Gretchen M. Dickson

FROM FAMILY MEDICINE MILESTONES TO ENTRUSTABLE PROFESSIONAL ACTIVITIES (EPAS)

Since publication of the 2 Institute of Medicine reports, To Err is Human1 and Crossing the Quality Chasm,2 the public and government expect and demand higher quality and safer patient care. To accomplish its mission of improving health care by assessing and advancing the quality of resident physicians’ education,3 the Accreditation Council for Graduate Medical Education (ACGME) encouraged competency-based education with the creation of 6 core competencies. Recently, the ACGME created the milestones, which emphasize competency-based developmental outcomes. The family medicine milestones, to become effective July 1, 2014, consist of 22 outcomes based on the 6 core competencies. A mandate for family medicine residency programs is to ensure their graduates are able to provide safe health care to their patients. As programs begin to implement the milestones, an emerging complimentary theme is the entrustable professional activity (EPA), which is a way to translate competencies into clinical practice.4 Collectively, a set of EPAs for family medicine constitute the core clinical activities of a family physician,5 ie, what does a family physician do in practice and how do we know a graduate is competent to independently and safely practice those activities? Going beyond a checklist of behaviors, EPAs define the “knowledge, skills, and attitudes” integrated across the competency domains and the work that a family physician does.4 As family medicine is such a rigorous and diverse specialty, constructing a comprehensive list of EPAs is indeed a daunting task. One educator recommends a graduate medical education program have no more than 20 to 30 EPAs that are clear but not too detailed.6 An initial attempt at defining EPAs in family medicine included a list of 76 items that mostly focused on the ambulatory setting.6 Ideally, EPAs should be independently executable within a given time frame as well as observable and measurable.4 Ultimately, the EPAs should be a list of what the public can expect from their family physicians. Currently, a committee of family medicine leaders is drafting a list of EPAs for our specialty. They are expected to release the list this fall–intentionally coinciding with the anticipated Family Medicine for America’s Health report. The emergence of EPAs in family medicine is intended to support the milestones, and it is important to note their differences. Milestones follow each competency along a developmental continuum. While milestones detail individual competencies, real care delivery requires integration of these abilities in a more complex manner.5 For example, an EPA on care for the underserved/vulnerable patient would require a resident (on multiple occasions) to demonstrate knowledge of population health, advocacy, and cost awareness, and to employ team-based care, utilize IT resources, etc. Proficiency in an EPA requires mastery of several competencies, and goes well beyond ACGME program requirements, time spent on rotations, or patient numbers. The EPA assessments are based on specific observable activities throughout residency and not just a general impression. EPAs can also be used to drive curriculum development at the residency level. Program directors should use EPAs as they are intended to strengthen professional standards, improve patient safety, and enhance outcomes. The implementation of EPAs is not meant to be burdensome; rather, they should help programs bridge the gap between initial competency-based assessments and real-world practice. EPAs will be particularly helpful for family medicine faculty who struggle with Likert scale numerical ratings. We are in an exciting time in family medicine education as we look to incorporating milestones and EPAs into our residency programs. Implementation should produce higher quality graduates who will provide safe, quality care to their patients and communities.

LEADING FAMILY MEDICINE INTO THE FUTURE: ARE WE PREPARED?

While the call to leadership to prepare family physicians to champion improvements in the practice of medicine is not new, it has perhaps never been more urgent. From patient-centered medical homes to health care reform to new initiatives to measure and improve quality of care, family medicine

A process for change: a methodology for academic family medicine.

