Innovative Longitudinal Training: Two Residency Programs Blow Up Their Block Schedules!   Tricia Hern, MD, Program Director Community Hospital East Family Medicine Residency Indianapolis, IN Carl Morris, MD, MPH, Program Director Group Health Family Medicine Residency Seattle, WA STFM ANNUAL CONFERENCE, Orlando, April, 2015

Objectives Learn about similar innovative longitudinal curriculum residency models from two unique programs Learn the benefits to this model of training over traditional models, as well as the challenges Consider applicability/innovation at your program

National Conversation Family medicine education leaders asking for innovation National interest in 4 year FM residency (ongoing pilot) PCMH focus Scope of practice changing Traditional FM education block rotation residency structure and FMC time has not changed significantly in 40 years Duty hour restrictions, yet more pieces to teach

Principles of New Curriculum Patients First More time in FMC starting from year one More teaching from family physicians Less LOW YIELD learning activities Subspecialty rotations supporting, not core Team-based practice and learning Mimics real world small practice Population management/QI PCMH leadership skills Longitudinal learning instead of block learning

Community Hospital East Family Medicine Residency Longitudinal Curriculum Tricia Hern, MD, Program Director Community Hospital East Family Medicine Residency Indianapolis, IN

Local Conversation $1.3 million HRSA grant to transform our practice and residency to PMCH-focused beginning in 2010 Could we become truly PATIENTS FIRST? PRIOR CULTURE Traditional hospital-focused training Some rotations weak Residents pulled to cover services over clinic “Patients last”

Our Program 10-9-10 residency program 10 physician faculty, 1 behavioral faculty Community hospital, unopposed program 40 year history FMC with 22,500 patient visits a year 1 NP, 2 pharmacists, 2 social workers Multidisciplinary student presence

PCMH Curricular Structure Acute Chronic Indiv Prev Inter-session PGY-1 6 wk 4 wk PGY-2 PGY-3

FMC Teams

Acute Care Module FMC time 2x per week on avg Inpatient Adult Medicine 6 weeks/year in 3 week blocks (18 weeks total) Inpatient Pediatric Medicine 3 weeks PGY1, PGY2 (6 weeks total) Emergency Department 3 weeks per in PGY1,2 (6 weeks total) Surgery 3 weeks in PGY1 Elective 3 weeks in PGY3

Chronic Disease Module Morning FMC time daily Afternoons rotating through chronic disease topics Behavioral Weeks Community Medicine, Video Reviews, Didactics Home Visits, Psych Consult Clinic, Chronic Pain Clinic, Addiction Medicine Chronic Disease Clinics CHF, Cards, Asthma/Allergy, Pulm, Derm, Neuro Endocrinology, some ENT/Ophtho/Uro Team Time Small group learning on Friday afternoons

Preventive Module Afternoon FMC daily Musculoskeletal/Sports Medicine (200 hours) Rheumatology, Podiatry, Sports Medicine, Spine Center, Peds/Adult Ortho, OMT Ambulatory Pediatrics (200 hours) Gynecology (100 hours) Procedure clinic FMC Community Medicine Team time Fridays

Individualized Module Limited FMC PGY1, 3-4 per week in PGY 2,3 PGY 1 year: OB floor days (6 weeks, in 3 week blocks) ICU (3 weeks) Night float/ED (3 weeks) PGY 2 & 3 year: Electives (17 weeks + 3 in acute) High track OB time Other interests (sports med, mission trips, hospitalist) Night float

Team Time Scheduled team time during Preventive and Chronic Care Modules Team based population management AAFP Metric/QI activities Small group teaching with Pharmacists Procedure workshops Simulations Relationship training, leadership skills

Outcomes ITE scores Highest in over a decade and above national avg in 2014 Board pass rate 100% in 2014 (1 fail per year on average prior) Recruitment/Match Significant improvement in recruiting to the program More quality applicants Better match success Faculty and resident satisfaction Surveys and anecdotal improvement FMC numbers stable (not as much increase as we expected)

