Family Medicine Residency Training Research Articles

Transforming the Heart of Practice

Burnout has been a recent trending topic not only in the health care setting but in the general workplace as well. A PubMed search for “physician burnout” shows over 300 publications per year since 2016, whereas fewer than 100 papers per year were published before 2008. In this context, the book Transforming the Heart of Practice is a relevant read for both health care workers and administrators alike. The book consists of 28 chapters divided into 6 large sections, addressing general physician well-being, burnout, and interventions for prevention and treatment. Both paperback and eBook versions are available. This is a review of the eBook, but the paperback version appears essentially the same when looking at online seller previews or samples of the paperback. The editors of the book are Dr Dianne E. McCallister and Dr Ted Hamilton. Dr Dianne McCallister is a board-certified Internist at The Medical Center of Aurora in Colorado. She received her MD and MBA from the University of Denver. Dr McCallister has been at the Medical Center of Aurora since 2013 and serves as the Chief Medical Officer and Patient Safety Officer. She pioneered a comprehensive Physician Wellbeing and Engagement program at the hospital, which has led the facility to become the first of 4 hospitals in the United States to receive the Medicus Integra Award from the Coalition for Physician Wellbeing. Of note, Physician Satisfaction at the Medical Center of Aurora has shown a significant increase across all metrics in the time she has been there. Dr Ted Hamilton is a graduate of the Loma Linda University School of Medicine. He completed residency training in family medicine at Florida Hospital and earned an MBA from Rollins College Crummer Graduate School of Business. Dr Hamilton is currently the vice president of Adventist Health System, FL. He is committed to working with hospitals to improve the quality of patient care as well as physician satisfaction by reducing burnout through enhanced balancing of personal and professional lives. He believes the most important step in treating the epidemic of burnout is acknowledgment and an actionable plan. Under his direction, a physician support services (PSS) department was created at Adventist which has helped as many as 1000 physicians at the health system over the years. Dr Hamilton is a pioneer in the field and has authored several papers on the topic of physician well-being and burnout. Part I delves into the general problem of physician burnout. The first 3 chapters explore the reasons for increasing rates of burnout, the current body of research on this topic, and the effects of burnout on physicians and on patient care. Part II describes the workplace culture and environment requisite for promoting physician well-being. These consist of factors such as an environment of accountability, respect, and trust. One of the highlights of this section delineates the importance of physician integration and the obligation to create achievable avenues to raise and address physician concerns. Part III equips health care organizations with specific ideas and guidelines for implementing programs for physician well-being. One extremely interesting and enlightening chapter examines common physician characteristics and correlates how these should be considered when creating physician wellness programs. In summary, the first 3 parts are most pertinent for readers who want to learn about physician well-being, burnout, and possible solutions. Parts IV–VI expound on these topics with vignettes from home and hospital that the authors have deemed effective and successful initiatives and programs. Part VI consists of a relatable compilation of personal accounts from physicians, chronicling their work in relation to family, pregnancy, and childcare. The final chapter closes with the dark consequences of burnout which include mental illness, substance abuse, and domestic violence. Overall, the book presents the topic in an organized and easy-to-read format that helps elucidate the distinct issues concerning physician well-being and burnout. The main merit of this book stems from the numerous personal anecdotes and experiences within various health care organizations, providing pearls and lessons for creating and implementing successful physician wellness programs. This compelling book could serve as a primer for beginners embarking on a journey to explore wellness. Moreover, it also serves as a comprehensive overview for veterans in the field in search of a cohesive synopsis of the increasingly important topic. Luis E. Tollinche, MD, FASAHoward Teng, MDCindy B. Yeoh, MD, FASADepartment of Anesthesiology and Critical Care MedicineMemorial Sloan Kettering Cancer CenterNew York, New YorkDepartment of AnesthesiologyWeill Cornell Medical CollegeNew York, New York[email protected]

General Practitioners in US Medical Practice Compared With Family Physicians.

