New, Expanding Family Medicine Residencies Aim to Boost Access

August 31, 2016 02:50 pm Michael Laff

Chike Ochieze, M.D., one of the first family medicine residents at the DeTar Family Medicine Residency in Victoria, Texas, consults with a patient.

A number of new and expanding family medicine residency programs promise to increase the number of resident positions available and boost access to care for patients. Even better, many are using innovative approaches to reach those goals.

A new program at DeTar Healthcare in Victoria, Texas, for example, welcomed its first class of six residents just this past July; a residency opening next year at John Muir Health in Concord, Calif., will add eight new residents to the mix.

Meanwhile, the North Colorado Medical Center Family Medicine Residency Program in Greeley, Colo., expanded the size of its current class from nine to 11 in July of this year by adding a rural training track in Sterling.

And more changes have been happening at other programs around the country. In all, the number of accredited family medicine residencies grew from 485 in 2015 to 491 in 2016.

Story Highlights
  • New family medicine residencies around the country aim to expand access for patients in underserved areas.
  • A program scheduled to open in 2017 at John Muir Health in Concord, Calif., will include a six-week rotation in a mobile clinic.
  • The DeTar Family Medicine Residency in Victoria, Texas, emphasizes the teamwork of the patient-centered medical home.

Care for Medicaid Beneficiaries and Uninsured Patients

Leaders at John Muir Health discussed several options for their new residency program, but a looming primary care shortage and a dramatic increase in the number of patients who obtained coverage through Medicaid expansion tilted the balance in favor of family medicine.

Jeremy Fish, M.D., director of John Muir's family medicine residency program, told AAFP News that the region is facing a shortage of 200 primary care providers in the coming years. Furthermore, the number of MediCal beneficiaries increased from 50,000 to 250,000 during the past five years in Contra Costa County, where John Muir Health is located.

"Many families are now divided by insurer," Fish said. "Here the whole family can come because we take all insurers."

To ensure that residents get exposure to community medicine, they will spend a six-week rotation during their first year working in a mobile unit in an East Bay community that has a high number of uninsured patients. They will be encouraged to take a Spanish immersion class with the goal of attaining proficiency in medical language, in particular, that will allow them to work better with the local population.

"Students are hungry for something new," Fish said. "They are taught that the health system is broken and needs to be fixed. There is a lot of interest in doing things in a new way."

Fish said many medical students want a program that offers opportunities to work in teams while advancing a social justice mission. Fish said the residency, which is affiliated with the University of California, San Francisco, School of Medicine, was designed to reflect changes between his own generation and the current one.

Janaki Samaraweera, M.D., consults with a patient at the DeTar Family Medicine Residency in Victoria, Texas.

"We worked residents so hard in the 1980s and 1990s that the creative ideas weren't there to harvest," he said. "Millennials want a work-life balance. They can build more lasting and sustainable innovation. They will be happier as family physicians. They are looking for ways to be innovative and find creative ways of working as a team."

To build teamwork skills, residents will work alongside pharmacists, behavioral health specialists, medical assistants and nurse practitioners in episodes that will be videotaped. Fish said the method allows for immediate feedback.

"You learn to make eye contact and speak and listen to each person on the team, not just the leader," he said. That's what teamwork and empathy are about."

Practicing Primary Care Integration

Health care leaders in Victoria, Texas, saw the need for more primary care training given the area's shortage of physicians and a widely dispersed population, and they wanted to emphasize the teamwork of the patient-centered medical home (PCMH).

The DeTar Family Medicine Residency aims to address these needs with a program that started in July with six residents. The class will increase to 12 to 2017 and top out at 18 in 2018. The program is supported through a combination of Medicaid waivers, Medicare graduate medical education funds and state grants.

Faculty from the Texas A&M Health Science Center College of Medicine serve as instructors.

The program follows the medical home model, emphasizes integrated care with mental health and uses telemedicine.

Residency director Sidney Ontai, M.D., M.B.A., established a primary care clinic at Gulf Bend Center, an area mental health care facility, to provide more care integration. Local donations enabled construction of adjacent transitional housing where recently discharged patients live while they learn how to shop, seek employment, rent a home and other life skills.

"The last thing we need is more fragmentation of care in the country," Ontai told AAFP News.

The hallmarks of a medical home -- and their associated rigors -- are incorporated into the curriculum right away.

"None of the residents will have a day off on weekends, which they are not happy about, but with a PCMH you have to provide access on nights and weekends, so we built that in," Ontai said.

Ontai opened several telemedicine clinics with Department of Agriculture grants while he was in private practice in Victoria, and he said the residency will use the technology to increase access to care.

Residents at DeTar will spend time in telemedicine clinics, learning how to provide care in a sparsely populated area and gaining crucial experience working in sites with limited financial resources and a low volume of patient consults.

Ontai said the program has the major advantage of being the first residency in the area, which has two hospitals with 300 beds each. Plastic surgeons and cardiothoracic surgeons already told Ontai they want the family residents to scrub with them. The wide range of experience will prepare residents to practice in a rural area.

"Often, you will be the only physician in town, so you have to be prepared to do anything from performing a C-section to surgery," he said. "We are in a position to prepare these residents to do that."

Some residencies struggle to keep residents in the area after their terms are complete, but Ontai thinks careful screening will lead to high retention rates. Incoming residents are recruited for their interest in social determinants of health and their ties to the area.

Residents will also practice skills such as training staff and evaluating payment models using simulations developed in partnership with the Texas A&M College of Engineering. The program uses video gaming technology, which Ontai believes is ideal to engage the new generation of residents.

"They really respond to that," he said. "When you talk about CPT codes or hiring and firing, their eyes glaze over."

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