Karen Mitchell

Accountable care organizations: an opportunity for synergy.

With the reelection of President Obama, full enactment of the Patient Protection and Affordable Care Act is all but certain. Part of that legislation is the establishment of Accountable Care Organizations (ACOs). These large networks require a minimum of 5,000 Medicare patients, and will assume the total costs for their care in many cases. Over 140 ACOs are already established with over 130,000 physicians and 2.2 million beneficiaries.1 Much of the broad legislation governing ACOs has yet to be converted to specific regulations, which will vary between states. Because so much of this change has yet to be decided, and large systems will have to rapidly adapt, ACOs may become a sudden order of business for family medicine program directors. ACOs are a model of shared risk for costs and savings of a defined population. The more patients a network has, the more easily they can spread the costs of expensive care of the relatively few. In the ACO model, hospitals will shift from revenue centers to cost centers. ACOs have the potential to shift systems to embrace wellness rather than reactive illness care. In the future, we may get reports on how much our patients cost the system, rather than how much revenue we generated with our level-4 visits, inpatient billing, and procedures. Many systems will need to increase their primary care workforce as more patients have health coverage, and systems shift their emphasis to outpatient and preventive care. Insurance and payment reforms are the first 2 steps in health care reform. The third phase is delivery system reform.1 A need to educate those making ACO formation decisions will exist, regarding the value of family medicine residency programs to ACO networks. One of the fundamental objectives of the National Institute of Program Director Development (NIPDD) training is to understand the worth of your program; in the world of ACOs, our 2 principal strengths to promote will be cost-effective care and workforce generation. To truly provide population health care (rather than just those who come to see us) will require a fundamental shift in perspective for our systems, and most of us as well. Many of us will need to learn new skills; we will need to strongly advocate for resources such as case managers, chronic disease registries, and searchable electronic health records to provide high quality, cost-effective health care to a population. We also need to advocate for payment reforms that truly reflect our value to our systems. If we are not involved in the early formation and leadership of ACOs, we risk maintaining the status quo of huge payment disparities between procedure-based specialists and diverse primary care practices. These disparities discourage future medical students from entering primary care, which eventually will hurt all of our patients. Residency education about cost-effective care is optimized if the system can provide each resident with clinical quality and cost data on their own panel of patients, rather than having them subsumed under the faculty patient panel. We need to advocate for not just teaching about quality improvement, but doing it in our residency practices. Family medicine has a long and celebrated history of advocating for our patients. With the formation of ACOs, there is a moral imperative that we advocate for systems that reflect our values as a specialty. In the next few months, many decisions will be made that will affect both process values (the rules that govern decision-making processes such as transparency, accountability, and participation) and content values (clinical effectiveness, cost-effectiveness, justice/equality, and autonomy).2 We all need to ensure that family medicine has a voice at the table, and that we are proud of the end result. After all, the ACOs created in the next few months will be the ones our graduates will be practicing in for the foreseeable future.

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.

THE NATIONAL GRADUATE SURVEY FOR FAMILY MEDICINE.

The Association of Family Medicine Residency Directors (AFMRD) is excited to announce the rollout of a standardized national graduate survey. Beginning in 2016, the survey will be conducted through the American Board of Family Medicine (ABFM) Maintenance of Certification process. Understanding the scope of practice and success of family medicine residency graduates post-residency is a crucial step in improving residency education. The Accreditation Council of Graduate Medical Education (ACGME) Program Requirements for Graduate Medical Education in Family Medicine state that “Program graduates should be surveyed at least every 5 years, and the results should be used in the annual program evaluation” (V.C.6, Detail Requirement). Although some residencies collaborated on standardized surveys and data collection previously, no standardized national initiative was in place. Recognizing an opportunity to both standardize the survey process and increase the response rate, the AFMRD approached the ABFM to explore opportunities to use ABFM-collected data to fulfill the graduate survey requirement. In turn, the ABFM offered to sponsor the development of a graduate survey to be administered through the Maintenance of Certification process, thus assuring a high response rate. In cooperation with the ABFM, the AFMRD led a steering committee of representatives from AFMRD, ABFM, family medicine research organizations, the ACGME, and a new graduate. The steering committee identified the major stakeholders of a national graduate survey to be, in order of priority: (1) residencies for use in program evaluation and improvement and for milestone validation; (2) family medicine organizations regarding family medicine practice scope and characteristics, as well as the quality of and trends in medical education; and (3) the “public” for use in educational research and policy analysis. The steering committee recommended and then conducted a competitive request for proposal (RFP) process to select a survey development team, ultimately choosing a team from the University of Washington, headed by Dr Freddy Chen. The survey development team completed a needs assessment and a literature search, reviewed previously developed graduate surveys, and conducted phone interviews of key stakeholders and recent graduates and roundtable discussions with program directors. In order to achieve a high survey completion rate, the goal was to limit the survey to questions that can be completed in fewer than 12 minutes. Two rounds of pilot testing have included input from stakeholders, including significant AFMRD input, to identify the most important questions to be included in the survey. The survey is now being rolled out by the ABFM to all ABFM Diplomates 3 years after graduation. The ABFM will incorporate the survey into its Maintenance of Certification process, providing information to residency programs each year on the survey cohort. This meets the ACGME program requirement and provides valuable information to each program for continuous quality improvement of residency education. The ABFM will provide each program with its own confidential survey results, with individual responses de-identified. Individual program data will not be available to the ACGME for individual program accreditation. Broader graduate survey data will be available in aggregate form only, to assure the anonymity of information that may be sensitive for individual programs. A data set for research purposes will be available in de-identified form through the ABFM upon request. The ABFM and AFMRD are committed to the protection of individual data, while providing only aggregate data for national analysis. The steering committee recommended using a 3-year post-graduation timeframe. Graduate scope of practice and success information is likely most useful to programs at that time, being neither too soon nor too long from the time of graduation. While the initial survey will include only residents 3 years after graduation, the ABFM intends to expand the survey so that each ABFM Diplomate completes a survey every 5 years, providing more robust information to programs. Starting in 2016, the AFMRD plans to create an advisory group to work with the ABFM to annually monitor the performance of the survey, the usefulness of the data for residencies, and to determine if any changes are needed in the questions. The AFMRD urges all program directors to inform their residents and graduates of the importance of the national graduate survey and to encourage their participation; additionally the AFMRD encourages program directors to incorporate the results into their annual program evaluation.