General practitioners (GPs) are part of the US physician workforce, but little is known about who they are, what they do, and how they differ from family physicians (FPs). We describe self-identified GPs and compare them with board-certified FPs. Analysis of data on 102,604 Doctor of Medicine and Doctor of Osteopathy physicians in direct patient care in the United States in 2016, who identify themselves as GPs or FPs. The study used linking databases (American Medical Association Masterfile, American Board of Family Medicine [ABFM], Area Health Resource File, Medicare Public Use File) to examine personal, professional, and practice characteristics. Of the physicians identified, 6,661 self-designated as GPs and 95,943 self-designated as FPs. Of the self-designated GPs, 116 had been ABFM certified and were excluded from the study. Of the remaining 102,488 physicians, those who self-designated as GPs but were never ABFM certified constituted the GP group (n = 6,545, 6%). Self-designated FPs that were ABFM certified made up the FP group (n = 79,449, 78%). The remaining self-designated FPs not ABFM certified constituted the uncertified group (n = 16,494, 16%). GPs differed from FPs in every characteristic examined. Compared with FPs, GPs are more likely to be older, male, Doctors of Osteopathy, graduates of non-US medical schools, and have no family medicine residency training. GPs practice location is similar to FPs, but GPs are less likely to participate in Medicare or to work in hospitals. GPs in the United States are a varied group that differ from FPs. Researchers, educators, and policy makers should not lump GPs together with FPs in data collection, analysis, and reporting.

The Outpatient Training Gap: A Pilot Study.

Most family medicine residency training takes place in hospitals, which is not reflective of the outpatient care practiced by most primary care clinicians. This pilot study is an initial exploration of family medicine residency directors' opinions regarding this outpatient training gap. The authors surveyed 11 California family medicine residency program directors in 2017-2018 about factors that influence decisions regarding allocation of residents' inpatient and outpatient time. Nine of the 11 program directors agreed to be interviewed. We analyzed the interviews for common themes. The participating program directors were generally satisfied with inpatient and outpatient balance in their residents' schedules. Factors identified as promoting inpatient training included the need for resident staffing of hospital services, the educational value of inpatient rotations, and a lack of capacity in continuity clinics. From the program directors' perspective, residency funding played no direct role in curriculum planning. Program directors also felt that the ACGME requirements prescribing 1,650 continuity clinic visits throughout residency inhibited the development of creative outpatient training opportunities. Family medicine residency program directors participating in this exploratory study did not feel that their programs overly emphasized inpatient care and training.

Certified Nurse Midwives as Teachers of Family Medicine Residents.

The high quality of obstetric care provided by certified nurse midwives (CNMs) has led some to hypothesize that collaboration with CNMs may encourage more family medicine (FM) residents to subsequently practice maternity care. Our goal was to understand the current state of CNM involvement in FM resident education. We conducted two surveys: one to a random sample of 180 FM program directors, and one to 147 CNMs involved in medical education. The surveys examined the nature, prevalence, and attitudes regarding CNM involvement in FM residency training. The surveys' response rate was 59% from FM program directors and 58% from CNMs. Thirty-six percent of FM directors reported no CNM involvement in their residency programs, 26% reported minimal interaction, and only 6% reported a fully integrated model with CNMs on faculty. Eighty-eight percent of CNMs and 64% of program directors reported a prefence for increased interaction. Programs with highly involved CNMs reported 33% of graduates subsequently practicing prenatal care, with only 13% of graduates practicing in programs with low CNM involvement (P<.003). However, there was no difference in those providing inpatient maternity care. Thirty-one percent of FM program directors and 25% of CNMs felt that physicians and CNMs have different ideas about how to treat patients; 26% of FM program directors who worked with midwives felt that CNMs should not be involved in residency curriculum planning. CNM participation in FM residency education is very limited. Our study identified a gap between the current state and the preferences of CNMs and FM program directors for greater educational collaboration. Residency program director attitudes may contribute to the low rate of collaboration between the two fields.

