P4 = Innovation

Samuel M. Jones

doi:10.1370/afm.715

The initial goal of the Preparing the Personal Physician for Practice (P⁴) Initiative is innovation in family medicine residency training, in real-life situations, in various settings. After an exhaustive process of evaluation and review, 14 programs from the initial 84 applications have been selected to participate in the P⁴ Initiative. The portfolio of innovations represented in this group is expected to align with new models of practice to enhance the performance of family physicians as personal physicians in modernized, frontline medical practice. The announcement of these innovative programs in February was yet another major step in making the P⁴ Initiative a reality and kicked off another phase in the evolution of this important project.

So what is the scope of the innovations being proposed in this portfolio? In the initial call for proposals, the P⁴ Steering Committee identified 1 general requirement (alignment with the New Model Practice) and 5 different areas where innovation was likely to occur:

Scope and content of training (eg, enhancements in chronic disease care, differentiation for a particular population)
Length of training (eg, lengthened to achieve more breadth or depth of competency, or to decompress the residency experience)
Place of training (eg, replacement of traditional family medicine center with other sites of training, reduced role of hospital in training)
Structure of training (eg, processes of instruction and experience)
Measurement of competency (eg, use of measures other than length of time)

These areas illustrated the possibilities for innovation, but were not meant to prescribe or prioritize the work of the residencies in P⁴. To that end, a “Wild Card” category was also included with the hope that a true “thinking outside the box” idea for training family medicine residents would emerge.

As hoped, all 5 categories are well-represented in this cohort of innovators and will be tested in this experimental initiative through a combination of adapting existing structures and creating new ones. Some of the innovations may require further modification to meet Liaison Committee on Medical Education (LCME) and Accreditation Council for Graduate Medical Education (ACGME) requirements, but the majority complies with current Residency Review Committee (RRC) requirements. This is important to the potential generalizability of the innovations.

As the portfolio of innovations has been reviewed and refined, a number of general themes have emerged. The major components of the New Model Practice (ie, patient-centered care, use of advanced information systems, chronic disease management and prevention, practice learning teams, and systems for assessing outcomes to improve quality and safety) are well represented within each program. Based upon preliminary finding from TransforMED’s National Demonstration Project, future graduates will require additional training in change management, leadership, and organizational development. Many of the projects have already incorporated these important components of professional development into their curriculum and this aspect of the initiative will be critical in training graduates as change agents in their communities. There is significant focus on learner-centered, competency-based training that includes competency-based assessment and advancement.

Approximately one-half of the innovators are extending training beyond the current 36 months by offering a structured 4-year curriculum that allows pursuit of an area of concentration or an advanced degree. Many programs are offering significant flexibility in allowing residents to tailor their training to meet the needs of a community or accommodate their own interests and skills. Two programs are reaching back into the fourth year of medical school to assist students in gaining a higher level of competency before entering residency by providing additional, family-medicine-focused clinical experiences. Many of the programs are moving the primary location of learning from the traditional family medicine center to smaller community-based practices. With this transition comes a decrease in the time spent in the hospital and an increased emphasis on longitudinal training in ambulatory settings. Assessing the financial health and viability of these community practices will be a critical component of this transition.

In the final analysis, the P⁴ Initiative can be viewed as a “voyage of discovery,” and residency training can be considered as one crucial period in the lives of physicians. This voyage will be defined by the primary goals of the P⁴ Initiative which are to stimulate innovation in family medicine graduate medical education in real life, evaluate the innovations, study what changes are needed to prepare graduates to succeed in new practice models, and share the learnings that will inspire change in training and certification. The first goal has been realized. The other 3 will be addressed and developed over the coming months and years. The best is yet to come.