Author Archives: stfmguestblogger

Implementing A Continuity-Clinic-Centered (C-3) Scheduling Model in Family Medicine Residency Programs: The Efficiency of Templated Automation 

by Derek Baughman, MD; Salma Green, DO; and Abdul Waheed, MD, MS, FAAFP
WellSpan Good Samaritan Hospital Family Medicine Residency Program, Lebanon PA

Background

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.

Problem

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 

Intervention

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.

Impact

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. 

Conclusion

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

References

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

3. AFMRD – Clinic First Collaborative. Association of Family Medicine Residency Directors. Accessed March 17, 2021. https://www.afmrd.org/page/clinicfirstcollaborative

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

Working for Health Equity –Together

By Lloyd Michener, MD

Family medicine groups have responded wonderfully to the COVID-19 pandemic, providing critical clinical services, and helping staff testing and vaccination sites. As COVID-19 underscored the depth of the disparities across our states and communities, family physicians have also taken on local and national leadership roles in health equity efforts, efforts to achieve health equity are now expanding rapidly, and the approaches and even the language used are changing as well.

As a particularly horrific example, a new report from the US Civil Rights Commission calls for equity in maternal health, noting that Black women in the United States are 3 to 4 times more likely to die from pregnancy-related complications than White women in the United States. The report calls for coordinated prenatal, maternity, delivery, and postpartum care that manages chronic illness and optimizes health, and points out the role that states can play in supporting equitable health, including Georgia, New Jersey, and North Carolina. Maternal health equity is an opportunity for family medicine, partnering with our health systems, our communities, and our states, to make a difference.

At the same time, academic health centers (AHCs) are increasingly engaged in health equity efforts, seeking to build and strengthen community partnerships for health. As David Skorton, CEO for the Association of American Medical Colleges, stated:

“the traditional tripartite mission of academic medicine — medical education, clinical care, and research — is no longer enough to achieve health justice for all. Today, collaborating with diverse communities deserves equal weight among academic medicine’s missions. This means going beyond “delivering care” to establishing and expanding ongoing, two-way community dialogues that push the envelope of what is possible in service to what is needed.

It means working with community-based organizations in true partnership to identify and address needs, and jointly develop, test, and implement solutions. This requires bringing medical care and public/population health concepts together and addressing upstream fundamental causes of health inequities.”

https://journals.lww.com/academicmedicine/pages/articleviewer.aspx?year=9000&issue=00000&article=96573&type=Abstract

This is a new challenge for many AHCs, and a place in which family medicine can make a much-appreciated difference. A private, research-intensive school headlined such an example:

In many ways, the COVID-19 pandemic forced positive changes in how medicine is practiced in communities and at academic medical centers, with family medicine departments working at the front lines to provide care and forge relationships with community partners, according to a Duke Health review.

https://corporate.dukehealth.org/news/pandemic-response-shows-path-improved-health-care-future?utm_source=newsletter&utm_medium=email&utm_content=The%20pandemic%20shows%20a%20path%20toward%20a%20better%20health%20care%20future&utm_campaign=dukedaily2021_09_20

As these partnerships grow, the language shifts. Family medicine is growing accustomed to the idea that we have a role in the ‘social determinants of health,” while community organizations may use a broader, more positive framing of the “vital conditions of health” which is inclusive of the intersections of health and safety, work, transportation, education, civic muscle, housing, and the environment. Family practices can have important roles in this larger effort, both as trusted sources of care and information, as one of the community hubs that link individuals and families to needed services, and as respected advocates for needed policy change so that all communities have the opportunity to thrive.

Guidance on how to partner and support community health equity is increasingly available, including, to cite just a few:

It is noteworthy that every one of these draws from diverse groups and sectors, as working effectively with community organizations towards health equity requires partnerships far beyond any one discipline, profession, or sector.

Within all this complexity and challenge, family medicine has a wonderful opportunity to serve as builders of bridges to and with our diverse communities, many of whose members come to us for care. By expanding our vision so that we are engaged with communities around their priorities and needs, we can help build on their strengths, add our own and those of our academic colleagues, to our shared goal of achieving health equity.

