Program's Match Improves After Adding Optional Fourth Year

Four-year family medicine residency training strikes a chord with some medical students and may, in fact, increase their interest in the specialty, says the director of the University of Arizona Family Medicine Residency.

Patricia Lebensohn, M.D., said match results for the university's residency program have improved dramatically since 1999-2000 -- the worst match year in the program's history -- after program coordinators instituted an optional fourth year of training. Incoming residents now can select a four-year option to gain additional training in sports or integrative medicine or to complete a master of public health degree, said Lebensohn.

The University of Arizona Family Medicine Residency launched its first four-year option in 2001-2002. A year later, the program filled all its positions with U.S. graduates, according to Lebensohn. This year, the program filled six of eight positions -- due in part to lack of student knowledge about the addition of two extra positions late in the match process, said Lebensohn.

The additional training isn't designed to allow residents to subspecialize, she noted. Rather, it provides additional fellowship training in an area of interest and allows additional time to sharpen residents' expertise in those areas.

"The resident, for example, gets more training in procedures that they'll need in a rural practice," she said. "They are working more independently, but they still can ask questions and take time to do the rotations" needed for additional expertise.

The effort has paid off, according to Lebensohn. "We saw an increase in both the number and the quality of U.S. graduates to interview," she said. "I think having a fourth year helped. They solidify what they learned during the first three years" with focused training.

The University of Arizona experience echoes that of other programs that offer four-year family medicine training options. Most, like Arizona's, consist of fellowship opportunities in areas ranging from sports medicine to integrative medicine to obstetrics to geriatrics. Others offer combined training, such as the four-year dual family medicine-internal medicine program at Eastern Virginia Medical School in Norfolk.

But interest in four years of family medicine training seems to be growing. The University of Arizona experience supports earlier research by Ariel Smits, M.D., M.P.H., clinical instructor of family medicine at the Oregon Health and Science University, and her colleagues. In March, they suggested that extending family medicine residency to four years would have a neutral or positive effect on student interest in the specialty.

Writing in "Residency Applicants' Perspectives on Family Medicine Residency Training Length" (PDF file: 5 pages / 143 KB. More about PDFs.) in the March Family Medicine, Smits reported that 77.2 percent of respondents to a 2004-2005 survey said "increasing training to four years would either make them more likely to choose family medicine or would not affect their decision."

Still, much of that increased interest in a four-year family medicine residency rests on the availability of focused training, according to Perry Pugno, M.D., director of medical education at the AAFP.

"Students and residents are favorably disposed toward four-year family medicine residency training programs with the caveat that the fourth year offers a value-added experience," said Pugno. "They aren't interested in four years of the same thing."

Smits agreed. "If family medicine training were extended to four years, applicants appeared to be most interested in additional training that was specific to their unique interests or needs," she and her coauthors wrote. "The majority (77.8 percent) of respondents indicated interest in a four-year program with specific additional training rather than generically increased training time."

Although an optional fourth year appears to be gaining in approval ratings, a mandatory four-year program remains troublesome for many in family medicine education. Beyond potential student reactions to a four-year residency, financial barriers top the list of concerns. Residencies' host institutions may be reluctant to fund four-year positions, and graduate medical education, or GME, funding through Medicare supports residency training only for the period of time required for board certification. That means GME funds for a four-year family medicine residency won't be available unless the American Board of Family Medicine changes its certification requirements from three to four years of training.

Moreover, post-training service commitments begin at the end of the board-required training, and many residents with National Health Service Corps or other contracts could not complete a fourth year.

"I'm not convinced -- with the system requirements now -- that we are ready for a mandatory four-year program," said Lebensohn. "But we can definitely see the benefits of offering an optional fourth year. In general, our graduates have been extremely happy."