inappropriate Proton Pump Inhibitors in a Family Medicine Residency Practice Office

Introduction: Proton pump inhibitors (PPIs) are often prescribed beyond their medically-approved duration of use. Long-term PPI use has been linked with numerous adverse effects and contributes to polypharmacy. This study sought to understand the effect of evidence-based education to resident and faculty physicians on deprescribing inappropriate PPIs. We hypothesized that this educational intervention would result in fewer inappropriate PPI prescriptions. Methods: We performed a chart review on all adult patients in a family medicine residency program practice, identifying those inappropriately taking PPIs. All physicians in the practice participated in an educational intervention regarding deprescribing inappropriate PPIs and were given frequent reminders to continue their deprescribing efforts. We reviewed charts at the end of the study to identify patients with successful deprescribing attempts. Results: Of the 187 patients prescribed inappropriate PPIs in the study, 100 remained on PPIs at the end of the study (46.6% success rate). There was a significant decrease in the number of patients inappropriately prescribed PPIs by each physician over the course of the study, from a mean of 17.0 (beginning) to 9.1 (end). Conclusion: Physician education with reminders is an effective means of reducing the number of inappropriate PPIs prescribed in a family medicine residency practice. Future studies could investigate the effectiveness of educational interventions with other medication classes that are often prescribed inappropriately.