For the first time in three years, STFM members were able to come together at the 2022 STFM Annual Spring Conference. Attendees from all over the world converged for three days in Indianapolis, Indiana — some traveled from as far as South Africa — for workshops, general sessions, poster presentations, meetings, networking, and the STFM Foundation’s Marathonaki, and Medipalooza events.
Donations made to the STFM Foundation — large or small — create scholarships, fellowships, awards, and more, allowing the STFM Foundation to provide up-and-coming family medicine talent with training, mentoring, and scholarship opportunities. These programs would not be possible without the generosity of the members of STFM. Thank you to all who have already participated in the 20 in 2022 We Can’t Do It Without You, and we invite those who haven’t to make a donation today.
by Derek Baughman, MD; Salma Green, DO; and Abdul Waheed, MD, MS, FAAFP WellSpan Good Samaritan Hospital Family Medicine Residency Program, Lebanon PA
As a core Accreditation Council for Graduate Medical Education (ACGME) accreditation requirement for residency programs, continuity clinic forms the foundation for competence in outpatient family medicine and is a practice focus of most graduates. The Association of Family Medicine Residency Directors’ Clinic First Collaborative1 is a popular conceptual model of achieving this foundational goal. Although many residency programs have adopted a clinic-first model, there is limited literature detailing the implementation of such scheduling models. Thus, we outline a high-yield Continuity-Clinic-Centered (C-3) scheduling model that is simple to implement.
Resident scheduling is complex due to multiperiod assignments and multiple constraints, including ACGME work-hour regulations and demanding coverage of the residency program’s inpatient services.2,3 For example, an analysis of scheduling complexity for a 24-resident family medicine (FM) program with only nine annual rotations resulted in more than 3,000 variables and more than 850 constraints3 Programs embracing a C-3 model can produce higher quadruple-aim care and have been endorsed by national organizations.4 Studies on FM residencies embracing these models have shown the feasibility of tackling complex scheduling with a two-pronged approach: separate master block schedules for core rotations and continuity clinics.5 The literature has highlighted the superiority of automated approaches to residency scheduling6 due to its ability to decrease drafting time,7 increase schedule quality,7,8 and improve resident satisfaction.8
Our 7-7-7 FM residency program utilized schedule templates constructed in hierarchical stages by postgraduate year (PGY). Starting with designated resident clinic days for each PGY class, we established a clinic team template (Table 1). A separate template (Table 2) designated alternate days to coordinate residents on hospital service rotations. Subsequently, a 13-block hospital service and longitudinal subspecialty rotation block schedule (Figure 1) was constructed (separate Microsoft Excel sheets built specific longitudinal subspecialty rotation blocks and continuity clinics). The Excel “countif” function confirmed accuracy and fairness of resident block schedules facilitating a threefold tabulation: (1) even numbers of resident core rotations, longitudinal blocks, vacation and electives; (2), even numbers of subspecialty rotations; (3) a balance of preceptors, clinical staff, and provider availability at clinics.
The automated Excel spreadsheets facilitated predictable clinic schedules, enhanced resident empanelment, and promoted continuity of team-based care to fulfill the 1,650 outpatient visit requirement.9 This improved schedule coverage of 273 unique 2-week blocks of core rotations and clinic coverage for our 21 residents across three PGYs (Figure 1). Automation provided more efficient and accurate tabulation than prior hand-counting methods resulting in fewer scheduling mistakes throughout the academic year. Spreadsheets served as templates for subsequent academic years and significantly reduced both quantity and duration of scheduling meetings for administrative staff, chief residents, and program director.
Although automated cloud-based physician scheduling software was considered for our program, high implementation fees10 rendered this an unfeasible option given our residency budget. Alternatively, we found simple Excel formulas an affordable solution to ensure accuracy of the C-3 model. Additionally, Excel’s conditional formatting feature facilitated instant visualization of gaps, over- or undercoverage, and preceptor supersaturation. Making schedule changes with this method also avoided the need to manually recount blocks as “countif” works in real time. This was exceedingly helpful for quickly understanding the effects of multiple residents requesting vacation or CME conference attendance. Most importantly, this same method can be applied to the clinic block schedule ensuring prioritization of clinics and their C-3 coverage.