AFMRD STRATEGIC PLAN 2014 – 2016

Dale Carnegie once said, “The person who starts out going nowhere, eventually gets there.” With that in mind, the AFMRD Board embarked on a yearlong endeavor to develop our 3-year strategic plan. We wanted a roadmap that would guide our decision making for the foreseeable future. We also wanted

THE RESIDENCY CURRICULUM RESOURCE: A USERS’ PERSPECTIVE

Ten months ago, the Association of Family Medicine Residency Directors (AFMRD) and the Society of Teachers of Family Medicine (STFM) launched the subscription version of the national Residency Curriculum Resource. This is the first time residency programs across the country have partnered to create a national curriculum that can be shared for teaching and learning. Through a peer-reviewed process, more than 220 topics are being developed into a standardized overall curriculum. The Residency Curriculum Resource has always contained information available free of charge, including content overview and links to the AAFP and other resources that can be used in residency education. The Residency Curriculum Resource is much like an app that you can get for free, which contains some basic features; however, if you want the full content you’ll need to pay. At the time of this writing, 177 programs have paid for their first annual subscription. Some programs are currently using the Residency Curriculum Resource for organizing their curriculum and learning sessions, filling in areas where previously quality content was not readily available. Faculty have taken this to heart and are using the learning sessions to improve their own lectures by adding case studies, as well as pre- and post-tests. Because these presentations are peer reviewed, they give a standardized set of information. Rather than concentrate on the esoteric and long lists of items to memorize, the Residency Curriculum Resource contains the meat of what must be learned, and creates discussion and further learning and scholarly inquiry for programs. The advantage of the Residency Curriculum Resource is that it is a continuous, living repository. By the time the 2016 Program Directors Workshop rolls around it is expected that nearly all of the initial curriculum will be finished. New content will be added over time, and all content will be continually updated. Authors are required to keep their information up-to-date and consider feedback on how to improve the learning and content in each session. Since this is a large shared system designed to improve program efficiency and quality—and to expand over time—the Residency Curriculum Resource is on track to be an annual investment no program will want to be without. Program faculty can now spend less time trying to create learning sessions and instead concentrate on effective teaching methods. Small programs with limited faculty no longer need to spend so much time reinventing the wheel. The AFMRD would encourage every program in the country to use these tools to improve their training, using their time effectively mentoring and guiding residents to self-learning. The faculty time saved in recreating and updating over 220 learning sessions translates into potential savings of thousands of dollars for a residency program. We have longed for the ability to have a living and shared system for all programs to improve the quality and performance of their residents on both board exams and clinical practice of family medicine. The Residency Curriculum Resource fills that need. This is such an exciting time for family medicine residency education. We look forward to the expansion and enhancements within the Residency Curriculum Resource over the coming years. We are committed to support the improvement of medical education in family medicine residencies through this ambitious initiative

THE SINGLE ACCREDITATION SYSTEM: MORE THAN A MERGER.

In February 2014 the Accreditation Council for Graduate Medical Education (ACGME), American Osteopathic Association (AOA), and American Association of Colleges of Osteopathic Medicine (AACOM) announced an agreement outlining a single graduate medical education accreditation system in the United

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.