P4 Initiative Produces 'Radical' Approaches to Residency Training

Fourteen family medicine residency programs this summer are launching what have been dubbed "radical" approaches to training residents.

The 14 programs, participants in the Preparing the Personal Physician for Practice, or P4, initiative, expect to reorder students' understanding of family medicine, other specialties’ assessment of family medicine and residents' own perceptions of themselves as physicians.

They're doing so by taking it to the streets, so to speak, and restructuring their programs to focus on comprehensive -- but still community-based -- care that builds relationships with nonphysician and subspecialist health professionals.

The American Board of Family Medicine Foundation and the Association of Family Medicine Residency Directors, or AFMRD, pledged more than $1.7 million in 2006 to get the P4 initiative off the ground. The six-year project, which will evaluate the efficacy and feasibility of innovations implemented by the 14 chosen residency programs, is being staffed by TransforMED, the AAFP's practice redesign initiative,

Under the innovations taking shape in the P4 programs, family medicine educators will instill a solid family physician identity among residents, become a more integral part of other departments' functions, and train future leaders in medicine and community advocacy.

"I think there are pretty radical ideas here," said Sam Jones, M.D., of Fairfax, Va., immediate past president of the AFMRD and co-chair of the P4 initiative, on June 11 during the Workshop for Directors of Family Medicine Residencies in Overland Park, Kan. "These projects focus on training residents to be leaders, managers and change agents once they leave residency. They have more teaching in the community and less in the hospital. They support the patient-centered medical home. They use practice learning teams, and they focus on chronic disease management and prevention."

The challenge, said many residency program representatives during a May P4 retreat in Kansas City, Mo., is convincing the medical education infrastructure to lower barriers to innovation. During discussions at the retreat, P4 participants, including the Baylor College of Medicine Harris County Hospital District (HCHD) Family Medicine Residency Program in Houston, the Christiana Care Health Services Program in Wilmington, Del., and the Hendersonville Family Practice Residency Program in Hendersonville, N.C., described the problems their innovations would address, how the innovations would address those problems and the barriers they had encountered in implementing their plans.

"We have the typical structure where our residents are guests on other people's services," said Jane Corboy, M.D., program director at the Baylor College of Medicine HCHD family medicine residency, during the P4 retreat. "Our residents haven't figured out who they are as family physicians."

Solution: Resequence training; maintain family medicine center continuity; and emphasize learning teams that build proficiency, quality outcomes, and chronic disease management. Baylor's residents will spend most of their first year in outpatient family medicine services that are complemented by longitudinal ambulatory specialty experiences. During their second and third years, they will get inpatient experiences "that focus on family physician training" within emergency departments, intensive care, obstetrics, and adult and pediatric medicine settings, said Corboy.

Baylor also will offer a fourth year that residents can customize to their interests, such as inpatient and maternity care, preventive medicine, or international medicine.

Traditional primary care residency training encourages family medicine residents to "hand off" patients when their conditions require subspecialty attention. That approach fragments residency training in the same way that the current health care system fragments patient care into body parts and single-system diagnoses, said Lisa Maxwell, M.D., assistant director of predoctoral education at the Christiana Care Health Services Program.

The Christiana program will reorganize family medicine training by requiring the resident to follow the patient rather than follow a rotation schedule.

"The (traditional) curriculum paradigm is centered on content," said Maxwell. "We think our expertise is also in the process of practice. Several curricula continue out of tradition and have lost relevance. We want patient care to dictate curriculum."

To that end, when family medicine patients need to see a subspecialist, such as a cardiologist, "the resident will go with the patient to that department and say, 'This is my patient, and I'm following him through your department as you diagnose and treat him,'" Maxwell explained.

Faculty development comprises a large component of the plan because measures of competency will change under the innovation. Some faculty have expressed concern about measuring residents' competence with such an approach "because it's harder to measure than checking a box that says they (residents) have 'X' number of hours on a floor of the hospital," she continued.

Those reservations have diminished, however, as the family medicine program worked with other departments to define competencies and determine the best measurement tools. During those conversations, said Maxwell, other departments developed a better understanding of family medicine and its role in comprehensive health care.

"Some of their deep-seated feelings about family medicine came out, such as, 'Why is a primary care specialty on the ICU,?" she said. After explaining the advantages of family physicians' knowing about ICU care and issues, that type of question faded.

The program's first year also will maintain traditional rotation blocks, with a focus on ambulatory care, such as outpatient surgery and ambulatory maternity care. However, years two and three will allow residents to focus on an individualized area of interest.

"We're going to nurture those interests," said Maxwell. "Everyone will maintain the core of family medicine, but if you want to know more about sports medicine, we will let you focus more on sports medicine."

A decline in student interest in primary care has hit rural medicine particularly hard, threatening access to care for millions of small-town and rural residents. The Hendersonville Family Practice Residency plans to turn that around by exposing residents to solo rural practice that can be professionally and financially rewarding. In doing so, the program will ensure competency in the full spectrum of family medicine.

"The myths about rural medicine are wrong," said Steven Crane, M.D., Hendersonville program director.

Such myths -- including those about rural physicians' long work days and professional isolation -- will fall away as more residents and medical students get first-hand experience with new model rural practices, he said.

The Hendersonville Family Practice Residency will move residents' continuity clinical experiences and medical student rotations to a health network of three rural practices "in one- or no-stoplight towns," said Crane.

There, residents and students will observe that professional isolation melts away and long workdays disappear, thanks to electronic communication. Through a hospital-based regional health information organization, the three rural practices will receive practice management software and an electronic health record, or EHR, that is embedded with decision support and patient self-care modules.

"To get the technology to rural medicine, we can't rely on the current system, where the doctors buy the information technology," said Crane. "A shared clinical information system is the way to go, and with this, there will be tremendous savings of scale. The rural practices will get free EHR software with a high-end patient portal for virtual visits, setting up appointments and so on."

In addition to exposing family medicine residents to acute and chronic conditions in patients of all ages in the community setting, the Hendersonville program will improve their community leadership skills, said Crane.