Family Medicine Residency programs must innovate rapidly to attract applicants, compete for patients, deliver quality, and ensure that all graduates can deliver New Model care. However, powerful forces inhibit innovation precisely at a time when it should accelerate. This is the “innovator’s dilemma”: investment in an existing product makes fundamental change very difficult.1
From a national perspective, we must choose between alternative paths as we seek to recreate residency training: prescriptive, incremental change with predetermined outcomes vs unplanned, disorganized experiments with both failures and successes. In other words, we must choose between “intelligent design” and “evolution.”
The choice is not simply between these 2 extremes; there are many points on the spectrum. However, ADFM believes we should move much farther toward “evolution” than we have to date. Failure risks extinction of the discipline of family medicine.
INTELLIGENT DESIGN
Careful, planned, incremental change in residencies is commendable. The Accreditation Council for Graduate Medical Education and its Residency Review Committees (RRCs), including the RRC-FM, exist “to improve health care by assessing and advancing the quality of resident physicians’ education through accreditation.”2 Unstated is the premise that accreditation is intended to protect the public by enforcing minimum standards for residency programs. The RRC requirements are the organizational equivalent of DNA, the “genetic code” describing minimal structure and function for life of residencies. Accreditation follows change; it does not lead it.
The “family” of family medicine has taken important steps toward planned, incremental change in practice and training. The New Model of family medicine was developed after extensive research and widespread input; TransforMED is helping 36 family practices implement the New Model.3 Keying off TransforMED, the ABFM, AFMRD, and AAFP have launched the Preparing the Personal Physician for Practice (P4) project to help residencies innovate.4 The P4 “experiments” will begin in 2007 and are expected to continue for 3 years, with evaluation of the changes in training a key part of the process.
The RRC-FM has new membership and a new executive director. We are hopeful they will be more supportive of experiments than the RRC-FM has been in the past, and that P4 will facilitate significant innovation. However, P4 will only work with a few programs, and it is not clear yet to what degree the RRC-FM will allow P4 residencies to deviate from requirements.
The process will also be slow. New RRC requirements, potentially incorporating results of “successful” P4 experiments, will not emerge for years. They represent one of our discipline’s last chances to adapt to changes in medical practice for years. If this is our strategy, we better be right! Unfortunately, however, this is like assuming for ourselves the role of an omniscient “designer” to precisely anticipate future environmental pressures and implant the mutations in our “residency DNA” to ensure survival of our species.
EVOLUTION
The alternative model is evolution, which occurs when there is sufficient genetic diversity in a population that some individuals have an adaptive advantage in the face of environmental change or competitive pressure. But diversity comes at a price: more mutations mean potential for failures.
We believe this model better describes the way family medicine should encourage innovation in our residencies. The practice of family medicine is already evolving rapidly. Family physicians are serving in a plethora of communities and environments, from large to small practices, corporate to independent work, New Model to retail clinics, hospitalist practice to low overhead practices to home visiting out of the trunks of cars.
There is no longer a single definition of family medicine. Family medicine is what people who call themselves family physicians do. Stated differently, in the high pressure ecology of practice, our species is already responding to “natural selection” forces in different markets. Family physicians are even acquiring “hybrid vigor” as they pursue Masters’ degrees, fellowship training, CAQs, and dual certification. Demand is high for residencies that encourage such vigor via special foci and extended training.5
Of course, the dichotomy of “intelligent design” and “evolution” is not absolute. Residents must acquire a core set of knowledge, skills, and attitudes to become family physicians. However, ADFM believes that we should not limit innovations to carefully controlled “experiments” in a few residencies around the margins of dangerously restrictive requirements. We should instead encourage residencies to find the most successful practicing family physicians in their communities, study what they do, and prepare residents to practice and adapt like these exemplary doctors. Then we should get out of the way and see what evolves.
- © 2007 Annals of Family Medicine, Inc.
