1. 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

2. What is the ABFM?

3. 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

4. THE CHANGING PARADIGM KNOWLEDGE-BASED ASSESSMENT
COMPETENCY-BASED ASSESSMENT

5. 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.

6. 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.

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

9. 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.

10. 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

11. 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

12. 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.

13. 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

14. Which Way Are We Going?

15. 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.

16. 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

17. 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.

18. 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.

19. 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.

20. 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

21. 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

22. 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.

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

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

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

26. 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

27. 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.

28. 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.

29. 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.

30. 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.

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

32. 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

33. 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

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

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

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

37. “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