IN PURSUIT OF 1,650

Many words can be used to describe the work that a family medicine residency program director does during a typical day: teacher, administrator, counselor, coach, cheerleader, and, of course, tabulator of patient encounters. Of the visits a program director counts, perhaps none is more famous than the 1,650 continuity patient encounters required in the family medicine practice site before a resident may graduate. Many a program director has wondered if evidence exists that 1,650 patient visits is the best marker for knowing a potential graduate has achieved adequate experience in ambulatory care during residency.

At the simplest level, the requirement for 1,650 patient visits can be viewed as an arithmetic calculation based upon the concept that experience will lead to expertise. Assume that residents progress in both number of sessions in the office and number of patients per session throughout residency and also assume that residents see patients for 44 weeks per year to allow for vacation or away rotation. The calculation is simply:

The ACGME Program Requirements exist to set minimum standards of education, thus, the 1,650 requirement is best understood as a baseline to ensure that the resident has appropriate patient volume and frequency of sessions.

A literature review reveals no studies that suggest a count of 1,650 patient visits confers the competence to practice ambulatory family medicine. Perhaps 1 resident is prepared for ambulatory practice after only 1,200 visits while another will require over 2,000. Determining competence is a much more nuanced process, requiring frequent observations of the resident. Feedback about performance of component skills as well as the integration of skills into a global whole rather than simply completion of a number of visits. A count of experiences cannot be an adequate substitute for thorough, frequent observations when the goal is determining competence.

The requirement of 1,650 patient encounters should not be dismissed as being without worth, however. Competency-based assessments are still very much in fledgling form, with educators striving to understand how to capture the data necessary for such evaluations in a manner that is accurate, reproducible, and doable. Competence requires experience so that a learner may begin to appreciate the common and not-so-common presentations of disease. The 1,650 requirement provides a surrogate marker of adequate experience to allow residency educators to begin to make an in-depth assessment of competence once adequate experience has been attained.

In our zeal to pursue competency-based assessments, it would be a grave mistake to discard all requirements based upon experience. In order to appreciate the breadth of family medicine, a resident must see a variety of patients. One does not learn all there is to know about diabetes from seeing 1 patient with diabetes. Adequate experience is key to ensuring an appreciation of the varied presentations of health and disease in patients across the spectrum of age and condition. An appreciation of the subtleties of the art of medicine cannot develop after seeing only a single example of pathology.

It would be a similarly serious error to consider the completion of 1,650 patient visits to be the sole indicator that a resident is prepared to enter practice. We ask our graduates to take on responsibility for patients, families, and communities with outstanding skills in diagnosis and treatment of disease as well as proficiency in communication, interpersonal skills, and systems-based practice. It is not enough to deem them competent after seeing a specified number of patients when what we ask of them is that they appreciate the complexity and context of each individual who presents with a given diagnosis and attend to their unique experience of health and disease in a continuous trusting relationship. A simple number can never tell us if they are prepared to undertake this critical and complex task.

Seeing 1,650 patients is a necessary but incomplete picture of a resident’s preparedness to embark upon unsupervised ambulatory practice. One thousand, six hundred and fifty patient visits provide experience in which the resident can develop competence in the art of medicine. Only when experience is coupled with careful assessments of competency performed by faculty and program directors can we ensure our graduates are truly prepared for the task they undertake as family physicians.

• © 2016 Annals of Family Medicine, Inc.