New Program Requirements Offer Residents Flexibility
FP Experts Praise Move Toward Competency-based Education
June 14, 2023, David Mitchell — New program requirements for family medicine residencies take effect July 1. AAFP News recently sat down with two officers of the Association of Family Medicine Residency Directors to discuss what the changes mean for residents, programs and students.
AAFP News: What should residents know about the new requirements from the Accreditation Council for Graduate Medical Education?
Sarah Cole, D.O., AFMRD president-elect and program director at Mercy Family Medicine in St. Louis: One of the questions my residents have been asking is, why do we have new requirements for training in family medicine? The way I’ve been responding is that each specialty reviews its training requirements every 10 years or so to make sure they are still training competent physicians. This time around, as we reviewed for a major revision, the family medicine review committee did something a little bit unique compared to what they’ve done in the past. They revised the requirements to prepare residents not only for the way medicine is practiced now but the way medicine might be practiced in 10 years, in 20 years, in 30 years, in 40 years.
Medical knowledge and the skills needed to deploy it are changing rapidly. Frankly, every element of our society is changing rapidly, so the medical knowledge a resident acquires in training now may be irrelevant during their career. Training in residency needs to be a little bit less about the exact information and skills that a resident is acquiring during residency and a little bit more about acquiring or mastering the ability to access information or to learn new skills that will be applicable to the community in which they’re practicing so that family physicians can remain accountable to society and society’s needs moving forward.
Kimberly Stutzman, M.D., AFMRD immediate past president and program director at the Family Medicine Residency of Idaho − Nampa: Residents should know that the new requirements really speak to the family physician as a master adaptive learner. Our ability to understand knowledge over time and to incorporate the needs of an entire population, a community, drive our ability to provide great care not just for the needs of the individual but the needs of an individual within the context of the family, within the context of their community, and to really recognize the ripple effect a single family physician can have. I think it’s through these new requirements that we help residents, and then future family physicians, leverage that ripple effect of their knowledge base and their skills.
Kimberly Stutzman, M.D.
AAFP News: As program directors, what are you most excited about in these changes?
Stutzman: I’m most excited about the flexibility that is being brought to bear on resident education. We recognize that not all family doctors practice the same medicine, the same scope of practice, but our training allows us to start flexibly moving into spaces that prepare a family physician to provide for the needs of their community through developing an individualized learning plan. An individualized learning plan allows a resident to seek opportunities to stretch into things they really love to do within the context of their program. It allows them to accommodate something that’s harder to learn and gives them the flexibility to have the time to do that, so we’re really looking at competency-based education models. Giving residents flexibility within the increased number of electives allows them to prepare themselves to be the best family doctor they can be for the community that they’re going to choose to serve.
Cole: One of the things that excites me the most about the new program requirements is that they really move us toward competency-based medical education. So both medical schools and residencies are migrating toward competency-based medical education, or CBME. But they’re doing it in slightly different ways. Medical schools may be more task-oriented. They may have a checklist: “Can medical students complete a history? Can they perform a physical exam? Can they pass a test? Can they pass Step 1 of their board exams?”
Residencies, particularly with these new program requirements in family medicine, are moving more toward behavior-oriented CBME or outcomes. So they are asking, Can you do this effectively? For example, another family physician and I may approach a patient with diabetes who needs a lowered hemoglobin A1c in two different ways. We may use different coaching methods. We may suggest different medications, but the end result is the patient has a lowered hemoglobin A1c. Both ways are effective, and that’s what these program requirements move residents toward, particularly in family medicine. Learning how to be effective, that’s an iterative process. That’s formative. That requires self-reflection. It requires feedback. It requires being receptive to feedback. These new requirements really challenge residents to practice a growth mindset in order to become master adaptive learners, so they continue to learn new knowledge and new skills that are going to be coming along through the 30-, 40-, and 50-year course of their career. I really think that medical school graduates and residents who can practice that growth mindset are the ones who are going to be thriving under the new program requirements. It’s exciting to think about their growth as adult learners and practitioners in their communities.
AAFP News: St. Louis is obviously a lot different than rural Idaho. How do the new requirements give you the flexibility to meet the unique needs of your communities?
Stutzman: The new requirements give us that flexibility to really customize a resident’s education to prepare them to work in different settings. We have some physicians in our residency that are going to go to small rural spaces, and they generally tend to have more desire to work in the emergency room or more desire to do inpatient medicine. I have residents who wish to track into OB and some who choose to track out of OB. I think these new requirements have allowed programs to give residents both the space to customize their residency education and the ability to learn how to assess yourself as a learner, to know where you need more time, where you need to develop better skills, because that doesn’t come naturally, necessarily, to all of us. And so really teaching residents how to assess their needs and their desires for future practice and then build their training model around those needs.
Cole: We’ve talked a lot about how the new requirements can help a resident be flexible in their individual needs. For example, my program is in a suburban area; about one-third of my residency graduates will go practice in a rural area, about one-third will stay in a suburban area and then about one-third will go to an urban area. So, each individual resident is able to use some of their additional community time with the new requirements and their elective time to really customize their training toward their future practice site.
Sarah Cole, D.O.
