April 19, 2016

In June 2015, most of OHSU Family Medicine's third-year residents did not graduate. Rather, they celebrated something a little extraordinary – the promotion to their fourth year of family medicine education. Now, they are in the middle of an experience unique to just a few family medicine residents in the country. 

The concept of a four-year family medicine residency is not new; studies and papers have been published as far back as 2004. Implementation of four-year residencies, however, is just now gaining steam. OHSU Family Medicine's decision to move from a three- to a four-year residency in 2012 was not taken lightly. First, the department had to consider what family medicine will look like in the near future, what new family medicine physicians should be capable of and how the department should prepare these physicians. 

"We wanted to reflect on the fact that residency training in family medicine has changed dramatically in 45 years since the specialty was created," said Roger Garvin, M.D., assistant professor of family medicine and family medicine residency director. "It was time to look at the Affordable Care Act, how it affects what family physicians need to do in the future and what it was we wanted to teach and learn."    

Over the course of several years, OHSU Family Medicine's residency team consulted with several groups. They met with physicians in practice to talk about what they wished they had learned in residency and what they hope their future colleagues will know and be able to do. The team also met with present faculty to reevaluate the residents' current scope of practice. "We needed to know if we were trying to teach too much," explained Dr. Garvin, "if we were trying to be too broad." 

Out of all of the department's conversations, some very clear messages evolved:

1. Oregon needs family physicians who are broadly trained in terms of the full scope of family medicine. This meant that OHSU Family Medicine would need to continue to train its residents in maternity care, inpatient care and care of all ages –from newborns to the elderly. Exposure to rural medicine would also be essential.
   
2. Training should include development of leadership skills. In the world of CCOs, ACOs and PHOs, family medicine physicians need to have strong voices as advocates of primary care – both for the specialty as a whole, as well as for its patients.
   
3. Family physicians need to have an understanding of population health. Various levels of health insurance expansion across states have shown us that just insuring patients is not enough to understand and improve public health.
4. New family physicians need to be competent enough to lead as soon as they enter the workforce. "When you graduated from residency 20 or 30 years ago, you would join physicians who knew you weren't completely trained and would help mentor you," explained Dr. Garvin. "Now, if we're going to do what we need to do in the Patient-Centered Medical Home, our residents may need to join practices as mentors rather than mentees."
   
5. Residents had to be adequately trained to use information technology. If used correctly, Electronic Health Records can be an excellent tool in managing population health, and OHSU Family Medicine wanted to be sure their graduates know how to ask the right questions and interpret those answers.
   
6. Residents should have the opportunity to prepare themselves for future practice by focusing on an area they are passionate about.
   

Finally, in examining previously-existing four-year programs and surveying students, Dr. Garvin and Patty Carney, Ph.D., professor of family medicine, outlined a study that determined most applicants were not deterred by the idea of a four-year residency. With all of this in mind, the group created the components of a four-year residency.

At the same time, the Accreditation Council for Graduate Medical Education (ACGME) had begun the process of formulating a Family Medicine Length of Training Pilot, with the intent of studying the effectiveness of extended family medicine programs. Whether or not the pilot would launch in 2013 was still undetermined, but for OHSU Family Medicine, the decision had been made. "We felt strongly enough that it was the right choice to transition to a four-year residency," said Dr. Garvin. "So we decided to go ahead and do it whether or not the pilot launched."

Shortly after OHSU Family Medicine transitioned to a four-year program, the ACGME formally announced that its Length of Training Pilot would begin in July, 2013. OHSU Family Medicine is now one of 12 schools participating. 

Since the inception of the four-year residency, OHSU Family Medicine's curriculum looks very different. Residents see more rotations in population health, leadership and technology. They also spend more time in the community, learning about food banks and other community resources vital to their patients' total wellbeing. Specialized training in pediatric care, maternity care and geriatrics has also increased. Residents with an interest in academics now have the opportunity to shadow faculty and develop skills in education and supervision. And, because residents have more time to fulfill their academic requirements, they have room in their schedules to participate in long-term projects and studies, called capstone projects.

"What we hoped to come out of the capstones," explained Dr. Garvin, "is that a resident can find a passion for something they want to do more. Whether developing a curriculum or conducting research, we want them to have an end product that will further their careers and act as a learning opportunity." Many of the residents' capstone projects, such as improving care for children and adults with Down Syndrome or bringing telemedicine palliative care to rural communities, will live on as services offered by OHSU even as residents leave. Residents will also carry their knowledge and specialized skills to wherever they practice in the future. 

The residency program has also partnered with Kaiser Permanente. The partnership is mutually beneficial in that Kaiser Permanente now has the opportunity to support the growth of family medicine in Oregon by helping fund the fourth year of OHSU Family Medicine's residency. Three first year residents are currently in place at Kaiser Permanente Beaverton, and others are rotating through to gain experience in Kaiser's unique practice structure. By July 2018, Kaiser's Beaverton clinic will host 12 of OHSU Family Medicine's residents. 

"As a department, we have never lacked resources like learning opportunities or mentors, but our residents didn't necessarily have the time to take advantage of them," said Alex Verdieck, M.D., assistant professor of family medicine and associate residency director. "Since we added the fourth year, great mentorships and projects have improved training in pediatric care, adolescent health, leadership skills and other areas that are still evolving." In spite of concerns that residents would balk at a fourth year, applicant interest has, in fact, increased. 

First year resident, Mustafa Alavi, M.D., reflected, "I chose a program with a four-year residency because it would allow me the flexibility to pursue my passions within Family Medicine." Of his fourth year colleagues, Dr. Alavi said, "seeing the first group of fourth year residents go through the program has been so inspirational…they are so confident and knowledgeable in their practice styles and go out of their way to make sure we as interns feel supported." 

"In the fourth year, we have had the opportunity to grow into our roles as independent practitioners in a supportive environment," shared fourth year resident, Anthony Cheng, M.D. "We have been able to learn leadership skills that traditionally fall outside of the domain of residency training but which are important, since physicians inevitably find themselves in leadership roles within their clinical work."

Whether OHSU Family Medicine residents go on to work as physicians, medical directors, educators or leaders in healthcare policy, they leave their residency equipped to advocate for public health and primary care. "When we meet with healthcare leaders across the country, we talk a lot about where the future is going, and they say OHSU Family Medicine is already there," said Dr. Garvin. "No one knows what primary care is going to look like in five years, but we're creating the people who can shape it."