Digital Healing: People, Information, Healthcare

Digital Healing takes the reader on an evolutionary journey focusing on the deployment of electronic health record systems across the United States from 2000 to 2018. The author, Marc Ringel, M.D., studied at the Abraham Lincoln School of Medicine in Chicago, Illinois followed by postgraduate training in pediatrics at Cook County Hospital (Chicago). He later became a general practitioner in Yuma, Colorado (population 2,000) as part of the National Health Service Corps where he fell in love with rural medicine and became Board Certified as a family physician. He has also practiced in rural Wisconsin and taught at the North Colorado Family Medicine Residency Training Program in Greeley, Colorado. He is an eloquent writer and speaker, and is dedicated to writing about rural health care, telemedicine, and continuing medical education. Dr. Ringel weaves relevant scholarly references and personal stories about his role as a family medicine physician to engage the reader in a thoughtful discussion about ways in which people are better than computers and vice versa in health care.A recurrent theme throughout the book is that no matter how sophisticated or impressive technology is, the determining factor for its successful implementation is the people involved in deploying and using the technology. Personal stories and clever examples of telemedicine applications are interwoven throughout the book in a way that draws the reader in. Dr. Ringel cleverly depicts the improvement offered by electronic health records while describing the importance of the human component of health care, focusing on patients’ stories and relationships, while using clever chapter titles such as “Left-Handed Pregnant Women,” “Everybody Wants Your Data,” and “Financial and Human Costs of EHRs.” The author commands an encyclopedic knowledge of medical history and integrates it well with the rapidly evolving digital revolution that is affecting health systems throughout the world.The central thesis of the book explores the ways in which human beings can utilize digital information and resources to improve health, while also allowing people to be more human. The author intercalates stories describing entire health systems, such as those in rural and urban centers in Colorado, with individual anecdotes that highlight the strengths and limitations of electronic health records. The author’s views, particularly advocating for rural health initiatives and reducing health services disparities, are prevalent throughout the text.As a rural practitioner, Dr. Ringel recognizes the importance of interventions that address disparities in healthcare access, particularly in remote areas of the country. All forms of telemedicine are emphasized, from phone calls to virtual consults with intensivists who offer around-the-clock expertise to clinicians in remote hospitals with limited or no access to specialists.The book is carefully organized into chapters focusing on specific areas ranging from virtual reality to artificial intelligence to clinical decision support. The author avoids jargon and aims for a balanced presentation that is accessible to medical and general readers alike. This book offers a set of perspectives on the evolution of the electronic health record system, but is not a comprehensive overview of the field. The book is available in hardback and eBook formats through a variety of services. Readers of all levels of experience will enjoy this welcome reality check in today’s digitally connected world.

Medicine Residency Training Program during COVID-19: Qatari Experience

Family medicine residency training programs should put in place COVID-19 action plan in conjunction with other clinical departments, employee health personnel, and infection control leads. Programs should develop coping strategies that balance resident and patient safety, resident wellbeing, clinical training services, and resident education.

Aile Hekimliği Uzmanlık Eğitiminde ‘Eğitim Aile Sağlığı Merkezleri’ Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi Deneyimi

Aile Hekimliği Uzmanlık Eğitiminde ‘Eğitim Aile Sağlığı Merkezleri’ Şişli Hamidiye Etfal Eğitim ve Araştırma Hastanesi Deneyimi

Leveraging quality improvement principles in comprehensive medication management pharmacy practice: A case example

ObjectiveTo maximize the time pharmacists providing comprehensive medication management (CMM) services spend providing direct patient care by tracking their time spent on various activities. SettingFifteen primary care clinics within an integrated health care system in Minnesota. Practice descriptionEleven pharmacists provide comprehensive medication management services in 15 clinic sites; 12 primary care clinics, 1 family medicine residency training clinic, and 2 specialty clinics. Practice innovationA team of pharmacists providing CMM developed and completed a self-reported workload sheet to document how much time they spent on various activities. These sheets were completed at 4 different points over 6 years to guide efficiency efforts to increase pharmacists’ time spent in value-added activities such as direct patient care. EvaluationBeginning in 2014, each CMM pharmacist was asked to complete the workload tally sheet to track the time they spent on all their daily activities for a 5-day period. The workload sheets were collected in 2014, 2016, 2017, and 2019 and represent a snapshot of activity at 1 point during each year. Workload sheets from each pharmacist were compiled and analyzed each year to assess time spent in direct patient care and other value-added activities. ResultsFrom 2014 to 2019, CMM pharmacists increased their time providing value-added services from 47.1% to 72% and increased time in direct patient care from 26.7% to 52.5%. This was achieved through a number of workflow optimization strategies, including appropriation of staff to schedule and recruit CMM patients, developing expanded collaborative practice agreements, and creating documentation efficiencies. ConclusionCollecting CMM pharmacist workload data across the years demonstrated the amount of time pharmacists were spending on various clinic-related activities and served to identify areas where workflow and processes could be improved to increase the time pharmacists spend in value-added services. As CMM practices continue to develop and expand, tracking and optimizing pharmacists’ time is essential to leverage efficiency and value of pharmacy services.

Implicit Bias Training in a Residency Program: Aiming for Enduring Effects.

