SPECIAL ARTICLES

The Length of Training Pilot: Does Anyone Really Know What Time It Takes? Peter J. Carek, MD, MS

BACKGROUND AND OBJECTIVES: With funding from the Ameri- insufficient innovation. Several oth- can Board of Family Medicine, the Review Committee for Family er medical educators voiced similar Medicine of the Accreditation Council for Graduate Medical Edu- concerns.4-10 cation has undertaken a project to examine the length of training More recently, proponents of a for family medicine residents. This project comes at a time when 4-year residency training period sug- concerns are being raised regarding how well family medicine resi- gested that the additional length of dents are being prepared for independent practice, especially in training would provide a longitudi- view of the changing health care environment. The declining per- nal educational experience in conti- formance of recent graduates on the American Board of Family nuity of care with patient population Medicine certification examination and reports of narrowing of the scope of practice of family physicians have only heightened these based in community practice set- 11 concerns. This special article is meant to provide a historical re- ting. Further, a lengthened period view of the issue as well as an overview of the project. of training would provide the capac- ity for trainees to customize their (Fam Med 2013;45(3):171-2.) residency experience by selecting a “value-added” component to their training. urrently, the required length that a more efficient approach would While some family medicine edu- of training for a family medi- allow an excellent program to be pre- cators support increasing the length Ccine resident is 3 years. This sented in 3 years if circumstances of residency training, others do time period was established more are favorable for this approach. not.12,13 Further, the medical litera- than 40 years ago and was based Since those early recommenda- ture provides mixed support for the on expert opinion with little if any tions, the length of training in fam- increased length. A survey of resi- support from the educational liter- ily medicine has been 3 years. Due dency applicants found that length- ature. During the development of to concerns raised following the im- ening training to 4 years would have the initial requirements and as not- plementation of resident duty hours neutral or positive effect on appli- ed in the Millis report, most physi- in 2003, the issue of the length of cants’ interest in family medicine cians were spending 4 or more years training has been raised again. In an training in Oregon.9 In contrast, pre- 3 in internship and residency train- editorial by Saultz, several issues liminary findings of a student survey ing in response to three factors: the regarding length of training were found that 72% considered 3 years to growing amount to be learned, hos- delineated: more to teach now than be optimum length for family med- pital needs for house staff, and the ever, 3-year duration not as long as icine residency, compared to 21% attitude that “My field is more dif- it used to be (ie, less work hours and who felt 4 years was ideal length of ficult than yours, so the residen- low visit volume in family medicine time. Additionally, a majority of re- cy should be longer, and anyway a center), significant minority of facul- sponding Uniformed Services Acad- long residency looks good and adds ty and residents favor such change, emy of Family Physicians members to prestige.”1 In parallel, the Willard specialty failing to attract sufficient report indicated that training would students, quality of care and qual- require more than 3 years after med- ity of service both lacking in Ameri- ical school, and 4 years would be the can health care systems, and risk of 2 more usual requirement. With that becoming stagnant field, focused on From the Department of Family Medicine, said, the Willard report did indicate our past and on our traditions with Medical University of South Carolina.