The Association of Family Medicine Residency Directors (AFMRD) Board of Directors recently rekindled the discussion pertaining to maternity care education in family medicine residency programs. At present, the ACGME-RRC for family medicine requires programs to provide 2 months of educational experience in maternity care as well as delivery experience that entails a minimum of 40 deliveries by each resident over the 3-year program, of which a minimum of 10 must be continuity deliveries. At least 30 of the total deliveries must be vaginal deliveries. The current discussion is meant to address the following issues: A decreasing number of physicians in active practice and who graduated from a family medicine residency program provide maternity care. Many programs are concerned that they are being required to provide an experience that a majority of the graduates will not use upon graduation. Many programs have difficulty meeting RRC-FM requirements for maternity care education. Maternity care is the most frequently cited curricular area noted by the RRC-FM. The RRC-FM issued an average of 6.6 citations per program. Maternity care, family medicine center patient encounters, and gynecology curricula were the most common areas of noncompliance citations. In addition to meeting minimal delivery requirements, a majority (58%) of programs responding to a questionnaire stated that they had difficulty in recruiting a faculty member with delivery skills. With this high rate of citations, the quality of education in maternity care for family medicine residents is inconsistent. In order to provide a position statement that best reflects the experience and expertise of its membership, the AFMRD Board of Directors conducted a process that would allow a significant amount of input from program directors as well as information from other sources. As an initial step in addressing the above issues, the AFMRD surveyed its membership regarding maternity care. Specifically, this survey examined such issues as whether a change in ACGME- Residency Review Committee for Family Medicine (RRC-FM) requirements for maternity care was desired, do programs have difficulty meeting RRC-FM Requirements for maternity care, should all family medicine residents have at least some required maternity care experience, and recommendations regarding number of total deliveries needed to better insure competence for a family medicine resident planning on providing maternity care in practice. To augment the data provided by the survey, a literature review was conducted to provide additional information to AFMRD members in preparation for a discussion forum regarding maternity care and family medicine conducted during the Annual Program Directors Workshop. The literature review provided information regarding issues regarding maternity care in family medicine residency programs, information regarding family medicine residency program graduates and maternity care, the experience of practicing family medicine physicians who are providing maternity care to their patients, and student interest in maternity care. Next, a facilitated discussion forum regarding maternity care and family medicine was conducted during the Annual Program Directors Workshop in Leawood, Kansas on June 8th, 2008. Using data collected from the previously described survey, 4 program directors were selected to present differing positions on this subject. Following these presentations, an open forum with opinions from the audience was conducted. In particular, specific suggestions to RRC-FM guidelines were requested. During this entire session, information and opinions presented were extracted, reviewed and summarized by members of the AFRMD Board of Directors. Using the 3 sources of information described above, an initial draft of a Maternity Care Position Statement was developed. This draft statement was presented to the AFMRD membership as well as to representatives from the Society of Teachers of Family Medicine, the Association of Departments of Family Medicine, the North American Primary Care Research Group, and the American Academy of Family Physicians for their review and comment. These comments were collated and presented during an AFMRD Board of Directors meeting. The Board members reviewed and extensively discussed the comments received. Following this meeting, the Position Statement has recently been again revised. The final version of the Maternity Care Position Statement by the Board of Directors of AFMRD will be forwarded to the Commission on Education (COE) of the AAFP for further review and vetting. The COE will present the final recommendation to the RRC-FFM. The process used to develop the final position statement to the COE has been deliberate, thoughtful, collaborative, balanced, and methodical. This method is presented as an example of a rational methodology to address significant issues currently present in family medicine education and hopefully will serve as a template for future such deliberations.

Perceived Impact of Proposed Institute of Medicine Duty Hours on Family Medicine Residency Programs

The ACGME is faced with an enormous challenge. On the 25th anniversary of the Libby Zion case[1][1] and the 5th anniversary of the ACGME Duty Hours,[2][2] the Institute of Medicine (IOM) released a December 2008 report calling for a revision in duty hours and trainee supervision.[3][3] The ACGME is

Advocacy: the time is now.

