1. 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

2. 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

3. 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

4. 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

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

6. 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”

7. 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

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

9. FMC Teams

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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)

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

17. 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

18. 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

19. Design/Implementation
Idea: 18 years (1995)
Prep faculty: 3 years ( )
Design: 18 months ( )
Implementation (7/ 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

20. Longitudinal Curriculum“ 20

21. 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

22. 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

23. 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

24. 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

25. Trimester Training
Community Medicine Trimester 25

26. Trimester Training
R1 Surgery Trimester 26

27. Trimester Training
R1 Medicine Trimester 27

28. 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

29. Outcomes 29

30. 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

31. Questions?? Contact us: Tricia Hern thern@ecommunity.com Carl Morris