My residents who plan to go to a rural area will now be spending more time precepting with our network of rural preceptors to go out there and get that exposure a little bit earlier on. But an additional way that these program requirements emphasize community is actually for the program itself. One of the new requirements is that we need to have an advisory council made up of diverse members who have lived experience representative of the community. That’s not something my program has had previously, and we’re looking forward to adding that. I think it would be a great way to see what clinical services we may be missing out on. What are the stakeholders of our program seeing that we are not doing that we should maybe think about moving into that space? What are the things that we are doing well that we should continue doing? Similarly, as a program, I think we can get out into our community area and start to partner in ways that we haven’t before, particularly now, because we used to do that to a greater extent than we do now and we had to take a step back during COVID. We’re sort of emerging into this timeframe when some of our community partners are ready to reengage at the same time these requirements are coming out. We have this opportunity to brainstorm about what can we as a residency clinic, as a residency program, do to help our community here in St. Louis in ways that we haven’t before. That’s also a neat way that the program requirements challenge us.
AAFP News: What do medical students need to know about how the new requirements will affect the future of family medicine?
Stutzman: I feel like the future of family medicine is so bright. We now have both the flexibility and the opportunity to allow residents to develop into the comprehensive, full-scope family doctors that many of us have as our ideal. And now we have some flexibility to create that full-scope family doc, not just the way I think they should be, but how a learner feels they should become that full-scope physician. I also feel like we are in some ways taking back the future of primary care as family physicians, being able to provide that continuity of care across generations for an entire family, and that becomes so critical to the future of the health of our country.
Cole: One of the things I appreciate about the new program requirements is they really have doubled down on this concept of continuity and comprehensiveness. Family physicians really serve as the first point of contact not only for individual patients and communities as we’ve been discussing, but that’s a longitudinal relationship, right? That lasts over time, so ACGME is now asking us to actually measure continuity. How well are we doing with making sure our resident physicians and training are establishing those longitudinal relationships with their patients in clinic?
They’re also asking us to double down on the comprehensiveness. How well are we training our physicians across the broad scope that is family medicine? So we’re really sort of putting our money where our mouth has been for a long time and starting to collect and provide data that shows how family physicians are those first- point-of-contact, continuous, comprehensive presences in our patients’ lives.
Family physicians have also long been advocates for social justice. Physicians in general, but family physicians in particular, are attuned to social determinants of health and how they affect not only our patients, but their multigenerational families and all life stages. And so that, too, is really emphasized in the new program requirements.
AAFP News: Dr. Stutzman, what would you want to add about social determinants of health and health equity?
Stutzman: That’s the heart string that pulls people into family medicine in a way that continuity doesn’t because medical students have no idea what continuity means. Unless they’ve had a family doctor, they don’t know what it means because they haven’t had it. They haven’t seen it and they don’t know why it’s valuable until they get here. And then they’re like, “Oh, my gosh, why doesn’t everyone have a family doctor?”
I think social determinants and health equity are just those things that are like, “Oh, I want to fix the world.” I see that in my kids. Like, “I want to go fix the world. The world is broken. You broke it. I want to go fix it.” What makes us excited is the addition of advocacy and of paying attention to our patients’ social determinants of health. And how do we as a program go about trying to help unpack the effects of social determinants of health on our patients? How do our health care systems really start to address where we can make changes there? Using the lens of health equity allows us to determine if the care we’re providing is, in fact, equitable.
Cole: One of the things that the new program requirements allow us to do, I think, is to roll out some pieces of our curriculum that previously only some residents have been able to do. So, I'm thinking in my program about advocacy. And so for a long period of time, we have had some elective experiences in advocacy for residents who are interested. So, residents with whom advocacy resonated, we could form a one-month educational experience around that that would involve speaking with some health policymakers, speaking with some lawmakers about health policy and ways they might influence those. With the new requirements, that can become a standard experience all of our residents in family medicine will be able to participate in and not just a few. I’m excited that we’ll be able to standardize experiences like that.
AAFP News: Imagine this: It is July first, or maybe it’s in June orientation, and you are now welcoming your incoming class, the class that is going to be held to these new program requirements for all three years of their residency. What would you say to them about being excited to them in your program and what they’re going to learn?
Stutzman: “One of the things that makes me so excited to welcome you in this next class of resident education is the opportunity to look at our patients and our outpatient curriculum as the model that will sustain you throughout your next three years. Using our practice, and our outpatient practice as your base family medicine curriculum is really exciting, being able to know that you will be assigned a group of patients that you will follow for three years and develop those relationships, learn what their needs are and in so doing learn what your own needs will be as a learner going forward. It’s that relationship building that will sustain you through the next three years.”
Cole: “You have probably heard that we have new program requirements in family medicine. We have been looking forward to those for a long time. One thing that excited me about that is it really had us take a critical look at our curriculum to see where the areas are that we can be improving. Where are the areas that we can be teaching our residents better? Where are the places that we can be engaging with our community in different ways?
“The theme of these new requirements is that you are now somebody’s doctor. For the next three years, you will have a panel of patients that will grow over time because people are going to love you, and they’re going to refer their family members to you and their friends to you and they’re going to have babies. Your patient panel will get bigger over time, and that is your curriculum, working with those patients. That’s how you’re going to learn is through that hands-on experience. Everything that we provide as a residency in your training is to help support you as you care for these patients in the best way possible — that’s what the new program requirements do.”