Completing a family medicine residency takes three years, but when -- and how -- do family medicine residents begin to identify themselves as fully functioning members of the specialty?
Researchers in the Lehigh Valley Health Network Department of Family Medicine in Allentown, Pa., may have found an answer. Their analysis of focus groups(journals.stfm.org) conducted with more than 70 first-year family medicine residents revealed a shift in how learners expressed their professional identities after curricular changes were implemented. The research, which was published in the May edition of Family Medicine, also suggested that working alongside strong role models contributed to the residents identifying earlier with the specialty.
According to Susan Hansen, M.A., medical education evaluation specialist at Lehigh Valley, "Development of a strong family medicine identity early in one's professional career lays the groundwork for becoming a practitioner who embraces the wholeness of the specialty and integrates relationship-centered care practices.
"With clarity of vision, family medicine residents can spend more time practicing the skills needed to incorporate this in the care of patients, their professional relationships and their connections within their community," she told AAFP News.
- A recent paper in Family Medicine highlighted the effects of changes in program curricula on how family medicine residents form and articulate their professional identity.
- An analysis of focus group transcripts showed that the longer the residents were exposed to family medicine, the more they identified with the specialty.
- The analysis also found that having strong family physician role models contributed to the residents identifying with the specialty.
Background and Analysis
In the fall of 2007, the Lehigh Valley Family Medicine Residency Program instituted a five-year educational redesign as part of the Preparing the Personal Physician for Practice(www.ncbi.nlm.nih.gov) national demonstration project. Curricular changes included providing more mentorship time with family physician role models to emphasize outpatient care and a revised first-year inpatient curriculum that was limited to specialties that provide first-contact care (i.e., emergency medicine, pediatrics, newborn nursery and labor/delivery).
As part of the residency program's evaluation process, each PGY1 class participated in two focus groups: one immediately after orientation and one at the end of the academic year. In these focus groups, first-year residents were asked a standard set of questions that included specific queries about their professional identity and what they considered to be a model of a family physician.
Focus group transcripts were divided into three time periods: before (July 2002 to June 2007), during (July 2007 to June 2012) and after (July 2012 to June 2014) implementation of the educational redesign. In all, the researchers analyzed 26 transcripts involving 73 first-year family medicine residents, using elements from the Family Medicine for America's Health role definition(www.annfammed.org) of a family physician to measure the redesign's effects on professional identity.
Specifically, the authors compared the transcript responses with the following concepts in FMAHealth's role definition, finding several key differences among the focus groups:
- Family physicians as personal doctors. Each group appeared to focus on a different aspect of this role. Before the redesign, residents focused on the personal relationships they formed with families. During the redesign, residents began to speak of family physicians as generalists who take all aspects of a patient's health into consideration when providing care. After the redesign, residents showed more self-awareness and acknowledged the role of their feelings in the way they practiced and acted as family physicians.
- Family physicians as a reliable first contact for health concerns. Immediately after orientation, residents from all three time periods noted their roles as primary care physicians. By the end of the academic year, differences were apparent. Before the redesign, family medicine residents differentiated themselves from other physicians by highlighting their desire to connect with patients and families. During the redesign, they noted the variety of patient populations with whom they worked. After the redesign, they stated that family physicians filled gaps in the health care system; one resident referred to family physicians as "the safety net of the medical community."
- Family physician partnerships. Although residents from all cohorts and time periods viewed themselves as partners with whole families in patient care, only residents trained after the curricular changes spoke about collaborating with other specialties. Notably, more pronounced differences between cohorts emerged at the end of the first year of training. Residents perceived strains between family medicine and other specialties; early cohorts internalized the criticism, whereas those who matriculated later embraced family medicine's reputation for establishing continuity relationships with patients as setting them apart from other specialties.
- Family physicians as leaders. Before the curriculum redesign, residents saw family physicians as respected community leaders. During the redesign, residents pondered how they could garner respect for the specialty and saw themselves as both patients' point of first-contact with the health care system and trailblazers for care models such as the patient-centered medical home. After the redesign, residents were more focused on overall changes in health care and the more immediate demands they would face as leaders in their residency training program.
In addition to these concepts, the authors noted other themes:
- Flexibility. Some residents appreciated that being a family physician allowed them more freedom in terms of when and where they could practice.
- Clarifying one's role. Before the redesign, many residents expressed a desire to have more family medicine role models. By the time the redesign was implemented, residents were embracing their roles as family physicians and expressed more ownership of the specialty.
- Curriculum. Before the redesign, some residents questioned the value of some of the inpatient specialty rotations. During the redesign, residents connected the scope of the inpatient rotations with their outpatient work, which allowed for better patient care.
Role Modeling Is Key
Arguably, the most important finding was the effect of having strong family medicine role models on professional identity development. The authors noted that previous research(www.jabfm.org) found that the more learners were exposed to positive family physician role models, the more likely they were to understand what family medicine entailed and have a positive perception of the specialty. Additional research(onlinelibrary.wiley.com) indicated that for medical learners, identifying oneself as a physician involved not just talking about the practice or listening to a lecture, but actually doing the work of a physician.
With respect to the current study, the evidence suggested that family medicine residents who trained in primary care settings with strong role models were better equipped to identify as family physicians because they not only received practical experience, but also learned how to talk, act and think like family physicians.
The authors also pointed to the influence of the curriculum change on how family medicine residents articulate that identity, with residents surveyed during and after the educational redesign using more elements of the FMAHealth role definition in their responses than those surveyed before the redesign.
The researchers concurred with earlier research suggesting that immersing family medicine residents in other specialty rotations during the first year of training could delay the process of developing a professional identity aligned with family medicine.
They also stated that it is up to family physicians to clarify -- to themselves and their patients -- the role they play in health care, with the FMAHealth role definition serving as a reminder of what family physicians are and do.
Finally, the authors reiterated the importance of residents having access to strong role models during the first year of training. By practicing alongside family physicians, residents become socialized in ways that cannot be taught in a classroom. The combination of academic learning and real-world experience, they suggested, gives residents opportunities to understand how family medicine functions and allows them to better identify with their chosen specialty.
"This study adds to the body of evidence underscoring that professional identity is an important focus for graduate medical education," Hansen added. "It is situated within an innovative residency model that highlights the unique identity of family medicine as a specialty that views health through a generalist's lens and emphasizes the principles of relationship-centered, evidence-informed care."
For Hansen, the take-home message for FPs who want to see the specialty continue to develop and grow is clear.
"If you have the opportunity to teach residents or medical students, do so," she said. "Increasing medical learners' exposure to and work experiences with practicing family medicine physicians is likely to have a lasting impact on how these individuals identify with the specialty."
Related AAFP News Coverage
Family Medicine Research
Residency Leadership Skills Drive Program Changes
Family Medicine: Measuring Family Physician Identity: The Development of a New Instrument(www.stfm.org)