Listening to Dr Joe Scherger1 recently, one understands that personal responsibility is required to create a functional health care system. “Creating” seems better than “reforming”, for instance, because the functionality of the current system is in dire straits. Consider a restaurant where the patrons and the workers are dissatisfied, ratings are bad and the books show red ink for almost 60 years in a row. Any sensible owner would have started over years ago (getting out of the business not being an option). Dr Scherger describes some success rising from the ashes, however: “Idealized micro-practices” where physicians have increased career satisfaction and patients are so pleased they are actually paying out of pocket to belong! Proactive care delivered to “activated” patients who are empowered to have an impact on their own health care. The family medicine physician is employing (and perhaps is actually an agent of) what he describes as “disruptive technology,” turning the tides of woe into currents of hope for frustrated patients and doctors. So perhaps, with apologies to Ronald Reagan, it is morning in family medicine--optimism awakens. The alarm clocks of the powers that be are playing a tune written by the nation’s primary care physicians and their patients. Perry Pugno’s “paralysis of inaction”2 could well dissolve in the face of many such success stories. The Clinton administration failed to focus on “systemic problems in funding, organization, and delivery of care,”3 and saw good ideas and well-intentioned initiative fall short of success. The Obama administration is taking aim at health care reform, and is listening to the family of family medicine. We cannot merely complain to legislators about “Big Pharma” and physician reimbursement, although these are undoubtedly important topics. Now is the time to get actively involved in legislative advocacy. We must rise to more effective tactics. Frontline private and academic physicians should learn to feel comfortable bringing issues to legislators and our patients. Those that we serve can become our biggest advocates. We must forge ahead and DO the things that have been shown to improve quality and reduce cost. Even office design now has evidence-based literature showing cost savings.4 We must be familiar with TransforMED’s findings and new models such as Idealized Micro-Practices, but our key talking points with legislators should be based upon our own personal or program’s experiences in trying to achieve patient-centered care. We need to identify current barriers to improving the quality of care and ask for help to eliminate them. We should discuss why the almost 45-year old hospital-based graduate medical education reimbursement system is particularly problematic for adequately financing primary care residencies and that it needs an overhaul. Legislators need to hear stories of how our local innovations are working to improve patient satisfaction and reduce cost, while also training future family doctors. These tales will resonate with lawmakers, and be more tangible than promises based on dreams of what could be done “if only we had more money.” Advocacy in family medicine, like a planetary nebula, is beginning to coalesce into some well organized efforts from the haze of the national-level health care issues. The focus tends to remain at a national, rather than state or local level, since ideas traded across listserves now understandably concern the Obama administration. We need to meet with our state and national legislators, and carry our message to our home residency communities at medical staff meetings and county medical society gatherings to develop key physician contacts for local and state as well as federal legislators. We must implement advocacy curricula to educate all family medicine residents as an opportunity for familiarity and comfort with the necessary topics and strategies, and to encourage development of relationships with legislators. Patient-centered medical home (PCMH) strategies are buzzwords in Washington now; staffers need to be aware that we are using tools such as open-access scheduling, health care teams, and patient registries to improve and document outcomes. It is imperative that we are giving more than lip service to the PCMH if we expect more than that out of legislation. Of all health care costs, 50% are consumed by 5 diagnoses: asthma, diabetes, hypertension, coronary disease, and depression. This sounds like the afternoon schedule of every family physician in America! How can Washington or anyone else deny that the practicing family physician is equipped to lead the change? We are already doing it. The time is now to beat a drum in our state and nation’s capitals to create the rhythm of change.

A prescription to advocate for graduate medical education reform.

