By Richard Young, MD
What is the best way to train comprehensive full-service family physicians to learn how to thrive in underserved rural Texas? How have duty hour restrictions affected residents’ training with this goal in mind? JPS might have some answers.
The John Peter Smith Hospital Family Medicine Residency Program was chosen to be one of 14 programs to participate in the Preparing the Personal Physician Practice (P4) experiment, which was conducted from 2007 to 2012. The leading organizations that regulate family medicine residencies allowed JPS and 13 other programs across the U.S. to blow up their curricula and start all over. JPS innovated its curriculum in two primary ways. This is a report on some of our preliminary results.
First, we allowed our residents to stay for one extra year of training, but it was totally optional. This extra year could include just about anything the resident wanted to do, within reason. The most common choice was a combination of maternity care, rural, and global. Other popular options were sports medicine and geriatrics. A few residents chose hybrid years, extra ER training, extra hospital training, and other combinations. Most stayed for an entire year, but some left in the middle of the fourth academic year, which we were completely supportive of.
The second layer of innovation was to take the career passions of our residents and get them involved in that experience as early as possible. If a young resident had a passion for taking care of pregnant women, why just shove that passion into a fourth year? Why not start them earlier? We thought the earlier, the better.
The curriculum for the intern year was fairly fixed. We had about two weeks we could play with. But starting in the second year, the residents could receive a few extra months of training in whatever curricular area they chose. They spent extra time in this area their third year and most of their time the fourth year, though we made it clear that we expected that their comprehensive family physician brain would not atrophy during the most concentrated fourth year. Residents were still expected to be able to cover general family medicine clinics, medicine call, and ICU call.
One of the central questions of the P4 experiment was “does it make a difference?” Some of the residents did extra training, but if their careers look no different, then why bother with the extra training? Why should residencies hassle with the changes?
Preliminary results of the JPS graduates show that the extra training indeed makes a difference. Specifically I want to report on the results of our graduates who had extra maternity care training. Compared to all other JPS graduates, those who completed extra maternity care training were more likely to provide prenatal care (90 percent vs. 13 percent), deliver babies vaginally (80 percent vs. 7 percent), and perform primary C-sections (80 percent vs. 6 percent). They were more likely to place IUDs (100 percent vs. 47 percent) and offer vasectomies (40 percent vs. 4 percent).
However these graduates were not just watered-down obstetricians. They were also more likely to work in underserved rural areas (30 percent vs. 23 percent), Health Profession Shortage Areas (25 percent versus 16 percent), and take care of hospitalized adult patients (87 percent vs. 59 percent) and newborns (93 percent vs. 19 percent). There were no differences in other outcomes such as providing elderly care (100 percent vs. 89 percent), nursing home care (30 percent vs. 24 percent), and ER coverage (33 percent vs. 51 percent).
Final results on the differences in practice patterns of JPS graduates versus other residencies will be available soon. Early results were that the average JPS graduate (3- and 4-year trainees) provided a more comprehensive basket of services to their patients than the graduates of the other 13 P4 residencies.
Since the completion of the P4 experiment, the JPS Family Medicine Residency has transitioned to the Accreditation Council for Graduate Medical Education Length of Training experiment. We are not changing much of what we have created, because it worked so well for us. One of our challenges has been to manage the large interest in the extra training options of our residents, especially for maternity care. In the early days, the residents had a lot of freedom to set up the extra year as they desired. The faculty has had to tighten the curriculum to try to make sure that all trainees have a meaningful experience, but we still allow as much individualization as practical. A strong positive of this whole journey for the faculty and residents has been how engaged the residents are in taking ownership of their education. The faculty’s role as mentors and coaches has grown, and it’s very rewarding.
Our message to other residencies is to innovate. The future of family medicine and the health care system remains uncertain. However, the interest of our residents to serve patients and provide comprehensive patient care services remains unchanged. By forming a collaborative educational process with our residents and providing them educational opportunities that match their specific interests, we can show that this process is associated with a meaningful difference in the scope of their practices. This is exactly what the underserved citizens of Texas need.
Richard Young, MD, is director of research and co-associate program director of the John Peter Smith Family Medicine Residency Program. He is a clinical associate professor of family medicine at the University of Texas Southwestern Medical School, and he blogs at www.healthscareonline.com.