December 21, 2021, 2:21 p.m. David Mitchell — One thousand six hundred and fifty has long been a significant number for family medicine residents in pursuit of graduation requirements.
Among the numerous notable changes in the proposed revisions to the Program Requirements for Graduate Medical Education in Family Medicine recently published by the Review Committee for Family Medicine, the standard of 1,650 continuity patient encounters would be eliminated. Instead, all residents would be required to have identified patient panels for the duration of their training. Those panels would have to meet certain requirements to reflect the scope of family medicine. For example, at least 10% of a resident’s ambulatory patients would need to be under age 18, and at least 10% would be 65 or older.
Karen Mitchell, M.D., vice president of the AAFP’s Division of Medical Education, said some residents have difficulty reaching the 1,650 face-to-face patient encounters currently required at the family medicine practice site. That challenge was exacerbated by the pandemic.
Mitchell said the proposed requirements would give programs flexibility while still allowing residents to gain experience in managing a patient panel, impacting population health and caring for a wide variety of patients with different levels of complexity.
The proposed revisions are the latest step in an exhaustive process that began in early 2020 when the Accreditation Council for Graduate Medical Education announced plans for a major revision of the family medicine residency requirements. The proposed requirements are available for review and comment through Jan. 28.
After the comment period and subsequent revisions, the requirements still must be approved by the ACGME Board of Directors. Mitchell said it is expected that the process will be finalized before the next academic year begins in July 2022. Programs would then have until July 2023 to fully implement the new requirements.
In a video that explains the process and the resulting proposed changes, Writing Group Chair Stacy Potts, M.D., M.Ed., urged her fellow family physicians to carefully consider the proposed requirements and provide feedback.
“Family medicine is critical to improving the health of our nation and rebuilding the health care system,” Potts said in the video. “We must provide the training for family physicians that will ensure that they are leaders and architects of future health systems to provide accessible, equitable and affordable care for our population. As a specialty that values our generalist roots, the breadth and scope of this training must allow the flexibility to serve the diverse community needs across our country — in rural areas, as well as urban underserved areas and everywhere in between. The moment is now, and we all have the responsibility to get this right.”
Another proposed change would reduce the minimum size of a residency from four slots per year to two. Small rural training tracks currently have to be connected to a larger program where residents spend their first year before working primarily in a rural setting for two years. Mitchell said the new requirements would allow training in the same location for all three years of residency, which would “create more flexibility, especially in rural training.”
Potts said the writing group sought to find the right balance of standardization and flexibility. She compared the proposed requirements to a popular baking show in which contestants are given some of the ingredients to make same product but also are afforded the leeway to add ingredients based on their own knowledge and skill.
“What we want these requirements to do is give programs the ability to focus on their community, the strengths their program has and to give their learners exactly what they are looking for for their future practice,” she said.
All residents would be required to have an individualized education plan, including six months of electives. Mitchell said the change would provide opportunities to fill an individual learner’s knowledge and skill gaps or to allow a resident more time to focus on areas of interest.
Other significant changes would offer programs flexibility regarding maternity care as well as overall length of training. All residents would be required to reach at least 25 vaginal deliveries for basic skills in uncomplicated deliveries. The requirements specify higher minimum delivery experience for those seeking the option to incorporate comprehensive maternity care into independent practice.
Additionally, there will be an opportunity to participate in an innovation trial for programs interested in providing four years of residency education instead of three. The trial will use the ACGME’s Advancing Innovation in Residency Education program.
“It’s one way to explore what competency-based medical education looks like,” Mitchell said. “Programs will have the ability to innovate and design educational programs with explicit attention to competencies in focused areas of additional training and share the data and learnings. The additional time can be used for robust integrated training, areas of clinical concentration such as addiction medicine, or embedding additional degrees or fellowship training.”
More information regarding the innovation trial is expected to be released soon by the ABFM, Mitchell said.
In addition to the proposed revisions and related webinar, the ACGME has posted a summary and impact statement regarding the proposal.
Potts said the revisions were not intended to be burdens to programs but to ensure that residents are well prepared for the future. However, she encouraged family physicians to highlight potential “unintended consequences” of the proposal during the comment period.
“The process has included the community of family medicine at every step,” Potts said, “but this period of public comment to the actual proposed requirement is critical to our success in this transformation.”