Training the next generation of physicians in a system wrought with funding disparities has left many residency program directors wondering if there is hope for change—and what role they might play in bringing about change. The current state of graduate medical education (GME) financing is based on outdated statutory formulas that are focused on cost-based reimbursements in the hospital setting. The consequences of this imbalanced funding are significant: the formula impacts access to care, contributes to physician workforce shortages, and ultimately fails to meet the health care needs in the United States. Between 1998 and 2008, there was an increase in the number of residency slots in specialties known for competitive incomes and appealing lifestyles (radiology, ophthalmology, anesthesia, and dermatology) and a decrease in primary care slots (family medicine, pediatrics, and internal medicine). Despite the increasing need for primary care physicians across the country, research indicates that hospitals largely favor higher revenue-generating specialty training, as there is a direct correlation between specialty income and GME slots offered.1 In response to the failures of the Centers for Medicare and Medicaid Services (CMS) to meet the health care needs of the public, the Institute of Medicine (IOM) issued a report calling for dramatic changes in GME funding and governance.2 Specifically, the report recommends providing funding directly to sponsoring institutions, thereby promoting more training at community-based sites. In addition, the report supports the creation of an oversight council to track performance outcomes and lead policy development. Shortly after the IOM report was released, the American Academy of Family Physicians (AAFP) also took a stand emphasizing the need to expand primary care GME by instilling accountability in a budget-neutral manner. The AAFP proposed that CMS limit direct graduate medical education and indirect medical education payments to the training of first-certificate residency programs. They also proposed that CMS require all sponsoring institutions and teaching hospitals seeking new Medicare and/or Medicaid-financed GME positions meet minimum primary care training thresholds as a condition of their expansion. This change could fund an additional 7,000 new residency training spots with a minimum of 50% going to primary care specialties. In addition, AAFP’s proposal would require hospitals and sponsoring institutions to demonstrate a commitment to primary care through the establishment of thresholds and maintenance of effort requirements applicable to all institutions currently receiving GME financing. This is to ensure that institutions truly support training the primary care physicians this country needs. These collective GME refinancing recommendations would result in positive changes for the future of family medicine training. We anticipate a more robust workforce in a variety of geographic and practice settings. The larger impact would be shifting the focus of health care away from acute illness and toward population health and preventative care. The medical organizations that represent teaching hospitals are opposed to these changes, however. As family physicians, we must start educating our colleagues in other specialties on why the current system is unsustainable and harmful to patients and physicians alike, emphasizing that better health outcomes occur when primary care is available and affordable. Second, we must collaborate with other primary care specialties in order to speak to the value of primary care with a unified voice. Program directors carry a strong influence in their communities. Our call to action: contact your representatives and ask them to sponsor or support a bill that includes the AAFP’s proposal for GME reform. Use the AAFP’s resources (http://www.aafp.org/advocacy/informed/workforce/gme.html) to educate your legislators on this very important topic. Encourage your residents, faculty, and patients to do the same. Change comes when we speak with one voice on an issue that affects every American. It’s time to fix this broken system.

PROGRAM DIRECTORS AND CERA: AN IMPORTANT RELATIONSHIP

How many acronyms do you know where one of the acronym letters stands for an acronym? An acronym within an acronym? We hope most family medicine program directors think of CERA right away. CERA stands for CAFM Educational Research Alliance; CAFM is the Council of Academic Family Medicine. Program directors are critical to the ongoing success of CERA for 2 reasons. CERA facilitates about 5 surveys every year. Only the program director population is surveyed twice every year and receives more proposals than all the other surveys combined, which tells us that we hold the answers to a lot of important questions from the rest of the “family” of family medicine organizations. CERA surveys contain questions that are submitted by a variety of family medicine researchers and educators. For example, the last CERA program director survey contained submissions from medical schools, community programs, program directors, residency faculty, social scientists, and pharmacists. CERA understands that program directors have limited time; therefore, they accept only proposals that include a good hypothesis, are related to what program directors do, contain decent questions, and finally, will likely end up in a published paper. Additionally, the results are archived to help others answer their research questions. For these reasons, responding to CERA surveys should rank as a high priority for program directors. This seems to be the case, as the PD response rate, at 38% for the first CERA survey of program directors, has increased to over 60%. This is great; but clerkship directors’ response rate is more than 90%! Another reason program directors are critical to the ongoing success of CERA is relevance. As program directors, we know the relevant questions to ask in order to advance family medicine education. We are in the midst of tremendous changes in both our clinical and educational infrastructures, and there is very little evidence to support any of the educational changes. We as program directors need to do our part to ensure our residents are still learning how to provide high-quality care to patients in the face of changing environments. CERA surveys can be excellent tools along these lines. Most program directors think of themselves as clinician-educators, and CERA gives us the means to ask questions in a rigorous way. Once a proposal is accepted, CERA provides institutional review board approval through the American Academy of Family Physicians (AAFP) as well as experienced mentors. This collegial support from the rest of our family medicine community through CERA is invaluable as program directors expand our scholarship into the realm of educational research. An added benefit of CERA involvement is that it also provides an excellent opportunity to help you and your faculty meet the review committee for family medicine’s faculty scholarly activity requirement. The AFMRD benefits greatly from the active involvement of its members in various organizations and activities, including CERA. For the last 2 years, Dr Paul Crawford, program director at Nellis Family Medicine Residency in Las Vegas, Nevada, has served as the AFMRD liaison to CERA. Dr Wendy Barr, associate program director at the Greater Lawrence Family Health Center in Lawrence, Massachusetts, is the new liaison. CERA covets proposals from program directors, yet a limited number of proposals are received from program directors because, for one reason, program directors find many questions in the CERA surveys lack relevance to their roles. This lack of relevance is also the reason the AFMRD is taking the initiative to assist program directors in developing CERA proposals. Those of us who consider ourselves novices at educational research and survey design will appreciate that the AFMRD Board is partnering with several researchers familiar with the CERA process to offer program directors mentoring, feedback, and suggestions prior to submission to CERA. Interested AFMRD members will be connected with a mentor/reviewer by contacting Lynn Pickerel at gro.pfaa@drmfa. CERA accepts program director proposals twice a year, but please do not wait until the deadline—plan now. Develop your research question and hypothesis and start on the path to getting relevant questions about residency education answered!

