Family Medicine Graduates Research Articles

Associations Between Medical Education Assessments and American Board of Family Medicine Certification Examination Score and Failure to Obtain Certification.

Family medicine residency programs can be cited for low pass or take rates on the American Board of Family Medicine (ABFM) certification examination, and the relationships among standardized medical education assessments and performance on board certification examinations and eventual board certification have not been comprehensively studied. The objective of this study was to evaluate the associations of all required standardized examinations in medical education with ABFM certification examination scores and eventual ABFM certification. All graduates of U.S. MD-granting family medicine residency programs from 2008 to 2012 were included. Data on ABFM certification examination score, ABFM certification status (as of December 31, 2014), Medical College Admission Test (MCAT) section scores, undergraduate grade point average, all United States Medical Licensing Examination (USMLE) Step scores, and all ABFM in-training examination scores were linked. Nested logistic and linear regression models, controlling for clustering by residency program, determined associations between assessments and both certification examination scores and board certification status. As many international medical graduates (IMGs) do not take the MCAT, separate models for U.S. medical graduates (USMG) and IMGs were run. The study sample was 15,902 family medicine graduates, of whom 92.1% (14,648/15,902) obtained board certification. In models for both IMGs and USMGs, the addition of more recent assessments weakened the associations of earlier assessments. USMLE Step 2 Clinical Knowledge was predictive of certification examination scores and certification status in all models in which it was included. For family medicine residents, more recent assessments generally have stronger associations with board certification score and status than earlier assessments. Solely using medical school admissions (grade point average and MCAT) and licensure (USMLE) scores for resident selection may not adequately predict ultimate board certification.

Factors perceived to influence rural career choice of urban background family physicians: A qualitative analysis.

BackgroundUrban background physicians are the main source of physician supply for rural communities across Canada. The purpose of this study was to describe factors that are perceived to influence rural career choice and practice location of urban background family medicine graduates.MethodsWe conducted a qualitative, descriptive study employing telephone interviews with 9 urban background family physicians practicing in rural locations. Those who completed residency training between 2006 and 2011, were in rural practice, and had an urban upbringing were asked: when the decision for rural practice was made; factors that influenced rural career choice; and factors that influenced choice of a particular rural location. Emerging themes were identified through content analysis of interview data.ResultsWe identified four themes as factors perceived to influence rural career choice - variety/broad scope of rural practice, rural lifestyle, personal relationships, and positive rural experience/physician role models. We also identified factors in four areas perceived to influence the choice of a particular rural practice location - having lived in the rural community, spousal influence, personal lifestyle, and comfort with practice expectations.ConclusionDecisions for rural career choice and rural practice location by practicing urban background family medicine graduates are based on clinical practice considerations, training experience, as well as personal and lifestyle factors.

Experiences of new family physicians finding jobs with obstetrical care in the USA

ObjectiveThis study aimed to explore how new family medicine graduates who want to include obstetrics in their scope of practice identify and select jobs and to understand how employment influences...

Exploring Change After Implementation of Family Medicine Residency Curriculum Reform.

In 2010, the College of Family Physicians of Canada (CFPC) launched its competency-based medical education (CBME) approach to residency curriculum and assessment. Named Triple C, this innovation was developed to ensure graduates of family medicine training programs are competent to begin unsupervised practice. Further, Triple C was intended to promote interest in practicing comprehensive family medicine. A program evaluation plan was launched by the CFPC alongside the implementation of Triple C to explore if intended outcomes were achieved. We conducted retrospective secondary data analysis of survey findings from graduating family medicine residents from two sources: National Physician Survey (NPS 2007 and 2010); and the Family Medicine Longitudinal Survey (FMLS 2015). Demographics and practice intentions reported by residents in the NPS 2007, NPS 2010, and FMLS 2015 were included in the analyses and a comparison between years was undertaken using a series of Pearson χ2 test. Findings indicate that in comparison to pre-Triple C (NPS 2007 and NPS 2010), significantly more residents reported the intention to include palliative care, intrapartum care, in-patient hospital care, care in the home, and practicing in rural settings after the implementation of Triple C (FMLS 2015; P<0.01). Family medicine graduates report an increase in intention to include a broader range of clinical domains after implementation of Triple C. While a causal relationship cannot be determined, using a historical control in the form of survey data that predates Triple C implementation could support future approaches to evaluation of education reform.

Trends in US Medical School Contributions to the Family Physician Workforce: 2018 Update From the American Academy of Family Physicians.

