RESIDENCY EDUCATION—COMPETENCY AND INNOVATION

Family medicine residency programs must take the lead in educating physicians to practice evidence-based personalized medicine that achieves the highest standards of efficient quality care. Such physicians are needed to meet current health care needs, to expand medical care delivery capabilities for the baby boomer generation, and for emerging comprehensive models, such as the patient-centered medical home.¹ For family medicine to succeed in meeting this challenge, greater flexibility to innovate as requested by the Future of Family Medicine Project must be granted to our residency programs by the residency review committees (RRC), the Accreditation Council for Graduate Medical Education (ACGME), etc.² Currently, innovation can only be implemented if all existing requirements are met. This leaves little room for flexibility and new conceptual models of training.

Family medicine residency programs can be conceptualized to encompass 3 educational stages: foundation building, ambulatory competency, and enhancement tracks. The foundational and ambulatory stages are common to all programs. The foundational stage generally consists of 15 to 18 months education in core rotations such as pediatrics, medicine, obstetrics, surgery, and a combination of essential medical and surgical specialties largely taught in the hospital setting.

The development of ambulatory competency occurs simultaneously with the foundation stage and extends beyond it. The skills required for competence in this stage are not defined solely by patient volumes or time spent in the program. Each physician enters their residency with interpersonal skills honed by their life experiences and educational background. The fine-tuning occurring in the residency enables them to develop superb doctor-patient relationships, gather accurate medical histories, perform appropriate physical exams, and communicate treatment plans and prognoses to patients and their families all of which can be competency tested. Additionally, skill sets to manage the common medical, surgical, and emergency and urgent problems need to be taught.

The final stage in training would be focused on the acquisition of mastery in 1 or more enhancement tracks. These tracks comprise those unique skill sets needed to fill the basket of services in the practice setting desired by the resident and their areas of special interest.³ They may include learning advanced procedural skills, advanced obstetrics, sports medicine, geriatrics, or other unique content areas. These tracks will not be defined solely by patient numbers or time in the program. Limiting factors may be an appropriate patient population from which to learn the skills, an appropriate curriculum, and the faculty’s competencies in these areas.

Although 3 stages can be identified, their educational components will often overlap; skills such as the ability to obtain a medical history and perform a physical exam will be common to all 3. Each stage can be subdivided into specific components which can be competency tested. The competency in most areas will not require a specific number of procedures to be performed, a predetermined number of patient encounters, or specific length of time in the program. Mastery will be shown to have been obtained when the resident demonstrates competency according to evidence-based principles utilizing evaluation techniques appropriate to the component being tested; for example—clinical demonstration, cognitive testing, oral discussion and/or medical simulation.

There will be some competencies which may require a specific number of patients seen in the clinical arena. For example, while many aspects of obstetrics can be competency tested, such as antenatal care, others such as delivery management may need exposure to a wide range of case situations. Decisions such as performing an episiotomy, repairing a fourth degree laceration, management of dystocia, or the use of a vacuum extractor require experience. To competently learn some required ob skills, a range of deliveries may need to be identified to ensure that the conditions leading to the competent use of these skills will be optimized.

For these changes to take place, the RRC and ACGME must allow flexibility in residency content beyond that found in the foundational and ambulatory stages today. Reducing absolute requirements of time and/or numbers would allow more curricular time for flexibility and innovation. Competency for independent practice must be redefined periodically in all programs.⁴ This educational model should foster an attitude of lifelong learning for our graduates who will expect a high standard of quality and competency-based practice to guide their medical care and future skill acquisition.⁵ This type of flexibility is capable of providing the physicians for medical home practices who can meet the demand of our evolving health care system.

This commentary was developed by the ADFM Residency Committee to further advocate for significant change in our residency educational programs.

• © 2008 Annals of Family Medicine, Inc.