Revived Duke Family Medicine Residency to Focus on Community Medicine

Less than a year after its announced demise, the Duke University Family Medicine Residency Program, like a phoenix, has risen from the ashes. The program, which stopped accepting new applicants in May 2006, will recruit residents for July 2008, according to an announcement by Brian Halstater, M.D., residency program director and assistant professor in the Department of Community and Family Medicine at Duke University School of Medicine, Durham, N.C.

"After much work, a final decision was made this week for us to move forward with our 'new Duke Family Medicine Residency Program,'" said Halstater in an April 23 online announcement.

AAFP President Rick Kellerman, M.D., of Wichita, Kan., lauded the move to revive the program. The Duke family medicine residency program, he said, "is important to the country because of Duke's stature. Duke has a long tradition of producing family physicians for the state of North Carolina as well as producing national leaders for family medicine."

Three days after the announcement, members of the Society of Teachers of Family Medicine, or STFM, learned more about the Duke program's revival during the 40th STFM Spring Conference seminar, "Tough Choices: Struggles to Create a Family Medicine Residency for the Future."

A key to the Duke effort was the Preparing the Personal Physician for Practice, or P4, initiative, said Victoria Kaprielian, M.D., professor and vice chair for education in Duke's community and family medicine department.

"What we were doing was not working for us, and we didn't think we had an option to do anything different," said Kaprielian of the 2006 decision to close the program. "This was a decision we made for ourselves. Then P4 happened."

Launched with initial funding from the Association of Family Medicine Residency Directors and the American Board of Family Medicine and staffed by AAFP's TransforMED practice redesign initiative, P4 will test teaching innovations designed to prepare family physicians for the new model of care described in the Future of Family Medicine Project report.

The P4 application process "gave us the option to put effort into designing what a dream residency program would be," said Kaprielian. Although the Duke family medicine residency program was not chosen as a final P4 program, the effort won the support of Victor Dzau, M.D., chancellor for health affairs at Duke University and president and CEO of the Duke University Health System. Dzau set aside funds for the program's residency positions. "This had never happened before," said Kaprielian.

Restructured to emphasize community-based continuity clinics, the revived residency program also requires coursework in clinical leadership -- such as fundamentals in health care financing, quality measurement and management, introduction to health care policy, and managing complex health care systems -- and confers a certificate of clinical leadership. The program will offer an optional fourth-year fellowship that leads to a master's degree in clinical leadership.

The new family medicine residency program will focus on meeting community needs and will work to match training with the reality residents will face when they enter private practice, Viviana Martinez-Bianchi, M.D., assistant professor of family medicine in the department and assistant director of the residency program, told seminar participants. For example, the residency program's inpatient rotations will be concentrated into the first year, and continuity and community clinics will be scheduled daily throughout training. That approach exposes residents to inpatient care but also reflects the reality that hospital admission rates from primary care physicians are down, said Martinez-Bianchi. Inpatient acuity is much higher than it was 20 years ago, and today's medical-surgical units are yesterday's intensive care units.

"The conditions we used to take care of in the hospital don't get admitted any more," she said. "People who have pneumonia or ketoacidosis are treated in the emergency department and sent home; they're never admitted. People with chest pain don’t get admitted; they're held in 36-hour observation to rule out (myocardial infarctions) and sent home."

As a result, although Duke residents will have rotations through hospital units, most resident training will occur in the community. The program is expanding procedures training and will rotate residents through a wound care clinic and the emergency room.

"The residency program should look to the community and identify community needs and reach out and meet those needs," said Martinez-Bianchi. Family medicine training should "start going to where the people are."