The United States needs more family physicians. Projections based on current trends show a deficit of 52,000 primary care physicians by 2025. Eight national family medicine (FM) organizations have set an ambitious goal of increasing the proportion of US medical school graduates who enter FM residencies to 25% by 2030. This paper describes the most recent number and percentage of students from each US medical school entering Accreditation Council for Graduate Medical Education (ACGME)-accredited FM residency programs, long-term trends in the contribution of allopathic and osteopathic medical schools to the FM workforce, and medical school characteristics associated with higher proportions of FM graduates. Data about graduates entering US ACGME-accredited FM residency programs were collected using an annual program census and supplemental sources. Longitudinal census data from allopathic and osteopathic schools were combined to examine trends over time. ANOVA analyses were conducted to compare schools by percent of graduates entering FM, public/private ownership, allopathic/osteopathic, size, and presence of FM department. Medical school length of operation was correlated with percentage of students entering FM. The overall proportion of US students entering ACGME-accredited FM programs has increased modestly over the past decade. Currently, only 12.6% of US allopathic and osteopathic seniors enter ACGME-accredited FM programs. Individual medical schools' contributions to the FM workforce are described. The proportion of US medical students beginning ACGME-accredited FM residency programs has increased slightly over the last decade. However, significant changes to undergraduate medical education are needed to meet the nation's primary care needs.

Buprenorphine Provision by Early Career Family Physicians

Buprenorphine can be used in primary care to treat opioid use disorder, but many family physicians feel unprepared to care for patients with opioid addiction. We sought to describe preparedness to provide and current provision of buprenorphine treatment by early career family physicians using data from the 2016 National Family Medicine Graduate Survey. Of 1,979 respondents, 10.0% reported preparedness to provide buprenorphine treatment, and 7.0% reported current buprenorphine provision. Residency preparation to provide buprenorphine treatment was most highly associated with current provision (odds ratio = 13.50; 95% CI, 7.59-24.03). Efforts to increase buprenorphine training may alleviate the workforce shortage to treat opioid use disorder.

30% of Recent Family Medicine Graduates Report Participation in Loan Repayment Programs.

Rising educational debt may discourage entry into primary care and practice in safety net settings, but little is known about participation in loan repayment programs that are thought to be part of the solution. A survey of 2052 recent family physician residency graduates found that 30% pursued loan repayment, only a portion of which is tied to service obligations, suggesting opportunities for research and areas for the attention of policymakers.

THE DEVELOPMENTAL TOOLKIT: A PLAY-BASED LEARNING TOOL

Abstract BACKGROUND Learning child development is complex. Recent paediatric and family medicine graduates reported feeling unprepared to identify and manage children with developmental and behavioural concerns (Comley et al 2008). As part of current developmental education at our centre, residents are trained to assess child development by integrating their pre-rotation knowledge about development with parental report and a general physical examination. This approach lacks hands-on training required to understand and learn the complexities of child development. To address this gap, our study team created the “Developmental Toolkit (Toolkit),” a non-standardized developmental teaching tool comprising specific toys and activities. OBJECTIVES The primary objective of this study was to explore how the toolkit may influence the teaching and learning of child development. Through the lens of reflective practice, this study sought to also explore residents’ learning of development in the context of a play-based toolkit. DESIGN/METHODS Using a constructivist grounded theory approach, paediatric and family medicine residents from two academic centres were interviewed after they used the toolkit as part of their interactions. Physician supervisors were also interviewed to determine the use of the toolkit as a teaching tool. RESULTS We recruited 10 residents to ensure saturation of data. Residents felt positively about their experience with the toolkit and its ease of use. They all agreed the toolkit enabled them to assess a child’s developmental skills in a short period of time. One paediatric resident found it “really useful; it was a more objective way for me to see what skills and milestones they [the child] were at. I think it was quite useful to correlate it with what mom was saying.” The residents’ supervisors all felt the toolkit allowed residents to more critically consider a child’s development and diagnosis in the context of the child’s environment. Furthermore, through the lens of reflective practice,the use of the toolkit revealed additional competencies in child development. These included: 1) maintaining a positive mood with the child; 2) getting a sense of the parent’s mood; 3) identifying when a child may have reached their limits during an interaction; and 4) critiquing previous assumptions about child development. CONCLUSION The toolkit is an innovative tool that may enhance paediatric and family medicine residents’ understanding of child development by enabling hands-on interactions and observations with children. Further exploration of how the toolkit may be enabling reflective practice and its implications on adaptive expertise need to be explored.

Barriers Faced by Family Medicine Graduates Interested in Performing Obstetric Deliveries.