Implicit bias often affects patient care in insidious ways, and has the potential for significant damage. Several educational interventions regarding implicit bias have been developed for health care professionals, many of which foster reflection on individual biases and encourage personal awareness. In an attempt to address racism and other implicit biases at a more systemic level in our family medicine residency training program, our objectives were to offer and evaluate parallel trainings for residents and faculty by a national expert. The trainings addressed how both personal biases and institutional inequities contribute to structural racism, and taught skills for managing instances of implicit biases in one's professional interactions. The training was deliberately designed to increase institutional capacity to engage in crucial conversations regarding implicit bias. Six months after the trainings, an external evaluator conducted two separate 1-hour focus groups, one with residents (n=18) and one with program faculty and leadership (n=13). Four themes emerged in the focus groups: increased awareness of and commitment to addressing racial bias; appreciation of a safe forum for sharing concerns; new ways of addressing and managing bias; and institutional capacity building for continued vigilance and training regarding implicit bias. Both residents and faculty found this training to be important and empowering. All participants desired an ongoing programmatic commitment to the topic.

Relationship of Patient Self-Administered COPD Assessment Test to Physician Standard Assessment of Chronic Obstructive Pulmonary Disease in a Family Medicine Residency Training Program.

Assessing the global impact of chronic obstructive pulmonary disease (COPD) on a patient's life can be difficult to perform in the clinical setting due to time constraints and workflow challenges. The primary objective of this study was to compare disease impact ratings between patient self-administered COPD Assessment Test (CAT) and physician standard office assessment. This prospective study was conducted at a family medicine residency clinic in northeast Tennessee. The study included two study groups: 1) adult patients seen at the clinic during the 3-month study period with an active diagnosis of COPD, and 2) their physicians. Physicians' assessment of the impact of COPD on their patients' daily lives was compared to patients' self-administered CAT assessments. Physician assessment of COPD impact and patient assessment of CAT categories significantly differed (χ2=11.0, P=0.012). There was very poor agreement between patient and physician ratings (κ=0.003), with 42.9% of physician ratings underestimating the impact, 28.6% overestimating the impact, and 28.6% correctly estimating the impact COPD had on their patients' lives. These findings support the use of validated assessment tools to help providers understand the symptom burden for patients with COPD.

Essential Office Procedures for Medicare Patients in Primary Care: Comparison With Family Medicine Residency Training.

Demographic trends show an increasing older adult population. Therefore, family medicine training programs may need to reevaluate how well their residents perform clinic procedures essential to older adults. Our objective was to compare the rates of the most frequently performed clinic procedures for Medicare patients in a large multiregional health care system (MRHCS) with those in a family medicine residency clinic. In this retrospective cohort study, Current Procedural Terminology coding data were queried from the billing systems of an MRHCS (the control group) and a family medicine residency clinic (the study group) for a 3-year period. The primary outcome was the procedural rate ratios per 1,000 office visits for the 10 most common clinic procedures in the MRHCS billed to Medicare. The study group consisted of 19,099 office visits by Medicare patients to the residency clinic; the control group consisted of 2,034,188 visits to the MRHCS. Except for large joint injection, procedural rates were significantly different for the other nine procedures (destruction of benign skin lesions, nail care, punch or shave skin biopsy, removal of impacted cerumen, wound debridement of skin, Unna boot application, excision of skin lesion, paring of corn or callus, and insertion of bladder catheter). The rate of skin excision was higher in the residency clinic than in the MRHCS but lower for the other eight procedures. These data suggest that teaching programs may need to adapt to meet the current and future practice needs of this increasing patient population.

25 X 2030: ANTICIPATING THE IMPACT

In 2025, 565 million visits to primary care physicians are projected in the United States. To meet this increasing demand, a study published in 2012 found that an additional 52,000 primary care physicians need to be added to the workforce.[1][1] In 2018, 3,654 family medicine residency training

Prevalence of Clinic First Curricula: A Survey of AFMRD Members.