Clinic-first models for residency scheduling can be streamlined with simple templates that ensure fairness, balance, and reproducibility of resident scheduling. Automated templating with spreadsheet software is an evidence-based approach to navigate accreditation constraints and solve complex multiperiod assignments for residency programs.
Figures and Tables
Table 1: C-3 Model of Resident Team-Based Clinic
Table 2: C-3 Model for Hospital Service Rotations (Including Inpatient, OB, and Night Float)
Figure 1: C-3 Model Longitudinal Block Schedule by PGY
1. Topaloglu S, Ozkarahan I. A constraint programming-based solution approach for medical resident scheduling problems. Comput Oper Res. 2011;38(1):246-255. doi:10.1016/j.cor.2010.04.018
2. Franz LS, Miller JL. Scheduling Medical Residents to Rotations: Solving the Large-Scale Multiperiod Staff Assignment Problem. Oper Res. 1993;41(2):269-279. doi:10.1287/opre.41.2.269
4. Brown SR, Bodenheimer T, Kong M. High-performing primary care residency clinics: a collaboration. Ann Fam Med. 2019;17(5):470-471. doi:10.1370/afm.2452
5. Bard JF, Shu Z, Morrice DJ, Leykum LK, Poursani R. Annual block scheduling for family medicine residency programs with continuity clinic considerations. IIE Trans. 2016;48(9):797-811. doi:10.1080/0740817X.2015.1133942
6. Ito M, Onishi A, Suzuki A, Imamura A, Ito T. The resident scheduling problem: a case study at Aichi Medical University Hospital. Journal of Japan Industrial Management Association. 2018;68(4E):259-272. doi:10.11221/JIMA.68.259
7. Perelstein E, Rose A, Hong Y-C, Cohn A, Long MT. Automation improves schedule quality and increases scheduling efficiency for residents. J Grad Med Educ. 2016;8(1):45-49. doi:10.4300/JGME-D-15-00154.1
8. Howard FM, Gao CA, Sankey C. Implementation of an automated scheduling tool improves schedule quality and resident satisfaction. PLoS One. 2020;15(8):e0236952. doi:10.1371/journal.pone.0236952
As the 2021-2022 term comes to a close, we sat down with incoming STFM President Linda Myerholtz, PhD to learn about her journey into family medicine education and her plans as President of the STFM Board of Directors.
Linda Myerholtz, PhD, Associate Professor and Director of Behavioral Science Education at the University of North Carolina, Chapel Hill start her term as STFM President during the 2022 STFM Annual Spring Conference. She brings with her a passion for human behavior, building community, and integrated healthcare.
Growing up as a “professor’s kid”, Myerholtz was born in Caracas, Venezuela. “My father was working for a company at the time, though I have no memory of living in South America. Our family moved back to the US when I was 6 months old, and landed in Racine, Wisconsin.” Myerholtz explained. “I spent my early childhood in Wisconsin, before we moved to Bowling Green, Ohio when I was 14. There was quite a bit of culture shock going from a big city like Milwaukee to a very small town, where I could see cornfields growing from my bedroom window.”
Myerholtz began to love the rural, small town university life, and went on to complete her undergraduate and graduate work at Bowling Green State University in Bowling Green, Ohio. “I married my husband and we started our family. The winters were long and gray, and we dreamed of moving further south.”
When asked if she always knew medicine was the career for her, Myerholtz said “I’m not sure why, as I lived in the middle of the Midwest far away from any beach or ocean, but as a child, I always wanted to be a marine biologist. I loved biology, and it sounded exciting. When I took Introduction to Psychology my freshman year, I was fascinated about human behavior, and I knew this was my career path.” Myerholtz went on to give a shout out to her professor, Dr Stone, proving the impact good educators have on young minds beginning their academic medicine journey.
