Sandra Carr

Residency “Dashboard”: Family Medicine GME’s Step Towards Transparency and Accountability?

As we drive to work each day, we each see things unique to our locales, but one thing in common is that we all look at our vehicle’s dashboard. We do this because it is one place that shows us information that affects each trip we make, unlike the weather outside, which may or may not have an

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.

The family medicine match: bull market or dead cat bounce?

This year’s national Match Day results were somewhat encouraging to America’s family medicine residency program directors. This year, 73 more training slots in family medicine were offered than last year[1][1] and US seniors filled 98 more positions than in 2009. However, only 7.3% of US medical

QUALITY IN RESIDENCY EDUCATION

The Association of Family Medicine Residency Directors (AFMRD) was founded 20 years ago to address the unique needs of family medicine residency directors. The founding principles included providing a forum for program directors to mutually assist each other. The organizational symbol of AFMRD has at its center the statement, “Leadership in Education”. An equally suitable statement for the center of the symbol would be, “Quality in Residency Education.” The AFMRD Board has been engaged in developing a strategic plan for the organization for the next 3 years. The centerpiece of the plan is a renewed emphasis on improving the quality of all residency programs. Other major components of the plan will be to raise the quality of resources for program director development, strengthen our advocacy efforts, promote and disseminate innovation in education, and structure our governance so as to most effectively operationalize our strategic goals. The Board vetted earlier versions of the strategic plan through thought leaders within family medicine education. We were challenged to be bold and to push our residency training programs and their directors to new levels of excellence. The Board was also challenged to consider if it could realistically improve medical student interest, improve the quality of those seeking to become family medicine residents, or tackle the level of medical student financial indebtedness without being part of a larger national effort. To that end, the Board has redirected its efforts in its strategic plan to those areas that we can most readily and directly influence, that is, to improving the quality of residency education. We expect that there will always be major medical knowledge content areas of family medicine that all residents will be expected to learn, regardless of any anticipated changes in the program requirements by the Residency Committee for Family Medicine of the Accreditation Council on Graduate Medical Education (RC-FM). These include adult medicine; care of neonates, infants, children, and adolescents; maternity care; musculoskeletal medicine; community medicine; and management of health systems, just to name a few. The AFMRD Board proposes that for each major content area, a series of robust and standardized goals, objectives, metrics, and competency-based evaluation tools be identified and developed. These tools would be made available to all residency programs. Individual programs could add additional tools to meet their local needs. Whether the RC-FM develops requirements for programs to prove that a resident is competent with the next iteration of the program requirements for family medicine or at a future revision, AFMRD is committed to developing a learning community in which best practices for evaluation of competency can be identified and shared. This ambitious goal will require the development of a platform(s) for sharing this information. The development and sharing of these tools is consistent with the foundational principle of program directors providing mutual assistance to each other. One of the cornerstones of improving the quality of residency programs is to raise the bar for all residency programs by increasing the transparency of residency program quality. To that end, the Board, and participating members, will develop a series of program quality metrics that can be incorporated into a quality dashboard. We envision a time when these measures will be publicly available. Although not a specific part of the plan, such an emphasis on developing best practices and increasing transparency may provide material for those engaged in educational research. The Board recognizes that these strategic goals for our AFMRD members are ambitious and are likely to extend beyond the current resources of the organization. To that end, the AFMRD Board will seek to identify opportunities for partnership with the full membership, other organizations within the family of family medicine, as well as other potential groups. In an era of increased transparency and scrutiny, non-profit entities, such as AFMRD, must be structured appropriately to be in full compliance of the law. In order to best serve its members, the Board has been actively exploring its governance, including its articles of incorporation so we can be able to form the partnerships needed to realize our goals. This article represents the first of a series of articles in the Annals of Family Medicine outlining components of the AFMRD strategic plan. Subsequent articles will be directed to expanding on some of the components of the plan. In addition, the plan will be presented to the full membership of the organization at the annual Program Directors Workshop in June 2010.

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.

How special is family medicine

Where, oh where have all the family doctors gone? In recent years, the number of US seniors choosing to train in primary care fields has declined. A major driver of this drop is the increased numbers of internal medicine and pediatric senior residents selecting to pursue fellowship training after

AFMRD—IMPROVING CONTINUITY OF COMMUNICATION

Program directors (PDs) and faculty deal with issues of ensuring and enhancing patient continuity of care by residents. In much the same way, the AFMRD strives to keep members informed and up to date on topics of common interest. Silence may be golden, but open, honest, and interactive communication is pure gold. One of the board’s tasks is to improve continuity of communication with our members. This is the responsibility of the AFMRD Communication Committee. Ascertaining the questions and concerns of our over 450 PDs, located in geographically diverse locations and working in a multitude of different practices, is a monumental task. Questions arise on a daily basis for PDs and family medicine faculty. To whom should the question be directed? Who is a recognized content expert? Many questions are posted on our AFMRD program director list serve. The traffic can be heavy and often redundant. Senior directors recognize that there are patterns of recurrent questions. Some of this may be due to high turnover rates. According to ACGME data, there have been 323 new or changed residency directors from 2004 to 2009 (http://www.acgme.org). With so many new or different leaders, continuity of communication is difficult. The AFMRD Communication Committee is choosing the most common frequently asked questions (FAQs) and seeking volunteer PDs to research and write a concise 250-word answer that will be posted on the AFMRD Web site (http://www.afmrd.org). These helpful answers will be located in the PD Toolbox. Hopefully, this will be a beneficial resource for new PDs as well as a quick reference for established directors. This will be an ongoing process with the ability to add new FAQs. “The AFMRD Board encourages you (directors) to actively participate in discussions on our list serve and to share your “best practices” with our membership by sending them to our staff for posting on our PD’s Toolbox section of our Web site,” wrote Dr Stan Kozakowski, President of AFMRD, on a recent AFMRD Web page. The PD Toolbox is one of the important components of the new and improved AFMRD Web site. To enhance communication, the AFMRD has a Features section of the home page covering current events of pertinent importance updated on a regular basis. The Highlights section emphasizes topics of timely information as well as board and member spotlights. Other important avenues of communication on the Web site include: (1) salary survey, (2) membership directory, (3) National Institute for Program Director Development (NIPDD), (4) financial management, (5) PD leadership awards, and (6) leadership and innovation. “I challenge each of you to share something that you think you do well with the rest of us,” encourages Dr Kozakowski in a recent AFMRD Web-page article. With so much change and stress in our workplace, PDs and faculty need the steadiness and support of an ongoing, open opportunity to communicate.

AFMRD STRATEGIC PLAN: PROGRESS IN GOVERNANCE

It is said that governance is the act or process of governing as it relates to consistent management, cohesive policies, processes, and decision making for a given area of responsibility; the kinetic exercise of managing power and policy in an organization. In August 2010 we celebrated 20 years as

INNOVATION IN FAMILY MEDICINE RESIDENCY TRAINING

“Here is Edward Bear, coming downstairs now, bump, bump, bump, on the back of his head, behind Christopher Robin. It is, as far as he knows, the only way of coming downstairs, but sometimes he feels that there really is another way, if only he could stop bumping for a moment and think of it. And