NCSC Delegates Debate Procedures Training, Resident Work Hours, PCMH

Chapter special constituency representatives who attended the AAFP's 2009 National Conference of Special Constituencies, or NCSC, here April 23-25 churned through a hefty agenda of education-related issues. One measure that sparked spirited discussion dealt with procedural training for family medicine residents. Other proposals asked the Academy to step up opposition to additional limits on residents' work hours and to call for increasing family medicine residents' exposure to the patient-centered medical home, or PCMH.

The upshot: NCSC delegates (i.e., voting representatives) approved measures directing the AAFP to explore reduced pricing options for procedures training coursework and develop formal policies opposing nonevidence-based duty hour restrictions and encouraging education about the PCMH during residency.

Proponents of a resolution promoting standardization of procedural training (Resolution No. 35; 21-page PDF; About PDFs) testified April 24 during a hearing of the Reference Committee on Education about the importance of procedural training -- especially for family physicians, who routinely perform a wide range of services and procedures.

Minority constituency representative and resolution co-author Ozioma Evans-Nwosu, M.D., of Aurora, Colo., was first to the microphone. She testified that because each residency program currently defines its own set of "core" procedures in which its residents are trained, there's a lack of consistency in this regard across programs nationwide.

Furthermore, Evans-Nwosu said, the prohibitive costs of providing many types of procedural training puts some programs and their residents at a disadvantage. The resolution she and her co-authors submitted would help address that discrepancy, she said, by directing the Academy to provide "affordable online and on-site access to the National Procedures Institute (NPI) courses and curriculum for residents and faculty."

Jay Lee, M.D., M.P.H., of Long Beach, Calif., a minority constituency co-convener and special constituency alternate delegate to the AAFP Congress of Delegates, was among those who supported the concept of a standard set of core procedures. "This sort of training would help strengthen the call for credentialing of family physicians across this nation," he testified.

Others, however, testified that some degree of regional variability in procedures training is not only to be expected, but may be preferable, given that FPs practice in diverse geographic areas and widely varying practice settings.

Some, like women's constituency representative Alison Lauber, M.D., of Augusta, Ga., pointed to the difficulty of achieving consensus on what procedures should be counted among such a standardized set. Inclusion of certain types of training, she told reference committee members, could raise moral issues among some residents or sponsoring institutions.

New physician representative Maren Dunn, D.O., of Cascade, Idaho, raised another concern, testifying that adding more requirements to family medicine residents' already full curriculum could mandate a longer residency. Moreover, she told the reference committee, "Most of us are motivated enough to figure out what we want added to our repertoire" of procedures, and can do so via CME activities.

In its report, (12-page PDF; About PDFs) the reference committee stated its belief that the concept of procedures training standardization is already being addressed by the Residency Review Committee, or RRC, for Family Medicine of the Accreditation Council for Graduate Medical Education, or ACGME, and offered a substitute resolution that calls for the AAFP to investigate a reduced pricing structure for procedural training courses for family medicine residents.

The delegates agreed with the reference committee's recommendation, adopting the substitute measure.

The prospect of further limiting residents' duty hours was another hot-button topic at this year's conference, with chapter representatives testifying on a resolution calling for the Academy to establish an official policy opposing further work-hour restrictions. (Resolution No. 12; 21-page PDF; About PDFs).

Resolution co-author and new physician James Gainey, M.D., of Spartanburg, S.C., said that although he recognized the actions the Academy already has taken on this issue, the AAFP should adopt a definitive policy opposing further work-hour restrictions in the absence of evidence supporting their effectiveness.

California AFP gay, lesbian, bisexual and transgender constituency representative Jennifer Burnett, M.D., of Selma, also cited the difficulties residency programs have adhering to the existing regulations. "If you keep on putting these restrictions in place with no evidence basis, you will eliminate family medicine residencies, because they won't be able to comply," she told chapter representatives at the April 25 business session.

Others, however, pointed out that evidence upholding the wisdom of limiting duty hours does exist. Robert Stenger, M.D., of Portland, Ore., resident chair of the National Conference of Family Medicine Residents and Medical Students and a resident delegate to the Congress of Delegates, spoke against the measure, which he said "doesn't look good in the court of public opinion," despite its positive intentions.

For third-year resident and Texas AFP resident representative Emily Briggs, M.D., of San Antonio, the issue boils down to what's best for patient care.

"Your patient in her 30th hour of labor isn't going to care that you need a nap," Briggs said. "We need to be there for our patients."

The delegates, apparently, agreed and adopted the measure despite the reference committee's recommendation that it be rejected.

After some last-minute maneuvering during the April 25 business session, NCSC delegates adopted a second measure that also had received the education reference committee's thumbs-down.

Although testimony on a resolution aimed at boosting PCMH training in residency programs (Resolution No. 39; 21-page PDF; About PDFs) was overwhelmingly favorable, reference committee members took exception to how this would be accomplished. Specifically, the measure asked the Academy to engage the ACGME and the Association of Family Medicine Residency Directors, or AFMRD, in removing barriers to implementation of the medical home in residencies and including more training in PCMH practices in the residency curriculum.

Both authors of the measure addressed the reference committee, with new physician representative Mark Johnson, M.D., of Seattle, testifying that ACGME requirements on the number of patient encounters residents must complete during residency posed an obstacle to PCMH implementation in his residency.

"We're asking the AAFP to advocate the training of residents in the patient-centered medical home, and we're asking that that training happen at the level of ACGME and the RRC," Johnson said. AFMRD's role, he added, would be to integrate more PCMH training into its practice management curriculum.

The reference committee recommended in its report (12-page PDF; About PDFs) that delegates not adopt the resolution, saying that the ACGME and AFMRD were "not appropriate targets for this action." That action spurred Johnson's co-author on the original resolution, new physician representative Risheet Patel, M.D., of Fishers, Ind., to offer an amended version during the April 25 business session.

The amended version, which delegates adopted handily, calls on the AAFP to develop a policy encouraging education about the PCMH during residency.