Clinic First residency curricular approaches hold promise as models to successfully prepare primary care residents for future practice. The objective of our study was to estimate the prevalence of the Clinic First model in current family medicine residency training environments, and assess beliefs surrounding curricular structure and postgraduate practice. An eight-question survey was conducted among Association of Family Medicine Residency Directors (AFMRD) members in 2017. Data were grouped and analyzed for statistical significance and correlation using analysis of variance, Kendall's τ, χ2, and Fisher exact test. Two hundred-eleven AFMRD members responded to the survey; 27% described their current curriculum as Clinic First; 68% stated that their ideal curriculum is Clinic First. Residents in Clinic First programs spend more half-days in continuity clinic per week compared with traditional programs during PGY1 (1.79, 1.39, P=0.001) and PGY2 (3.18, 2.90, P=0.024). In group analyses, 63% of Clinic First respondents prioritized clinic in developing resident schedules, compared with 8% of traditional respondents (P<0.001). Seventy-four percent of Clinic First respondents described their philosophy as full spectrum, compared with 93% of traditional respondents (P<0.001). Seventy-five percent of respondents listed their graduates' most common practice type as outpatient practice, and there were no differences between groups (P=0.361). Sixty-one percent of traditional respondents stated that their ideal curriculum is Clinic First (P<0.001). There is a high level of interest in the Clinic First model as a tool to prepare residents for future practice, but barriers to implementation need to be explored and addressed.

The use of Dermoscopy Following a one-day Workshop Among Family Medicine Residents

Skin cancer is the most common form of cancer in the United States. The purpose of this study is to determine if a single grand rounds workshop impacts the use of dermoscopy in a single Family Medicine Residency training program. Dermoscopy is a non-invasive tool to allow for higher magnification of skin lesions thereby increasing the ability to assess qualities which are unable to be seen by the naked eye. This study utilized a pre- and post-workshop survey questionnaire to assess participant practices in evaluation, diagnosis, and management of skin lesions. Eighteen (18) residents completed the survey prior to the grand rounds workshop. Nine (9) residents completed the follow-up survey three-months post-workshop. The results showed that the frequency of dermoscopy use increased post-workshop (Pearson’s Chi Square=8.83, p=0.012; Fischer’s Exact=0.008) and residents felt dermoscopy decreased the need to refer skin lesions (Pearson’s Chi Square=9.11, p=0.028; Fischer’s Exact=0.023). However, there was no significant change in resident comfort level when using dermoscopy post-educational workshop (Pearson’s Chi Square=5.34, p=0.255; Fischer’s Exact=0.272).

Changes in Preparation and Practice Patterns Among New Family Physicians.

Family physicians' scope of practice is declining despite being well prepared to provide a range of clinical services. To evaluate whether this is a new phenomenon, we compared the proportions of regional family medicine residency graduates who report practicing and those who report feeling more than adequately prepared to practice various procedures and clinical services from 2 points in time-a survey in 2000 of graduates from 1996-1999 (n = 293) and a survey in 2012 or 2014 of graduates from 2010-2013 (n = 408). The recent graduates felt better prepared, but reported a narrower scope of practice than those who graduated more than a decade earlier. These findings suggest that family medicine residency training has improved over time but the declining scope of practice is a concerning trend.

PREFACE

................ The Government of Indonesia has recently launched the nation’s postgraduate family medicine residency training programs, based in 17 universities spread across the country. For the first time, medical graduates will receive postgraduate training in comprehensive primary medical care. Formal assessment at the end of training will lead to Fellowship of the Indonesian College of Primary Care Physicians. These new graduates will lead the transformation of health care in this country............One of the main tasks of primary care doctors or family doctors is disease prevention and health promotion. Health education is a way that most take to promote public health. The research articles in this edition show us about how health education is implemented with the aim of general society such as school students, health cadres and puskesmas officers. Education and experience (experiential-based) trigger behavior changes which are then expected to improve health status1. How health education is implemented can affect the results to be achieved. For example, the interactive learning process can achieve the expected results, rather than independent learning and lectures2..............

A physician-physiotherapist collaborative model in a family medicine teaching clinic

Persons with musculoskeletal disorders frequently seek care in family medicine clinics. However, musculoskeletal education provided in medical schools is often considered insufficient. The implementation of a collaborative model that integrates physiotherapists into teaching clinics may benefit the musculoskeletal training of medical residents. This paper describes a model developed in a family medicine teaching clinic by examining the interprofessional educational and collaborative activities implemented in this model. The model allowed to provide physiotherapy services, involve the physiotherapist in the training of family medicine residents and enhance interprofessional collaboration, particularly for the management of persons with musculoskeletal disorders.

Prescriber Attitudes Toward Implementation of Pharmacogenomic Testing in a Family Medicine Residency Program.