TRAINING IMPLICATIONS OF FAMILY MEDICINE FOR AMERICA’S HEALTH: A PREVIEW

Family Medicine for America’s Health was launched in October 2014, heralding a major initiative by family medicine organizations across the country to reform health care. This initiative is focused on 6 key implementation areas: practice, payment, workforce education and development, technology, research, and engagement. Family medicine program directors will serve an essential role in workforce education and development. The primary care workforce shortage has been recognized as one of the major deficiencies in our health system. As program directors, we have a responsibility to not only educate more family physicians, but to ensure our graduates are prepared for a different health care system. If we are to produce a workforce of family physicians who will thrive in a new environment and deliver higher quality care with greater value, many aspects of medical school, residency, and CME demand some redesign. Considering the prominent roles that family physicians will serve within tomorrow’s medical system, our graduates must be equipped with an increasingly wider range of skills and characteristics, including the following: Diagnostic: Family physicians will be expected to have a broad medical knowledge base across specialty domains and patient assessment skills for undifferentiated patients of all ages. This is a core skill of critical importance and the key to providing the right care at the right time for all patients in the practice. Acute care: We must be able to diagnose acute conditions ranging from minor to severe illness and manage their initial treatment. Chronic disease management: Family physicians will require a mastery of chronic disease care for the most common diseases in the population as well as prevention and early recognition of complications. Secondary (hospital) care: Family physicians must have the ability to transition care to and from outpatient and inpatient settings, coordinating care by either managing inpatient care directly or closely working with hospitalists to assure care is personalized and efficient. Maternity care: The level of maternity care that family physicians will provide will be based on the community they are serving. Residency training will include the skill sets outlined by the CAFM Maternity Care Training Guidelines that will be published this spring. Primary care team leadership: It is essential that family physicians have training in leadership skills, team-based care, quality improvement and safety. By the nature of their skill sets, family physicians will frequently be relied upon to direct the care team in the management of the practice’s population. Patient advocacy: Our graduates must understand the sociology of health. The profound impact of socioeconomic factors on the patient, the family, and the community is well documented and must be at the forefront of our advocacy work as physicians within our communities. Mental health partnering: Because family physicians evaluate and manage a high percentage of mental illness within our medical system, our training in primary interventions, treatment, and integration of mental health services within the primary care clinic will be crucial. Health systems management: Because of the breath of our practice and knowledge of the community, family physicians will play a critical role in the design of future health systems. Medical education is a continuum. Program directors cannot ignore the training in medical school nor can we neglect the education of practicing physicians as we move our specialty forward. There is much to do in medical schools across our country to increase the pipeline of students entering family medicine and to prepare them to enter residency. Continuing medical education for practicing family physicians will need to address the core expectations of family physicians outlined above. There will be a need for retraining and re-expansion of the scope of practice for some of our physicians as we take on more responsibility for the care of our populations. The incentives will change significantly as we expand the role of primary care and encourage physicians to employ a variety of skills in delivering care to the patient. In the new model of care that is envisioned, we will be asked to provide care of greater value and not of greater volume. In the end, the greatest value we can bring is the robust set of skills outlined here into the clinics we work in every day.

