'Innovate, Create,' Say Speakers at RAP Workshop

Assumptions collided with reality when residency faculty and staff at a recent meeting pondered how to train family physicians for the 21st century. "We should look at fundamental change," John Saultz, M.D., professor and chair of the family medicine department at Oregon Health & Science University, Portland, said at the Residency Assistance Program Workshop for Faculty & Staff of Family Medicine Residencies, April 2-4 in Kansas City, Mo.

During a session on creating new residency models, Saultz and Alan David, M.D., professor and chair of the family and community medicine department at the Medical College of Wisconsin, Milwaukee, built from ideas in the Future of Family Medicine Project report. They challenged assumptions on which the specialty's training programs are based.

"Our first assumption has been that our residencies are hospital-based," said Saultz. "But a busy family doctor today has a census of hospital patients that is about one-fourth the size it was a few decades ago." He suggested making residencies no longer hospital-based but patient- and population-based, with residents receiving much of their training in exemplary family medicine practices.

"If your residency teaching clinic can't be exemplary, then eliminate the clinic and have the residents trained in family practices," Saultz said. However, he added, "We're not saying that all rotations go away. They need to be concentrated on things you can't get in the practice" in sufficient numbers for training, including deliveries, fracture management, hospital admissions, ICU care, trauma care, and certain office procedures (e.g., vasectomy).

Turning to a second assumption, Saultz said, "We want residents to take care of myocardial infarction and shoulder dystocia," but many more patients may need help with prevention of illness than with treatment, and current training emphasizes treatment. Calling for a focus on prevalent diseases rather than individual episodic care, he said, "We may know how to diagnose hypertension and may know the drugs for it, but we may not know how to help patients reduce hypertension. Instead of emphasizing high acuity, what if we trained to mastery of high-prevalence conditions?"

David suggested training to basic competencies and building residencies on competency modules, not rotation blocks. "The new RAP criteria define competencies and call for no curriculum-block requirements," David said. "I tell medical students, 'You can be good in a couple of areas. The future of family medicine is five or six family physicians with a team of others. Some family physicians may do more inpatient hospital care; some may do treadmills; some may do echocardiograms.'"

David also tells medical students, "If I have a patient who needs a colonoscopy, I say, 'Dr. Jones does this here every Friday morning, and he's as good as the gastroenterologist at the hospital,' and the patient is glad" to have the procedure at the family medicine practice.

David also described the process for hospital rounds: People scurry around the hospital, see which patients need what and then do rounds for perhaps 15 patients. He questioned the assumption that rounds are just for hospital care. "Shouldn't we have rounds in our practices?" asked David. "Shouldn't we ask who's made ER visits? Is there a predominance of gastroenteritis in the patients? Do we take care of the population? Do we teach our residents to do this?"

During the question-and-answer session following the presentation, Deborah Clements, M.D., associate director of the family medicine residency at the University of Kansas Medical Center, Kansas City, commented, "With the Future of Family Medicine Project, we don't know what we need to do."

In response, Saultz said he tells medical students the specialty is trying to invent a new way of doing family medicine, and then he says, "We don't know where that will take us, but we want to do it with you."

In an interview after the session, Clements reflected on Saultz's response. She said residencies hadn't before been given permission to tell medical students, "We don't know what we need to do" and to ask them to learn along with the faculty. "Will this turn away medical students? Yes," she said. "Will it keep the ones we most need? Yes."