Few qualitative studies have explored the attitude of prescribers towards the implementation of pharmacogenomic testing in the family medicine (FM) setting, and none among FM residents. The purpose of this study was to describe the level of engagement and interest in the implementation of pharmacogenomic education and testing in an FM clinic within a residency program. A qualitative study utilizing semistructured interviews was conducted among prescribers within the FM clinic at The Brooklyn Hospital Center (TBHC). Voluntary prescribers included FM residents and attendings. No prescribers were excluded. Prior to the interview, informational sheets about pharmacogenomics were provided to standardize participant knowledge base. The research team created an interview guide of specific open-ended questions. Interviews were audio recorded and transcribed until a point of saturation was achieved. Transcripts of interviews served as data for analysis. Coding and analysis were performed to develop a hypothesis. No formal statistical analysis was required. Of the total 28 providers eligible for participation, 15 were recruited and interviewed (53% response rate). Based on analysis of interview data, four key conceptual concerns emerged regarding benefits and risks of testing, feasibility, accessibility, and modification of FM residency training curricula. Positive attitudes and perceptions provide support for pharmacogenomic education and testing to be incorporated into FM residency curricula. Addressing practical barriers, such as curricular education and training, will allow for expansion of such initiatives in the future.

Innovative utilization of pharmacist-led board review in a family medicine residency curriculum

Background and purposeThe Society of Teachers of Family Medicine Group on Pharmacotherapy recommends a formal curriculum during family medicine residency training and describes benefits of utilizing pharmacists. Limited literature exists on how programs have incorporated questions from family medicine board preparation sources into pharmacotherapy academic education. The primary objective was to assess the impact on family medicine residents’ perceived knowledge after incorporation of board review items into pharmacotherapy sessions. Educational activity and settingPharmacists affiliated with the University of Alabama Family Medicine Residency program incorporated questions from board preparation sources into monthly interactive pharmacotherapy sessions as part of a didactic curriculum between 2014 and 2016. An anonymous survey was administered for two consecutive years in 2015 and 2016 to assess residents’ perceptions of the sessions and utilization of board-type questions as an active learning component. The change in residents’ perception of knowledge was quantitatively analyzed and written comments were evaluated for recurring themes. FindingsThe cumulative survey response was 78% (68/87). Over 80% of residents reported that pharmacotherapy sessions and the use of board-type questions was quite or very helpful. The percent of residents that rated their knowledge as good or excellent significantly increased after every session compared to baseline. Residents noted the sessions’ information, applicability, interactive nature, and relevance as strengths. SummaryIncorporation of board preparation questions into interactive pharmacotherapy sessions was well received and improved residents’ perception of pharmacotherapy knowledge. Utilizing this model in a formal pharmacotherapy curriculum taught by pharmacists is beneficial for family medicine resident learners.

How can we change medical students\u2019 perceptions of a career in family medicine? Marketing or substance?

Family Medicine (FM) is the care of unselected patients with undifferentiated problems in the settings where people need care in our communities. It is intellectually challenging, providing breadth and depth unparalleled in other areas of medical practice. In one survey only 19% of Israeli students reported being interested in FM. Students interested in FM had greater interest in bedside and direct long-term patient care. Students not planning FM residency training had preconceived notions that the discipline had lower academic opportunities and prestige. What can be done to increase student interest in careers in FM?This commentary includes perspectives of family practice leaders from several countries:The problem isn’t the students it is the scope of practice and expectations both of which can and should change if FM in Israel wants to stay viable. The scope of FM should be broadened to include more procedures and new technologies. This may also increase the earning potential of Family Practitioners (FPs). Payment policy and credentialing barriers should be change to expand scope of practice and allow FPs to practice at the full extent of their training.FM should offer clear professional horizon with potential for many sub-specialties and areas of focus. The Israeli HMOs, the Ministry of Health and the Israeli Association of FM should invest heavily in building academic departments of FM and promoting research. This will enhance the image of FM in the eyes of the students, the profession and the public.The clinical work environment should be improved by reducing bureaucratic assignments, such as issuing certifications, dealing with quality measurements and renewing chronic prescriptions. Much of this work can be done by nurse practitioners (NPs) working as part of an FP-led team. These NPs can also take care of patients with limited complaints to make the work of the FP more challenging and attractive.Training must include opportunities to develop longitudinal relationships with patients and families across problems and over time. It is these relationships that add value to the process of care, improve patient outcomes and provide meaning to sustain clinical careers that meet the needs of patients and communities.