AAMC Academic Family Medicine Fall Session The P4 Project: Transforming the Education and Training of Family Physicians James C. Puffer, M.D. President and Chief Executive Officer The American Board of Family Medicine AAMC Academic Family Medicine Fall Session Seattle, Washington October 29, 2006

What is the ABFM?

Objectives of the American Board of Family Medicine Improve the quality of medical care available to the public Establish and maintain standards of excellence in the specialty of Family Medicine Improve the standards of medical education for training in Family Medicine Determine by evaluation the fitness of specialists in Family Medicine who apply for and hold certificates

THE CHANGING PARADIGM KNOWLEDGE-BASED ASSESSMENT COMPETENCY-BASED ASSESSMENT

DEFINING COMPETENCE The ACGME and the ABMS have worked together to develop the definition of a competent physician that encompassed all important domains of professional medical practice.

THE COMPETENT PHYSICIAN The competent physician should possess the medical judgment, professionalism, and clinical and communication skills to provide high quality patient care. Patient care encompasses the promotion of health, prevention of disease, and the diagnosis, treatment and management of medical conditions with compassion and respect for patients and their families.

ACGME General Competencies Medical knowledge Patient Care Interpersonal and communication skills Professionalism Practice-based learning and improvement Systems-based practice

The Future of Family Medicine Concurrently, the family of Family Medicine undertook the Future of Family Medicine Project. The final report of this project was published in March 2004. It called for a transformation of the specialty.

FAMILY PHYSICIANS Key Characteristics A deep understanding of the dynamics of the whole person A generative impact on patients’ lives A talent for humanizing the health care experience A natural command of complexity A commitment to multidimensional accessibility

THE NEW MODEL PRACTICE Characteristics Patient-centered care Whole-person orientation Team approach Elimination of barriers to access Advanced information systems Attractive, convenient and functional offices Focus on quality Equitable reimbursement

The Future of Family Medicine Task Force Two proposed a dramatic change in the way family physicians are trained. The integral element in this new training paradigm was the development of family physicians who could function optimally in the New Model practice environment.

Residency Review Committee for Family Medicine Undertook a three year review of the program requirements in Family Medicine Created new program requirements that became effective July 1, 21006 Instituted changes that at best can be viewed as incremental

Which Way Are We Going?

Historical Perspective The percentage of generalists declined from 79.2% in 1938 to 17.3% in 1970. The number of specialists increased from 20.8% in 1938 to 75.7% in 1970 Study groups convened in the 1960s to address the public’s need for an adequate number of community-based, generalist physicians.

Historical Perspective The National Commission on Community Health Services – The Folsom Report The Citizens Commission on Graduate Medical Education – The Millis Report The Ad Hoc Committee on Education for Family Practice – The Willard Report

Study Group Findings Individuals should have access to physicians who would treat them as individuals, not as isolated diseases or organ system dysfunctions. The scope of services from such physicians should be comprehensive. A continuing relationship should exist between the physician and patient.

Study Group Findings (continued) The scope of the physician’s competencies should be broad enough to treat all members of the family. The profession should train new family physicians in the immediate future.

Crossing the Quality Chasm: A New Health System for the 21st Century Our health care system frequently falls short in its ability to translate knowledge into practice. A highly fragmented delivery system results in poorly designed care and duplication of services. Absence of progress toward addressing quality and cost is distressing.

Crossing the Quality Chasm The New Health Care Paradigm Care is based on visits Professional auton-omy drives variability Professionals control care Information is a record Decision making based on training Care based on contin-uous relationships Care customized to fit patient needs/values Patient is the source of control Knowledge is shared and flows freely Decision making is evidence-based

Crossing the Quality Chasm The New Health Care Paradigm Do no harm is an indi-vidual responsibility Secrecy is necessary The system reacts to needs Cost reduction is sought Preference is given to professional role Safety is a system property Transparency is necessary Needs are anticipated Waste is continuously decreased Cooperation among clinicians is a priority

Health Professions Education: A Bridge to Quality Issued by the IOM in 2003 The education of health professionals has not kept pace with the new realities posed by the changing health care environment. It must be reformed to address new challenges created as a result of this dynamic.

“Professional competence is developmental, impermanent, and context-dependent.” Epstein RM and Hundert EM. Defining and assessing professional competence. JAMA 2002; 287:226-235

Health Professions Education: A Bridge to Quality The Five Competency Areas Patient-centered care Interdisciplinary team work Evidence-based practice Quality Improvement Informatics

The Solutions Reconnect with Patients Integrated Care Teams Reimbursement Reform Information Systems Health Care Outcomes Education and Training

The Solutions Reconnect with Patients Safran believes that the potential exists for a powerful shift in primary care relationships if the physician-patient experience is formally defined. It should define shared objectives with regard to the patient’s health and individual roles and responsibilities in achieving them

The Solutions Integrated Care Teams Considerable evidence links the performance of care teams to improved health care outcomes and reduced costs. Teams members must be visible and valued by the patient. Teams should be constructed to improve access, communication, collaboration and coordination.

The Solutions Information Systems Patient-centered information systems would provide decision support tools that would help patients and physicians make decisions with regard to their health. They would interface with the patient’s electronic medical record and provide mechanisms for measuring quality of care.

The Solutions Health Care Outcomes Primary care must be committed to developing systems which deliver high quality care. This care must be substantiated by documenting measurable health care outcomes. The use of the EMR and practice-based information management systems will be essential to achieve the goal.

The Solutions Education and Training Academic health centers and graduate training programs must be leaders in developing the infrastructure to support innovative training in primary care. Clinical training must occur in settings that provide high quality, patient-centered, evidence-based and outcomes oriented care.

Change in Family Medicine residency training must be transformative, NOT incremental! Thus the genesis of Preparing the Personal Physician for Practice, or P4.

Scope and Content of Training Enhancements in chronic disease care Differentiation for a particular population Change in approach to maternity care Reflective practice Patient-centeredness Enabling health behavior change

Length of Training Shortened by incorporation with the 4th year of medical school Shortened with integration into intended future New Model practice site Lengthened to achieve more breadth or depth of competency Lengthened to decompress the residency experience

Place of Training Greater emphasis on home care Replacement of traditional family medicine center with other sites of training Role of hospital in training

Structure of Training The order and timing of training components, processes of instruction and experience

Measurement of Competency Use of measures other than length of time Use of simulators Outcome based advancement

“Primary care is the logical foundation of an effective health care system.” Primary Care: America’s Health in a New Era The Institute of Medicine, 1996