Fewer family physicians are providing deliveries, which raises concern for access to obstetric care. We found that among recent family medicine graduates who would like to do deliveries, difficulty finding a position that supports including deliveries was a major barrier.

Burnout and Scope of Practice in New Family Physicians.

Family physicians report some of the highest levels of burnout, but no published work has considered whether burnout is correlated with the broad scope of care that family physicians may provide. We examined the associations between family physician scope of practice and self-reported burnout. Secondary analysis of the 2016 National Family Medicine Graduate Survey respondents who provided outpatient continuity care (N = 1,617). We used bivariate analyses and logistic regression to compare self-report of burnout and measures of scope of practice including: inpatient medicine, obstetrics, pediatric ambulatory care, number of procedures and/or clinical content areas, and providing care outside the principal practice site. Forty-two percent of respondents reported feeling burned out from their work once a week or more. In bivariate analysis, elements of scope of practice associated with lower burnout rates included providing more procedures/clinical content areas (mean procedures/clinical areas: 7.49 vs 7.02; P = .02) and working in more settings than the principal practice site (1+ additional settings: 57.6% vs 48.4%: P = .001); specifically in the hospital (31.4% vs 24.2%; P = .002) and patient homes (3.3% vs 1.5%; P = .02). In adjusted analysis, practice characteristics significantly associated with lower odds of burnout were practicing inpatient medicine (OR = 0.70; 95% CI, 0.56-0.87; P = .0017) and obstetrics (OR = 0.64; 95% CI, 0.47-0.88; P = .0058). Early career family physicians who provide a broader scope of practice, specifically, inpatient medicine, obstetrics, or home visits, reported significantly lower rates of burnout. Our findings suggest that comprehensiveness is associated with less burnout, which is critical in the context of improving access to good quality, affordable care while maintaining physician wellness.

Impact and Reception of a Required 4-Week Palliative Medicine Rotation.

Hospice and palliative medicine (HPM) is one of three Accreditation Council for Graduate Medical Education accredited clinical subspecialties available to family medicine graduates for fellowship training. Despite this, training is not currently a curriculum requirement. We have pioneered a required 4-week palliative medicine rotation into the curriculum. Twenty-eight residents who completed the palliative medicine rotation across four classes were surveyed to assess how the rotation improved their level of comfort with providing end-of-life (EOL) care and to demonstrate the need of formal palliative medicine training. Wilcoxon signed ranks test was used to detect statistical differences between the mean level of comfort of residents pre- and postrotation with providing the basic skills needed to practice HPM. The HPM rotation significantly improved the residents' level of comfort in all areas of measured EOL care (P<0.001). All residents surveyed strongly agreed that the rotation was valuable to their future and 100% of residents strongly agreed that an HPM rotation should be required. Formal HPM training should be a required component in residency education and considerations should be given to the 4-week format. This rotation provides a model that can be implemented in other residency programs nationally. Implementation of this rotation may help close the enormous gap of patients not receiving quality EOL care.

Does rural generalist focused medical school and family medicine training make a difference? Memorial University of Newfoundland outcomes.

Rural recruitment and retention of physicians is a global issue. The Faculty of Medicine at Memorial University of Newfoundland, Canada, was established as a rural-focused medical school with a social accountability mandate that aimed to meet the healthcare needs of a sparse population distributed over a large landmass as well as the needs of other rural and remote areas of Canada. This study aimed to assess whether Memorial medical degree (MD) and postgraduate (PG) programs were effective at producing physicians for their province and rural physicians for Canada compared with other Canadian medical schools. This retrospective cohort study included medical school graduates who completed their PG training between 2004 and 2013 in Canada. Practice locations of study subjects were georeferenced and assigned to three geographic classes: Large Urban; Small City/Town; and Rural. Analyses were performed at two levels. (1) Provincial level analysis compared Memorial PG graduates practicing where they received their MD and/or PG training with other medical schools who are the only medical school in their province (n=4). (2) National-level analysis compared Memorial PG graduates practicing in rural Canada with all other Canadian medical schools (n=16). Descriptive and bivariate analyses were performed. Overall, 18 766 physicians practicing in Canada completed Canadian PG training (2004-2013), and of those, 8091 (43%) completed Family Medicine (FM) training. Of all physicians completing Canadian PG training, 1254 (7%) physicians were practicing rurally and of those, 1076 were family physicians. There were 379 Memorial PG graduates and of those, 208 (55%) completed FM training and 72 (19%) were practicing rurally, and of those practicing rurally, 56 were family physicians. At the national level, the percentage of all Memorial PG graduates (19.0%) and FM PG graduates (26.9%) practicing rurally was significantly better than the national average for PG (6.4%, p<0.000) and FM (12.9%, p<0.000). Among 391 physicians practicing in Newfoundland and Labrador (NL), 257 (65.7%) were Memorial PG graduates and 247 (63.2%) were Memorial MD graduates. Of the 163 FM graduates, 148 (90.8%) were Memorial FM graduates and 118 (72.4%) were Memorial MD graduates. Of the 68 in rural practice, 51 (75.0%) were Memorial PG graduates and 31 (45.6%) were Memorial MD graduates. Of the 41 FM graduates in rural practice, 39 (95.1%) were Memorial FM graduates and 22 (53.7%) were Memorial MD graduates. Two-sample proportion tests demonstrated Memorial University provided a larger proportion of its provincial physician resource supply than the other four single provincial medical schools, by medical school MD for FM (72.4% vs 44.3%, p<0.000) and for overall (63.2% vs 43.5% p<0.000), and by medical school PG for FM (90.8 % vs 72.0%, p<0.000). This study found Memorial University graduates were more likely to establish practice in rural areas compared with the national average for most program types as well as more likely to establish practice in NL compared with other single medical schools' graduates in their provinces. This study highlights the impact a comprehensive rural-focused social accountability approach can have at supplying the needs of a population both at the regional and rural national levels.