THE COUNCIL OF ACADEMIC FAMILY MEDICINE PROCEDURAL AND MATERNITY CARE TRAINING GUIDELINES: A BETTER PATH TO CONSISTENCY IN COMPETENCY ASSESSMENT IN FAMILY MEDICINE

As an organization devoted to training residents to deliver high-quality family medicine care to their communities, we have struggled to determine those procedures in which we should require all residents to develop competency. To date we have lacked consistency in educational standards for both procedural and maternity care training. This lack of standardization has led to a wide range of skills (or lack thereof) in our graduates, which has impacted our scope of care and potentially endangered our credibility as a specialty. A consistent methodology in determining competency has also been lacking. The latest guidance by the RC-FM is, “Residents must receive training to perform clinical procedures required for their future practices in ambulatory and hospital environments.”1 In the FAQ related to this, the RC-FM states, “As the list of procedures performed by the practicing family physicians varies based upon the needs of the community, the program directors and members of the faculty should develop a list of required procedures based upon the needs of their FMP (family medicine practice) and recommendations of organizations…”2 In response, the Council of Academic Family Medicine (CAFM) formed 2 task forces in the spring of 2014. The AFMRD took the lead on developing these guidelines, working with faculty members across the country to provide input into the process. The Society of Teachers of Family Medicine (STFM) Maternity Care and STFM Hospital and Procedures groups formed much of the task forces. After conference calls, a careful literature review, and collaborative efforts, draft guidelines were completed in December 2014. Next steps: gather broader input from family physician educators, update the guidelines based on this feedback, then return the documents to CAFM for final approval. The task forces agreed upon a better method of determining competency that actually passes the common sense test—blending a minimum experience with a standardized competency assessment tool that breaks down the skills that need to be demonstrated by the trainee. The key feature is not relying on numbers alone and, in fact, the minimum numbers are reserved for the most skilled residents, not for the average resident. Most residents will need to exceed the minimum number for complex procedures before they are ready for competency assessment and to potentially be signed off as ready for independent practice. The Maternity Care Guidelines outline training expectations for the 3 tiers of maternity care already being practiced in our family medicine community. These tiers are designated Ambulatory Maternity Care, Comprehensive Maternity Care, and Advanced Maternity Care. Instead of having a one-size-fits-all requirement from the RC-FM, we will have recommendations that reflect what individual residents are seeking in their training, based on the community in which they intend to practice. However, since maternity care is within the domain of our specialty, all programs are expected to offer Ambulatory Maternity Care training to residents to allow them to possess basic spontaneous delivery skills and sound prenatal care training. Even if a graduate does not plan to provide prenatal care for their patients in their practice, they must still possess knowledge of the medical complications of pregnancy and to be able assess the maternity care their patients may be receiving from another physician. The Comprehensive Maternity Care criteria now include labor management as a key portion of experience requirement. With the current duty hour requirements, many residents manage women in labor for extensive periods of time, often making complex care decisions, but would receive no credit by credentialing bodies for that experience. The guidelines have a similar experience criteria model as the procedure guidelines—the minimum number of deliveries is 40, but in addition, they should manage an additional 40 patients in labor (that they may not deliver) during their training. The Advanced Maternity Care tier outlines the expectations for training residents, and often fellows, to gain operative obstetrical maternity skills and management of higher risk pregnancies. This robust level of training is often needed in rural and underserved areas of our country and will create skilled providers of maternity care that those communities need. We are entering an era of greater accountability to our communities we serve. Having these training guidelines for maternity care and for procedures will help us ensure we are training skilled family physicians with a sufficiently broad scope to provide care of higher quality that meets more the needs of their patients. We encourage broad adoption of these guidelines and tools in order to enhance both the skills and credibility of our graduates. These working guidelines can be found on the AFMRD website, http://www.afmrd.org.