FAMILY MEDICINE VOL. 45, NO. 3 • MARCH 2013 171 SPECIAL ARTICLES

indicated that 3 years was the opti- residencies participating in the pi- CORRESPONDENCE: Address correspondence mal length of family medicine resi- lot are expected to inspire and guide to Dr Carek, Medical University of South 15 Carolina, Department of Family Medicine, dency. substantial changes in the content, 5 Charleston Center Drive, Suite 263, MSC While valid arguments exist for structure, and location of training 190, Charleston, SC 29425. 843-876-2921. Fax: maintaining or extending the length of family physicians and guide revi- 843-876-2918. [email protected]. of training for family medicine resi- sions in accreditation and certifica- dents, either recommendation would tion requirements. References currently be based on expert opinion To complete the objectives of this 1. Millis Commission. The graduate education of physicians: the Report of the Citizens Commis- only with little evidence to support project, a Steering Committee has sion on Graduate Medical Education. Chicago: either option. Despite any disagree- been appointed by the Review Com- American Medical Association, 1966. ment regarding the most appropriate mittee for Family Medicine (RC-FM) 2. Willard Committee. Meeting the challenge length of training, both sides of the and the American Board of Family of family practice: the Report of the Ad Hoc Committee on Education for Family Practice discussion agree that medical edu- Medicine. The Steering Committee of the Council on Medical Education. Chicago: cation in family medicine needs to is providing direct project manage- American Medical Association, 1966. adapt to a changing health care en- ment and will select both participat- 3. Saultz JW, David AK. Is it time for a 4-year vironment and prepare family phy- ing residency programs as well as a family medicine residency? Fam Med 2004;36(5):363-4. sicians to effectively manage both core evaluation team. Approximately 4. Tiemstra JD. Fixing family medicine residency individual and population health. 25 participating residency programs training. Fam Med 2004;36(9):666-8. To do so, several options exist: in- in both a study (4 years of training) 5. Duane M, Covey SM, Klein L, Green LA. Fol- crease intensity of training and re- and control (3 years of training) low-up on family practice residents’ perspective vise requirements and curricula to group are being sought. The core on length and content of training. J Am Board Fam Pract 2004;17:377-83. more efficiently train residents; max- evaluation team will work with the 6. Blake GH, Stockton MD. A 4-year family medi- imize the use of information tech- participating residency programs cine residency program. Fam Med 2005;37(1):6. nology during training and practice; and Steering Committee to organize 7. Dysinger WS. The length of residency train- improve integration of graduate and and oversee assessment strategies ing—can we be flexible? Fam Med 2005;27(1):7. continuing medical education, more that will include both quantitative 8. Zweifler J. Point-Counterpoint: The argument effectively addressing the needs of and qualitative measures that in- for a 2-year versus 4-year family medicine residency. Fam Med 2005;37(5):367-8. the individual physician in the spe- clude such areas as standardized 9. Smits AK, Walsh E, Ross RG, Gillanders WR, cific patient care environment; and test scores, patient care experienc- Saultz JW. Residency applicants’ perspectives revise the curricula and expectations es, quality of care indicators, scope on family medicine training length. Fam Med of the fourth year of medical school. of practice activities, level of profes- 2006;38(3):172-6. While several options are present sionalism, patient satisfaction and 10. Lebensohn P, Campos-Outcalt D, Senf J, Pugno PA. Experience with an optional 4-year resi- to better prepare family physicians, utilization of quality improvement dency: the University of Arizona Family Medi- increasing the length of residen- activities, and principles of evidence- cine Residency. Fam Med 2007;39(7):488-94. cy training is a logical alternative based medicine in practice. 11. Pugno PA. One giant leap for family medicine: that requires further study. Specifi- In summary, the Length of Train- preparing the 21st-century physician to prac- tice patient-centered, high-performance family cally, the Family Medicine Length of ing Pilot Project is an innovative and medicine. J Am Board Fam Med 2010;23:S23- Training Pilot will examine whether exciting endeavor for the RC-FM. Be- S27. extending the length of family medi- yond learning more about the most 12. Fields KB. More in the 4-year FM residency cine training to 4 years through the appropriate time period for residency program. Fam Med 2005:27(1):8. development of innovative training training in family medicine, the ex- 13. Scherger JE. Residencies: heal thyself before extending. Fam Med 2006;38(3):158-9. paradigms further prepares family periences and results of this project 14. Stephens M, Lennon R, Saguil A, Reamy BV. physicians to serve as highly effec- will provide guidance to educators Four-year training in family medicine: strength tive personal physicians in a high as they further develop curriculum through versatility using the Uniformed Ser- performance health care system. and direction for accreditation and vices as a model. Fam Med 2011;43(9):664-6. In addition and maybe more im- certifying organizations as they re- portantly, the innovations tested in vise requirements.

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