Group Health’s Longitudinal Curriculum Carl G Morris MD MPH Program Director Group Health Family Medicine Residency

Clinic First Policy 2009 – present Traditional block model limiting Local Conversation PCMH conversion 2009 Clinic First Policy 2009 – present Traditional block model limiting R2 FM Identity Crisis Poor patient service Medicine: 6 months total, divided into one week blocks over three years, from VM to Swedish 2/2016 OB: 6 months total, divided into three 12-hr shifts every 4-5 weeks over three years, from FBU to Swedish 3/2015 17

9 physician faculty, 2 behavioral faculty Our program 6-6-6 residency program 9 physician faculty, 2 behavioral faculty Integrated Care Delivery System Sponsor Large system, one residency One of the first 11 FMRs 2 FMCs with 6500 paneled resident patients Medicine: 6 months total, divided into one week blocks over three years, from VM to Swedish 2/2016 OB: 6 months total, divided into three 12-hr shifts every 4-5 weeks over three years, from FBU to Swedish 3/2015 18

Design/Implementation Idea: 18 years (1995) Prep faculty: 3 years (2009-12) Design: 18 months (2013-14) Implementation (7/2014 - present) Medicine: 6 months total, divided into one week blocks over three years, from VM to Swedish 2/2016 OB: 6 months total, divided into three 12-hr shifts every 4-5 weeks over three years, from FBU to Swedish 3/2015 19

Longitudinal Curriculum “ 20

Longitudinal Curriculum Medicine: 6 months total, divided into one week blocks over three years, from VM to Swedish 2/2016 OB: 6 months total, divided into three 12-hr shifts every 4-5 weeks over three years, from FBU to Swedish 3/2015 21

Trimester Training Surgical Specialties R1 – Gen surgery, Sports medicine, Ortho R2 – Abortion training, Peds ER (2 wk block), Sports medicine, Ortho, Circumcision, Minor procedures clinic, Gyn, Teen Pregnancy Clinic R3 – Peds ER (2 wk block), Ortho, Circumcision, Minor procedures clinic, Abortion training, Anorectal clinic, Colposcopy clinic, Teen Pregnancy Clinic. 22

Trimester Training Medical Specialties R1 – Outpatient Pediatrics, Inpatient Peds (4 wk block), Peds Urgent Care, Hospice R2 – Outpatient Peds, Dermatology, Hospice, HIV, Geri Group Visits, Minor procedures clinic, Teen Pregnancy Clinic R3 – ICU (4 wk block), Outpatient Peds, Dermatology, Hospice, Geri Group Visits, Minor procedures clinic, Teen Pregnancy Clinic 23

Trimester Training Community Medicine R1 – School Health Centers (Middle School), Behav. Med Clinic, Chem. Dependency, Occupational Med, Psychiatry R2 – School Health Centers (High School), Away Month (4 wk block), Behav. Med Clinic, Chem. Dependency, Occupational Med, Psychiatry, Teen Pregnancy Clinic R3 – School Health Centers (Homeless Teens), Away Month (4 wk block), Behav. Med Clinic, Occupational Med, Community Health Center, STD Clinic, Teen Pregnancy Clinic 24

Trimester Training Community Medicine Trimester 25

Trimester Training R1 Surgery Trimester 26

Trimester Training R1 Medicine Trimester 27

Lessons Scheduling is rate limiting Communication is key Rapid PDCA helpful Share the vision Teamwork makes the dream work First 3-6 months are difficult 28

Outcomes 29

Outcomes Increased clinic, inpatient unchanged, decreased observational specialty, improved community medicine Recruitment/Match: positive effect on recruitment FM Identity/performance: Anecdotally improved Burnout: Less resident, more admin/faculty Quality, access, patient satisfaction – pending Cost – less, more patient care in FMC 30

Questions?? Contact us: Tricia Hern thern@ecommunity.com Carl Morris morris.cg@ghc.org