Transforming a toolbox into a treasure chest.

When approaching a task there is nothing better than having a collection of useful tools organized in an easy-to-find location. This is especially true for family medicine residency program directors whose tasks seem endless, are often complex, and cover a myriad of issues. The mission of the Association of Family Medicine Residency Directors (AFMRD) is to inspire and empower family medicine residency program directors to achieve excellence in family medicine residency training. One way we aim to serve this mission is by providing our members with a great collection of tools. On the AFMRD website (http://www.afmrd.org) is our AFMRD Toolbox, which over the years has grown to include various documents and processes as well as links to important websites. This toolbox has long been one of the AFMRD’s most popular member benefits. Over time, however, some of these tools have become outdated or obsolete. As the number of tools piles up, finding the right tool becomes increasingly difficult. The good news is that a major initiative in the 2014–2016 AFMRD Strategic Plan is an overhaul of the toolbox. Essentially, we are redesigning the old toolbox and creating a newly formatted “treasure chest” on the AFMRD website. Members of the AFMRD Toolbox Task Force are currently in the process of removing outdated tools and placing the remaining tools in a visually attractive space that will allow members to find what is needed easily. Once the toolbox is built and existing content is organized, we will begin adding new tools, starting with a campaign asking all program directors to submit their best tools. The tools will be reviewed and, if accepted, placed in the toolbox for all to use. We are hopeful that by the 2015 Program Directors Workshop we will be able to demonstrate our new toolbox of treasures. In addition to revamping and restocking our own toolbox, we assisted the Society of Teachers of Family Medicine (STFM) in collecting resources for the Residency Accreditation Toolkit. Dr. Ted Epperly led members of AFMRD and STFM as they worked collaboratively to develop this comprehensive collection of resources designed to help program directors with all aspects of implementing the Next Accreditation System and complying with milestones and the new RC-FM requirements. This toolkit is on the STFM website and available to AFMRD members at a discounted rate. Though some items on background and implementation may seem basic to current program directors, they serve as an introduction to these concepts for new program directors, new faculty, and new staff. The Residency Accreditation Toolkit is divided into 6 broad categories: Milestones/Resident Assessment, Program Accreditation, Institutional Accreditation, Faculty Development, Coordinator Timeline, and General Accreditation Resources. Each section of the toolkit does an excellent job at providing a broad overview as well as drilling down into specifics. For example, in the Milestones section, Dr. Epperly provides a short video on why the ACGME created Milestones and their anticipated effect on graduate medical education. In addition, this section has multiple specific evaluation tools, with titles such as “cultural competency observation tool,” “resident peer evaluation,” and “observable behaviors list.” For many of us, the Milestones have uncovered deficiencies in our assessment process. As we seek to plug those gaps, such tools will be invaluable. In the future, the AFMRD hopes to add to its member resources a peer residency program innovation hub to evaluate and identify residency program innovations. There is no doubt that collectively we can create a powerful resource for all directors. Besides minimizing re-work and partnering with each other, the exciting potential of the use of shared resources is our collective ability to study our tools for validity and reliability. For example, we are lacking evidence that will help us produce better-trained family physicians. We also have little evidence that any of our assessment tools measure what we think they do. By using some of these assessment tools across residencies, there is the potential for educational research with sufficient power to determine what are “best practices.” This is truly an exciting time for AFMRD members seeking resources that will assist them in achieving excellence.