Samuel M. Jones

Assessing the impact of innovative training of family physicians for the patient-centered medical home.

BACKGROUND New approaches to enhance access in primary care necessitate change in the model for residency education. PURPOSE To describe instrument design, development and testing, and data collection strategies for residency programs, continuity clinics, residents, and program graduates participating in the Preparing the Personal Physician for Practice (P(4)) project. METHODS We developed and pilot-tested surveys to assess demographic characteristics of residents, clinical and operational features of the continuity clinics and educational programs, and attitudes about and implementation status of Patient Centered Medical Home (PCMH) characteristics. Surveys were administered annually to P(4) residency programs since the project started in 2007. Descriptive statistics were used to profile data from the P(4) baseline year. RESULTS Most P(4) residents were non-Hispanic white women (60.7%), married or partnered, attended medical school in the United States and were the first physicians in their families to attend medical school. Nearly 85% of residency continuity clinics were family health centers, and about 8% were federally qualified health centers. The most likely PCMH features in continuity clinics were having an electronic health record and having fully secure remote access available; both of which were found in more than 50% of continuity clinics. Approximately one-half of continuity clinics used the electronic health record for safety projects, and nearly 60% used it for quality-improvement projects. CONCLUSIONS We created a collaborative evaluation model in all 14 P(4) residencies. Successful implementation of new surveys revealed important baseline features of residencies and residents that are pertinent to studying the effects of new training models for the PCMH.

Five Key Leadership Actions Needed to Redesign Family Medicine Residencies

BACKGROUND New skills are needed to properly prepare the next generation of physicians and health professionals to practice in medical homes. Transforming residency training to address these new skills requires strong leadership. OBJECTIVE We sought to increase the understanding of leadership skills useful in residency programs that plan to undertake meaningful change. METHODS The Preparing the Personal Physician for Practice (P4) project (2007-2014) was a comparative case study of 14 family medicine residencies that engaged in innovative training redesign, including altering the scope, content, sequence, length, and location of training to align resident education with requirements of the patient-centered medical home. In 2012, each P4 residency team submitted a final summary report of innovations implemented, overall insights, and dissemination activities during the study. Six investigators conducted independent narrative analyses of these reports. A consensus meeting held in September 2012 was used to identify key leadership actions associated with successful educational redesign. RESULTS Five leadership actions were associated with successful implementation of innovations and residency transformation: (1) manage change; (2) develop financial acumen; (3) adapt best evidence educational strategies to the local environment; (4) create and sustain a vision that engages stakeholders; and (5) demonstrate courage and resilience. CONCLUSIONS Residency programs are expected to change to better prepare their graduates for a changing delivery system. Insights about effective leadership skills can provide guidance for faculty to develop the skills needed to face practical realities while guiding transformation.

Financing Residency Training Redesign

BACKGROUND Redesign in the health care delivery system creates a need to reorganize resident education. How residency programs fund these redesign efforts is not known. METHODS Family medicine residency program directors participating in the Preparing Personal Physicians for Practice (P(4)) project were surveyed between 2006 and 2011 on revenues and expenses associated with training redesign. RESULTS A total of 6 university-based programs in the study collectively received

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

5,240,516 over the entire study period, compared with

A Model for Catalyzing Educational and Clinical Transformation in Primary Care: Outcomes From a Partnership Among Family Medicine, Internal Medicine, and Pediatrics.

4,718,943 received by 8 community-based programs. Most of the funding for both settings came from grants, which accounted for 57.8% and 86.9% of funding for each setting, respectively. Department revenue represented 3.4% of university-based support and 13.1% of community-based support. The total average revenue (all years combined) per program for university-based programs was just under

Perceptions of Becoming Personal Physicians within a Patient-CenteredMedical Home

875,000, and the average was nearly

Preparing the personal physician for practice: changing family medicine residency training to enable new model practice.

590,000 for community programs. The vast majority of funds were dedicated to salary support (64.8% in university settings versus 79.3% in community-based settings). Based on the estimated ratio of new funding relative to the annual costs of training using national data for a 3-year program with 7 residents per year, training redesign added 3% to budgets for university-based programs and about 2% to budgets for community-based programs. CONCLUSIONS Residencies undergoing training redesign used a variety of approaches to fund these changes. The costs of innovations marginally increased the estimated costs of training. Federal and local funding sources were most common, and costs were primarily salary related. More research is needed on the costs of transforming residency training.

Aspects of the patient-centered medical home currently in place: Initial findings from preparing the personal physician for practice

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.

A New Foundation for the Delivery and Financing of American Health Care.

Purpose To report findings from a national effort initiated by three primary care certifying boards to catalyze change in primary care training. Method In this mixed-method pilot study (2012–2014), 36 faculty in 12 primary care residencies (family medicine, internal medicine, pediatrics) from four institutions participated in a professional development program designed to prepare faculty to accelerate change in primary care residency training by uniting them in a common mission to create effective ambulatory clinical learning environments. Surveys administered at baseline and 12 months after initial training measured changes in faculty members’ confidence and skills, continuity clinics, and residency training programs. Feasibility evaluation involved assessing participation. The authors compared quantitative data using Wilcoxon signed-rank and Bhapkar tests. Observational field notes underwent narrative analysis. Results Most participants attended two in-person training sessions (92% and 72%, respectively). Between baseline and 12 months, faculty members’ confidence in leadership improved significantly for 15/19 (79%) variables assessed; their self-assessed skills improved significantly for 21/22 (95%) competencies. Two medical home domains (“Continuity of Care,” “Support/Care Coordination”) improved significantly (P < .05) between the two time periods. Analyses of qualitative data revealed that interdisciplinary learning communities formed during the program and served to catalyze transformational change. Conclusions Results suggest that improvements in faculty perceptions of confidence and skills occurred and that the creation of interdisciplinary learning communities catalyzed transformation. Lengthening the intervention period, engaging other professions involved in training the primary care workforce, and a more discriminating evaluation design are needed to scale this model nationally.

Preparing the Personal Physician for Practice (P4): A National Program Testing Innovations in Family Medicine Residencies

Objective: Residency training is transforming how to teach residents about practicing as a personal physician in a Patient Centered Medical Home [PCMH], but little is known about how trainees experience these responsibilities. Methods: This study used an online survey with open-ended questions to assess residents experiences with curricular innovations as part of learning to practice as physicians in a PCMH. The survey questions were distributed every six to 12 months. This analysis focuses on responses to a single question administered once, “What does being a personal physician working in a medical home mean to you?” Two independent researchers analyzed text responses using an immersion-crystallization approach. The full research team met to discuss emerging themes. Principal findings: Sixty-two residents representing 78.6% of participating training programs responded to the online survey question that is the focus of this analysis. Overwhelmingly, resident respondents reported finding meaning in the humanistic and interpersonal aspects of medicine. In particular, residents reported that being a personal physician in a PCMH meant being the go-to person for patients’ healthcare needs. This included delivering patient-centered, continuous care in the context of a physician-patient relationship that broke down the traditional physician-patient hierarchy. Being a personal physician also included an important role for the physician and clinical team members in orchestrating the referral and care coordination process. To accomplish this, residents recognized that personal physicians needed to learn the art of practice. Conclusion: Physicians trained in newly redesigned residencies understand and embrace their role and relationships with patients and health care teams that emerge as part of the PCMH. Residency redesign efforts can inculcate new family physicians with key practice ideals and knowledge about how to achieve these in practice.