'One Giant Leap'

Four-year Family Medicine Residency Would Enhance Quality, Performance, Says Educator

June 09, 2010 03:05 pm Barbara Bein

At a time when some medical schools are considering condensing their programs -- and others already have -- one medical education expert says family medicine residencies should be expanded to four years to teach physicians-in-training more clinical skills, allow them time to concentrate on areas of particular interest and provide additional practice management education. The result, he says, would be a better-trained, highly skilled and business-savvy physician who can practice high-performance family medicine.

In an article(www.jabfm.org) in a supplement to the March/April issue of the Journal of the American Board of Family Medicine, Perry Pugno, M.D., M.P.H., director of the AAFP's Division of Medical Education, says that many of today's medical school graduates lack clinical patient-assessment skills, in part because economic pressures are pushing medical schools to shorten their time requirements. A four-year family medicine residency could enable those clinical skills to be taught and could be tailored to accommodate trainees' practice preferences.

"Some medical schools are not adequately teaching students how to do a basic history and physical, so residencies have to do it," Pugno said in an interview with AAFP News Now. "Duty-hour limitations (among residents) have severely constricted the time available for education. Demands on faculty give less time for one-on-one teaching, and there is more to teach every day."

Pugno writes in the article, "One Giant Leap for Family Medicine: Preparing the 21st Century Physician to Practice Patient-Centered, High-Performance Family Medicine," that postgraduate education of family physicians must change.

In addition to lengthening the residency, trainees should have longitudinal experience in continuity of care with a patient population in a community practice setting. They also should be able to customize their residency experience with a "value-added" component, such as a focus on preventive medicine, maternal/child care or geriatrics.

Pugno told AAFP News Now that family medicine residencies based in community health centers are an attractive model of his ideal of "a training program within a practice" instead of "a practice within a training program." Another promising model, he said, are residencies in large family medicine group practices that focus on being patient-centered medical homes, or PCMHs.

The key to the latter model, Pugno emphasized, is that the residencies exist within a practice that consists exclusively of family physicians.

"Ambulatory clinic settings, even with a PCMH framework, might not have the family medicine philosophical underpinnings that we feel are so important in the training of a family physician. And the 'personal engagement' part of practice is hard to teach in a multispecialty clinic," he said.

Pugno says in the article that a lengthened residency could help trainees better mold their training to their personal interests and priorities. During the third year, residents could take electives to pursue those interests and to leverage clinical areas of concentration. During the fourth year, in addition to polishing their PCMH skills, they could complete a scholarly project or learn about practice management issues, such as personal and small business economics.

"When residencies survey their grads, the No. 1 thing they say they wish they had more education in is practice management," Pugno said. "First- and second-year residents are too busy learning how to care for patients. So practice management, health policy and economics are best taught when residents are most open to learning these topics -- later in their residency."

Not surprisingly, the major barriers to implementing a four-year residency, according to Pugno, are time and money.

Many residencies don't have the infrastructure or funding to support scholarship among residents, he said. Current funding for graduate medical education is built around a three-year residency. The lengthened residency would delay getting family physicians into practice during a time of primary care shortages, although the quality of FPs entering the workforce would be enhanced.

"Everyone is in a hurry to get primary care health professionals into the workforce, so there is a lot of pressure to turn them out faster, without sufficient attention to the quality of the final product. I think an 'enhanced product' will do a better job for the American people and, ultimately, make the specialty more attractive to medical students," Pugno said.


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