As Myerholtz’s career took off in community mental health, she moved into more administrative roles, but continued providing training for graduate psychology interns. “This brought me so much joy, and there were a few STFM members who trained with me at the same time.” While this passion for working with marginalized individuals continued to grow, the administrative aspects pulled Myerholtz away from the more enjoyable parts of her work, namely clinical care, teaching, program development, and research.
“One day, I saw a posting in my inbox for a position as a Director of Behavioral Science in a family medicine residency program [Mercy Family Medicine in Toledo, Ohio]. I was enticed by the opportunity to teach bright young adults who shared my passion in making communities healthier and the opportunity to resume my research and practice integrated behavioral healthcare. When I first started at Mercy, I couldn’t tell you much about medical education or what it was like to be a resident, but the residents taught me and I felt like I really found my passion.”
That passion resulted in Myerholtz’s ability to work closely with different learners and fellow faculty. “Each day is different,” she went on to explain. “We’re always reflecting on how we can continue to improve the wellbeing of our communities through the practice of family medicine – what could be better?”
Myerholtz is quick to mention lessons abound in family medicine education, but there is one that has stuck with her. “Be kind to your future self. As you reflect on your past self, do so with compassion,” she explained. The first part helps me prioritize and reminds me to make decisions today that support myself in the future. The second part reminds me not to judge my past self, based on the knowledge and the wisdom I have today. Past decisions and mistakes are a part of being human, and we need to offer compassion for the person we were when those things happened.”
While her career progressed, Myerholtz’s dream to move her family further south was solidified when she accepted a position with the University of North Carolina. “Being a behavioral scientist in graduate medical education is truly a dream job, and it’s been fantastic living in North Carolina. We still get the change of seasons, but the winter is much shorter! We can go hiking in the mountains, relax at the beach, and explore great restaurants and cultural gems.”
As she prepares to be installed as STFM President, Myerholtz looks forward to bringing that passion for wellbeing to STFM members. “I’m proud and humbled to represent the STFM membership as president. My passion for interprofessional team-based education and practice promotes system change and supports wellbeing within the graduate medical education structure. The journey to family medicine education is exhilarating and exhausting,” she explained. “What I most look forward to, though, is continuing to foster connections among our members. I’m so excited we will be able to renew collaborations together at our Annual Conference in Indianapolis. Connection is what makes STFM so exceptional,” she continued. “None of us can do this alone, nor do we have to reinvent the wheel. Through STFM, we come together to make the wheel even better.”
Part of improving that wheel comes from the utilization of STFM resources. “As I reflected on what I’ve used most, the list continued to grow. I was fortunate to participate in the first class of the Behavioral Science Family Systems Educator Fellowship, and this was pivotal in my career. I found so many collaborative relationships and true friendships. I also utilize the STFM Resource Library frequently to gain inspiration from other excellent educators. I’ve learned so much from our Collaboratives – being able to reach out to a Listserv of amazing colleagues when I have a question is so incredibly valuable. Whether through fellowships, collaboratives, toolkits, certificate programs, or the resource library, STFM allows us to connect with each other and share our learning, with the ultimate goal of transforming family medicine education and the health of our communities.”
When she’s not revolutionizing family medicine education and empowering marginalized communities, Myerholtz finds joy with her family. “While my career has brought me a strong sense of accomplishment, I’m most proud of the adults my children have become. Raising three human beings who are living the values that are important to me… kindness, compassion for others, generosity, a commitment to social justice, valuing diversity… it fills my heart. Watching them go out into the world, knowing they make the world a better place now, and for future generations, is a tremendous joy.”
That love for her family extends to acting as a personal travel guide for their adventures. “Planning the trip is about enhancing the joy while practicing delayed gratification.”
STFM and its members will benefit immensely from Myerholtz’s leadership, experience, compassion, and drive. We welcome her to the Board of Directors for the 2022-2023 year.