Developing the National Family Medicine Graduate Survey.

Developing the National Family Medicine Graduate Survey.

Who Will Deliver the Babies? Identifying and Addressing Barriers

The policy brief in this JABFM issue reinforces the low percentage of new family medicine graduates who intend to perform obstetric deliveries, and that only 7% of all family physicians currently do so.[1][1] These impressions, gathered from the American Board of Family Medicine Family Medicine

Intention Versus Reality: Family Medicine Residency Graduates' Intention to Practice Obstetrics.

Although 21% of new family medicine graduates in 2016 reported an intention to include obstetric delivery in their scope of practice, only 7% of family physicians currently do so. The reasons for this stark difference must be identified in order to address potential barriers leading to family medicine graduates ultimately not including obstetric delivery despite intent.

Feasibility Of Square-stepping Exercise To Improve Mobility And Cognition In Long-term Care And Retirement Living.

Square-stepping exercise (SSE) is a visuospatial working memory task with a cued stepping response; it has demonstrated mobility and cognitive benefits in older adults. PURPOSE: To explore whether a SSE program is feasible in long-term care (LTC) and retirement living (RL) facilities in populations with diverse mobility and cognitive abilities. METHODS: A cluster-randomized trial was conducted; 4 sites (2 LTC and 2 RL) were randomized to SSE [2x/wk for 12-wks by trained kinesiologists (kins)] or control (CON). Recruitment, attendance, program fidelity, and feedback were monitored throughout the program. RESULTS: All residents were invited to participate; in the intervention sites, there were 192 and 144 beds for the LTC and RL, respectively. Recruitment was via information sessions. Intervention participants (n=30) were 80.5 ± 13.2 yrs old, 77% female, and had 12.2 ± 3.2 years of education. In LTC (n=15) there was an average of 5.5 residents in attendance at each session ranging from 3-9 over 19 sessions. LTC residents attended an average of 45.6% sessions (range: 10.5-79.0%); 6 attended >50% of sessions. In RL (n=15) there was an average of 7.8 residents in attendance at each session ranging from 3-12 over 24 sessions. RL residents attended an average of 21% of sessions (range: 8.3-75%); 8 attended >50% of sessions. To maintain a pragmatic approach, SSE was modified following feedback: sessions were reduced from 60 to 45 min; residents who used gait aids were assisted by kins; and in LTC program, progression was limited. Residents in RL became peer-coaches to assist kins and act as moderators. Anecdotal feedback from kins and residents was positive, with comments about SSE being fun but also a ‘good’ challenge; both sites have continued the program. CONCLUSIONS: Recruitment for this study was considered a success from the perspective of the LTC and RL facilities. Attendance was variable; it is understandable with a variety of mobility and cognitive abilities that achieving perfect attendance is unlikely. It is reasonable, with program modifications and flexibility in program progression, for this to be a feasible program for adults living in LTC and RL facilities to engage physically, cognitively and socially. FUNDING: Western Centre for Studies in Family Medicine, Schlegel Villages and Ontario Graduate Scholarship.

Assessment of a Novel Point-of-Care Ultrasound Curriculum's Effect on Competency Measures in Family Medicine Graduate Medical Education.

