Learning environment

Education time is essential to the residential learning environment

In June 2019, the Accreditation Council for Graduate Medical Education (ACGME) reduced the teaching time spent by faculty in family medicine residencies by approximately two-thirds. Prior to this date, the ACGME required sponsoring institutions to provide family medicine residency directors with 0.7 FTEs for educational and administrative responsibilities and 0.6 FTEs for teaching time for each core faculty member, with 1 core faculty member required per 6 residents. The 2019 ACGME requirements were imposed as part of the common program requirements for all residencies, despite formal objections from the American Board of Family Medicine, the American Academy of Family Physicians, and the Council of Academic Family Medicine. To cushion the impact, as well as support succession of residency leadership, the ACGME Family Medicine Review Board added a requirement for an Associate Program Director with 0.4 FTEs dedicated to residency training. For a 24-resident residency, the cumulative effect of the 2019 changes resulted in a reduction in time spent on residency training from 3.5 FTEs to approximately 1.1 FTEs as of July 2019.

The impact of these changes on the learning environment in family medicine residencies has been significant. A survey of program directors1 by the ABFM and the Association of Family Medicine Residency Directors (AFMRD) in July 2020, one year after the changes, demonstrated that 75% had already seen a significant negative impact. The overall response rate was 363/681 or 52.8%. Of the respondents, 75% had seen an immediate and negative impact, and nearly 70% reported rapid budget cuts and/or reallocation of faculty training time to clinical duties.

To address the concerns of family medicine and other specialties, and to establish more consistent policy across specialties, the ACGME created another ad hoc task force, collected evidence from all review boards of specialties and leaders interested in each specialty, then announced guidelines for all specialties. to follow for leadership and educational time. The new guidelines provided for a range of time dedicated to residence directors and training time dedicated to core faculty, with some flexibility based on specialty needs and the ability to request an exception.

The ACGME Family Medicine Examination Board has used this framework to develop new guidelines on faculty training time as part of its major requirements revision project.2. In addition to adjustments for program leadership support, the draft requirements propose dedicated teaching time for faculty of 0.25 FTEs and the reduction of the resident-to-faculty ratio of 4:1. This proposal was based on data on faculty hours spent on educational duties collected by the ACGME itself from family medicine residencies over 10 years, and was supported by an expert evaluation of the Council of academic family medicine, based on the recommendations of a family medicine society. Family Medicine Teachers Working Group (STFM) and with input from AFMRD, Association of Departments of Family Medicine and AAFP3. Thus, for 24-resident residences, this would imply 2.4 FTEs of dedicated residence teaching time, with lesser requirements for smaller and rural programs. This would represent a significant increase in time dedicated to education compared to the 1.1 FTE of time dedicated to education after the 2019 changes, although still significantly lower than the pre-2019 requirements. review panel will indicate that precept time will not count toward education time, because that faculty time is already partially supported by Medicare.

Why is teaching time necessary for the family medicine residency learning environment? As educators know, education actually takes time outside of precept in both outpatient settings and directly supervised hospital care. Curriculum development, implementation and evaluation and resident performance appraisal are essential, as is face-to-face teaching, which averages 4-8 hours per week.4 in family medicine residencies. In family medicine, faculty time is especially important given the complexity of curricula across the continuum of care and the need for continuous coordination and improvement of a variety of experiences. Family medicine residency teachers spin a lot of plates!

In addition, the preliminary requirements will require significantly more dedicated faculty time. They envision a dramatic shift towards competency-based residency training (CBME): away from 1650 visits and specific hours set for specific experiences, and towards more general requirements, combined with strong competency assessments in skills base, allowing much more flexibility for residences to adapt to the needs of their local community and the learning needs of each resident. The EMBC, however, is largely new to family medicine residency faculty. They will require extensive faculty development, and it will require work across the specialty sponsored by our specialty academic organizations to develop and assess assessments of the 6 ACGME Core Competencies, not only clinical skills and knowledge, but also professionalism, communication, problems. systems-based learning and systems-based practice.

In addition, the new requirements emphasize the power of printing5 and its implications for the practice of family medicine for many years. Recognition that “the practice is the program”6 will force increasing attention to the measured quality of practice, the environment in which our residents are ‘immersed’, and will affect the cost and quality of their care for years to come. This is innovative in all specialties and highly complementary to competency-based education. For example, metrics should include both continuity of care and referral rates, which are important assessments of the core competencies of individual residents as well as the function of family medicine centers. But transforming residency practice requires leadership and faculty time. Additionally, in response to the dramatic increase in the incidence of behavioral health disorders, suicides, and overdose deaths across the country, the new requirements also require a substantial increased commitment to behavioral health. It also requires time spent educating physicians and behavioral science teachers.

Another emphasis of the new standards is the significant extension of activity in communitiesseven. The reason for this is clear: the shameful persistence of health and healthcare disparities by race, ethnicity, rurality and income, highlighted by the COVID pandemic and events such as the murder of George Floyd. Family medicine residencies should play an important role in meeting the needs of communities and addressing the unfortunate lack of trust that often occurs between communities and sponsoring institutions. How to do this well is unclear, and family medicine residencies will learn together over the next decade. What is clear, however, is that dedicated faculty time will be needed to lead this effort.

Why should sponsoring institutions support time spent in family medicine training? Why can’t family medicine do this work in addition to its ongoing clinical work? Of course, federal GME funding is a public good: not all hospitals deserve funding. Funding is dependent on sponsoring institutions meeting ACGME requirements; the ACGME mission itself envisions residency training as a pathway to improving the health of the public. Additionally, the family medicine business model in most settings does not support additional time for education time. The fixed costs of primary care practice are substantial, and most family practice centers should cover their expenses based on clinical income. The substantial indirect margin from family medicine patient care, including laboratories, hospitalizations, and referrals to subspecialists and the tests they perform, generally goes to hospitals or subspecialties, and is not reinvested in residency training in family medicine. This is in stark contrast to the grants that teaching hospitals often provide for practices and training programs in other specialties. For example, proceduralists and other subspecialists often see the costs of setting up their teaching facilities (operating rooms, procedural suites, and hospital floors) covered by the hospital, and not charged to their residency programs. Hospitals generally do not provide such grants for the costs of the Family Medicine Center and its teaching function. This is despite consistently lower payment rates for ambulatory care (E&M) facility assessment and management fees compared to inpatient rates and facility fees.

For ABFM, faculty time dedicated to education is fundamental to the residence learning environment. We have documented the significant negative impact on family medicine residencies of the change in ACGME requirements in June 20191. We also believe that dedicated faculty time is necessary for the transition to CBME – which the ACGME supports – and is necessary for excellence in education and to deliver on the promise of family medicine and care. primaries. We understand that teaching hospitals need to preserve headroom for continued capital investment and that, at least early in the pandemic, teaching hospitals – like many in medicine – had significant financial difficulties. We also understand the need for consistency across specialties. But being a sponsoring hospital also entails social responsibility, including, ultimately, responsibility for the health of the public.

The ABFM sets education standards that allow family physicians to seek board certification. We believe that learning environments must provide sufficient dedicated time for faculty education and administration to implement the new vision of personal physician education embodied in the draft requirements. Providing adequate support for this dedicated time is essential.