The Promise of Aire

A Competency-Based Framework

The major revision⁴ represents a significant shift toward competency-based medical education (CBME) grounded in the needs of patients, families, and communities and away from numbers of patient encounters and hours of curriculum. We expect that all AIRE applications will use a competency-based framework and be able to describe succinctly what the additional time in training will provide for medical students, residents, employers, and the public.

It is important to recognize that CBME is much more than developing thoughtful goals and objectives and a curricular map.⁵ Applications should include systematic attention to the Van Melle framework⁶ which is now the gold standard for competency curriculum redesign. CBME begins with explicit attention to the community needs the residency program is addressing and is grounded in a system of outcomes-based assessment. The curriculum should include a progressive development of competencies, with experiences and teaching focused on specific competencies, and ongoing assessment of learning tailored to those competencies. We expect residents to co-create their education, reviewing assessments regularly with clinical mentors and guiding their own education. The residency leadership and faculty must also commit to ongoing faculty development and a systematic approach to reviewing and improving their programs.

Developing a systematic program of assessment will require new thinking for most family medicine residencies: it is more than building the 6 ACGME competencies into standard evaluation forms! The overall goal is to assure the public and future employers that a residency’s graduates are broadly competent. This in turn requires explicit assessments of the key competencies necessary for family physicians working across the continuum of care. In this regard, the draft residency standards are intimidating, identifying as many as 65 different competencies, and it is difficult to imagine setting up separate evaluation systems for each of these competences. We therefore expect residency directors to be pragmatic, selecting the most important competencies for assessment. These might include, for example, continuity and comprehensiveness of care in the family medicine center, diagnosis and management of acutely ill patients in the hospital, or management of newborns or patients at the end of life. In building the system, the perfect may become the enemy of the good: residencies should feel comfortable in repurposing existing assessments like evaluations by preceptors and video reviews of resident-patient encounters. The new expectation that “the practice is the curriculum,” with ongoing measurement of access, continuity, and rates of referral will provide additional assessment of resident performance. We also believe that there must be dialogue across Family Medicine to develop priorities for sampling and assessment tools. The ACGME Family Medicine milestones version 2.0, level 4, may represent reasonable goals for residency training, as would the entrustable professional activities (EPAs) developed by the specialty in Family Medicine for America’s Health.⁷ The Society of Teachers of Family Medicine (STFM) is proposing a national summit to help develop consensus on the outcomes we will assess for; we are delighted with this and other efforts for the specialty to work collaboratively on residency redesign.

The Themes of Innovation

While competency assessment must be built into all AIRE proposals, the goal of the AIRE project is not just competency. The major focus should be on development of the best possible training for comprehensive family physicians. It is important to note this is not just an extension of the previous Length of Training Project. We are looking for fundamental innovation, and we are relying on the creativity and thoughtfulness of our specialty’s residency directors and faculty. Over the last 3 months, we have talked with many residency educators about what they envision. So far, we see 3 different patterns of innovation.

One group is focused on increasing the degree of competence of graduating residents. The current ACGME milestone framework is built on the developmental progression initially described by Dreyfus⁸ from novice to proficient to expert and its extension to mastery over a career. Most residencies currently train to “proficient.” Thus, this group of residencies planning AIRE proposals aspires to move their graduates further towards expertise and mastery in some dimensions of care. Their assumption is that graduating residents will provide value with their increased skills; their challenge will be to define the experiences and assessments that will drive greater competency. For example, if a residency focuses on greater competency in continuity and comprehensiveness of care, assessments of motivational interviewing or shared decision making, referral quality, effectiveness of pharmacotherapy, or integration of ultrasound or medication-assisted treatment into continuity practice might be included.

Another approach being considered is to integrate what are currently fellowships into a 4-year program. Thus, for example, folding a sports medicine fellowship into a traditional residency might allow broader clinical experiences, competence with more procedures and learning population interventions to increase physical activity. The ACGME fellowship requires specific rotations and assessments, and these requirements help clarify what residents get out of extended training. But participation in AIRE is not limited to incorporation of ACGME-approved fellowships. Many residencies have fellowships in surgical obstetrics or hospitalist care, or chief residencies with a focus on education skills development, and some are developing programs for future researchers or health care executives. Such programs clearly address the future needs of the specialty. Finally, there are some institutions developing many different areas of concentration.⁹ Residents would have the opportunity to choose from a variety of different focus areas, all integrated within the context of a traditional residency program focused on, for example, addressing the urgent and diverse needs of rural communities. This is one of the strategies that has been so successful in the growth and development of psychiatry residency programs.

A third approach being developed is to identify clinical focus areas important to improving population health or delivery of health care. Examples include community health equity, clinical ultrasound, lifestyle medicine, HIV in primary care, street medicine and behavioral health, including MAT and cognitive behavioral therapy. Each of these areas responds to the evolving needs of our population and health care system and support graduates in addressing urgent community needs. As in the other approaches to innovation, the challenge for these residencies will be developing quality educational experiences and the assessments to ensure competence.

Building fundamental innovation into family medicine residency education will not be done in 1 year! We are acutely aware that the pandemic has had a major impact on the organization and financing of residencies as well as their associated hospital systems: it will take time to build back. In addition, new ideas, faculty development, and financing take time to put in place. We therefore plan to keep applications open for as long as is necessary. We will develop general templates and models of applications to facilitate programs’ applications, and we are now beginning to plan a national collaborative modelled on I^310-12 and P^{4 13} that will support faculty development, networking of faculty, residents, and staff, and support scholarship.

How the Family Medicine AIRE Program Will Be Organized

The ACGME and the ABFM have created a steering committee which will guide the development of the program, including an outreach and communication strategy, an efficient application process, and a strategy for evaluations. The Association of Family Medicine Residency Directors, the STFM, the Association of Departments of Family Medicine, and the American Academy of Family Physicians have liaisons to this committee, and the AIRE program will also coordinate with these organizations’ initiatives to support residency redesign.

Our intent is to make the AIRE program as easy as possible to participate in, learn from, and improve both clinical care and education. Participating residencies will have the option to enroll some or all of their residents in the AIRE curriculum. They will be required to make a formal application, submit data annually about their programs, review and improve their residencies annually, and participate in a national collaborative. In return, residencies will share learning at the cutting edge of clinical and residency education transformation across geographic regions, have the opportunity for faculty, resident, and staff development and facilitation of networking and scholarship, with some support of direct costs. We are accepting applications starting this summer and plan for the first cohort of residencies to begin in July 2023. The ACGME Family Medicine Review Committee and the ABFM will review applications on a rolling basis. We welcome your ideas!