Point-of-care ultrasound has been shown to decrease the use of expensive diagnostic studies and improve quality outcome measures. Currently, there is a large desire for training in family medicine residencies, but very few programs have established curricula. We sought to develop a family medicine residency curriculum and evaluate it with tools we developed. We wanted our curriculum to be easy to adopt by other residency programs, even if they did not have many well-trained ultrasound faculty. We developed a curriculum in the form of a 4-week rotation in a family medicine residency program. It consisted of self-study videos, hands-on training, and image review. We followed residents in postgraduate years 1 to 3 over a 12-month period. We developed tools, including a knowledge exam, to test image interpretation and clinical decision making, an observed structured clinical exam to assess scanning skills, and a survey to assess perceptions of point-of-care ultrasound in family medicine. The assessments were administered before and after each resident's rotation. Seventeen residents completed the rotation. The average knowledge test score improved significantly, from 62 to 84%. The average observed structured clinical exam scores also improved significantly, from 41 to 85%. The average perception survey scores improved slightly from 4.4 to 4.6. We developed a point-of-care ultrasound curriculum for family medicine residency programs that improves measures of resident attitude, skills, and knowledge. This curriculum can be adopted by residency programs with few faculty members who are experienced in ultrasound.

Education in quality improvement for practice in primary care during residency training and subsequent activities in practice.

Quality improvement (QI) is an integral aspect of graduate medical education and an important competence for physicians. We examined the QI activities of recent family medicine residency graduates and whether a standardized curriculum in QI during residency resulted in greater self-reported participation in QI activities in practice after graduation. The family medicine residency programs affiliated with the South Carolina Area Health Education Consortium (N = 7) were invited to participate in this study. Following completion of introductory educational activities, each site implemented regularly occurring (at least monthly) educational and patient care activities using QI principles and tools. Semiannually, representatives from each participating site met to review project aims and to provide updates regarding the QI activities in their program. To examine the impact of this project on QI activities, we surveyed graduates from participating programs from the year prior to and 2years after the implementation of the curriculum. Graduates in the preimplementation and postimplementation cohorts reported participating in periodic patient care data review, patient care registries, QI projects, and disease-specific activities (57%-71% and 54%-63%, respectively). There were no significant differences in QI activities between the 2 groups except in activities associated with status of their practice as a patient-centered medical home. Most but not all family medicine graduates reported they were actively involved in QI activities within their practices, independent of their exposure to a QI curriculum during training.

Who Chooses to be a Family Physician

The US population is predicted to increase by 18% between 2005 and 2025. The over 65 population will increase by 73% during this same period.1 These are contributors the predicted shortage of primary care physicians in the United States. The American Academy of Family Practice (AAFP) has predicted a 51% shortage of 40,000 primary care physicians by 2020.2 It is understood that family physicians are more likely to practice as generalists, and along with general internal medicine and pediatrics, provide 52% of all ambulatory visits in the United States. These visits include 80% of all hypertension visits and 69% of all diabetic and COPD visits.2 Efforts to expand allopathic medical school size by 30% are well under way across the United States. In 2009, 7.5% of US medical school graduates were first year family medicine graduates, compared with 8.2% in 2008 and 8.3% in 2007.9 Osteopathic medical school numbers and class sizes are growing rapidly with a nine-fold increase in number of osteopathic students in the last 40 years and nine new osteopathic medical schools (including branch campuses) in the past five years.4 Attention must be paid to the types of physicians produced with this expansion. The factors that affect medical students’ choices regarding specialty choice are varied and complex. Positive influences such as strong family medicine role modeling and aggressive recruitment for family medicine tend to help students select family medicine careers. Negative influences, such as educational debt and lifestyle, have also grown in importance to medical students.16 The Affordable Care Act has identified primary care physicians as the foundation for cost effective, efficient care for our nation. It is imperative that medical educators work to influence students’ choices as well as promote public policy that would support such a choice.

Length of Training Debate in Family Medicine: Idealism Versus Realism?

How long a resident must train to achieve competency is an ongoing debate in medicine. For family medicine, there is an Accreditation Council for Graduate Medical Education (ACGME)-approved proposal to examine the benefits of lengthening family medicine training from 3 to 4years. The rationale for adding another year of residency in family medicine has included the following: (1) overcoming the effect of the duty hour limits in further reducing educational opportunities, (2) reversing the growing number of first-time takers of the American Board of Family Medicine primary board who fail to pass the exam, (3) enhancing the family medicine training experience by "decompressing" the ever-growing number of Residency Review Committee requirements to maintain accreditation, and (4) improving the overall quality of family medicine graduates.