Family Medicine Residencies Lead the Charge to Innovate Education

"I honestly think that this is the best time in our specialty to come into a residency program. Every program director I talk to has the spirit of innovation. This is a once-in-a-generation opportunity."

With that, Joseph Gravel, M.D., director of the Tufts University Family Medicine Residency program at Cambridge Health Alliance, Malden, Mass., introduced himself to residents, students and peers during the National Conference of Family Medicine Residents and Medical Students Town Hall on Education here on Aug. 2.

Gravel joined three other family medicine educators in a discussion about family medicine education and the role of students and residents in forming and fomenting change. His colleagues were Reid Blackwelder, M.D., professor and director of the family medicine residency program at East Tennessee State University, Johnson City; Samuel Jones, M.D., immediate past president of the Association of Family Medicine Residency Directors and director of the Fairfax Family Practice Center at Virginia Commonwealth University, Fairfax; and Terrence Steyer, M.D., assistant professor of family medicine at the Medical University of South Carolina, Charleston.

The revolution in health care simmers in family medicine residency programs, where each year, incoming first-year residents bring along their expectations for patient care and office management processes, according to Gravel. Residency programs "are the culture of change," he said. "We change every year. We have a new class every year."

Residency training must foster leadership, "because the leaders of health care reform are going to have to be the generalists," Gravel continued.

Jones agreed. "I think a lot of the change agents are going to be our residents," he said.

Increasingly, those residents expect training programs to offer experiences in their areas of interest. Residency programs have responded by offering optional four-year training that adds, for example, a master's degree or a focus in a specific clinical interest, such as sports medicine or international health. Others provide fellowships in specific areas.

"A lot of our residencies are doing this," said Jones. "They are providing an individual education plan, so to speak, that gives additional skill sets that meet your career goals. They recognize that if our graduates are going to have to adapt to community need, their education must prepare them to adapt."

That approach does not and should not detract from comprehensive training, however, said the speakers. Limiting educational experiences ultimately limits a resident's career options, said Blackwelder.

Between 50 percent and 70 percent of program graduates find they are practicing in a location far different from what they initially planned, according to the panelists. The upshot: FPs who hadn't planned to offer obstetrics are delivering babies, or doctors who thought they wanted a suburban practice are flourishing in an urban or rural setting that demands the full complement of family medicine skills.

Equally important to medical students are residency programs that have implemented -- or are planning to implement -- patient-centered processes, such as group visits, open scheduling and online patient communication. Students can spur such innovation by communicating their expectations during their residency interviews, according to the panelists.

"Ask questions," Gravel advised. "Don't ask just the program directors; ask the residents. Try to ascertain the philosophy of the program, the openness of the program, the culture of the program and if they want to be innovative."

Steyer agreed. "Ask specific questions, such as, 'Do you have group visits?' or 'Do you have open-access scheduling?' Don't ask whether they have the new model of care, because the residents won't know what you're talking about. A lot of residency programs implemented the new model for more years than the residents have been there. So, to them, the new model has always been there."

Family medicine has led the medical community in meeting patient needs and expectations and in implementing quality-of-care measures, said Blackwelder. With the model of care launched by the 2004 Future of Family Medicine Project report and AAFP's leadership in establishing performance measures, the specialty and family medicine educators have designed a system that -- if fully implemented -- "allows us to focus on a continuous healing relationship" with patients, said Blackwelder.