Fierce Women and New Stars

For a long time I thought I was lucky to have fierce women who walked beside me & now I see the real luck was that these fierce women stayed there until I learned how to be fierce myself. —Brian Andreas, Creator of Story People and Flying Edna

AndreaAnderson

Andrea Anderson MD
The GW School of Medicine and Health Sciences

These words hang on the wall of my office and were the inspiration of my remarks when I accepted the 2019 Advocate Award for my work in encouraging resident advocacy. As I reflect on my career thus far as an academic physician, it is clear that actively seeking opportunities and receiving excellent mentorship have been driving forces. It is not a secret that mentorship is important in any career path. It is crucial for us as Black and Brown medical educators.

I grew up as the daughter of an inner city public school teacher. Even now, some 20 years later, my mother’s influence is still evident when former students happily greet her around town and proudly show off their accomplishments. After high school, I was accepted into the combined BA/MD program at Brown University. Even at a large progressive school like Brown, I could count on one hand the numbers of Black and Brown faces who stood before our medical school class as faculty or deans. My school was not unique. Nationwide, the numbers of Underrepresented in Medicine (URM) Faculty in US medical schools remains well below 10% and has not kept pace with the increasing diversity among the student body or the society as a whole. One of those faces who significantly impacted me was Alicia Monroe MD, current provost of Baylor College of Medicine. She was one of the plenary session speakers at the last STFM Annual Spring Conference in Toronto. When she was our dean of Minority Students at Brown, my friends and I would go to her office to receive support, guidance, mentorship, or frankly just to see a face that looked like ours. Recently I was heartened to hear that among the reasons she was encouraged by her then department chair to pursue promotion early in her academic career was because of all the female junior faculty and women who looked up to her. I was definitely one of them. My experiences as a student leader at Brown solidified my passion for advocacy and imprinted me with the notion of my responsibility to speak for those who have no voice.  I was awarded the National Health Service Corps Scholarship and committed myself to a career in family medicine.

After Brown I trained at Harbor-UCLA and completed an academic medicine fellowship and chief resident year. I continued to raise my voice as an advocate for marginalized and immigrant populations. In Southern California I became the president of our Resident Union and collaborated with local labor unions to help fight cuts to the community health center safety net.  I began to see how I could combine my passion for social justice with my love of teaching and medical education. Rooted among hardworking new and first generation mainly Spanish speaking immigrants, I became firmly bilingual. One of my patients even called me an honorary Latina. This work became not just something I loved to do, rather, it was something I had to do.  After completing my fellowship, I came to Washington, DC to serve my 2-year NHSC service commitment.

Those original 2 years morphed into 15 years as I stayed far past my service commitment serving a largely immigrant population at a 25,000 patient FQHC in DC. I sought out leadership roles such as medical director, director of student and resident education, and director of family medicine. As core faculty for our teaching health center/GME residency, I was introduced to STFM and attended my first conference in 2015.  I applied for and was selected for the Quality Mentoring Program and the Emerging Leaders Fellowship. In DC I continue to be active in professionalism and assessment as the appointed chair of the DC Board of Medicine and as an item writer and reviewer for the NBME. As a local advocate I have had the privilege to testify on a variety of topics affecting marginized populations before audiences as diverse as the AAFP, the Association of Clinicians for the Underserved, DC government, and the Senate HELP Committee. I taught health literacy, advocacy, and health policy to the students who rotated at our center and to the residents in our THCGME residency. I am excited to continue my interests in advocacy and professionalism as a recent appointee to the Board of Trustees of the Family Medicine Education Consortium and to the Board of Directors of the American Board of Family Medicine.  During my time at Unity, I taught scores of students from the GW School of Medicine and Health Science, a DC target school without an FM presence. I served as a kind of de facto community family medicine clerkship director as FM experiences were few and far between for the students.  My work as an adjunct was recognized—I advocated for increased roles for community medicine faculty role and was accepted into the Master teacher Leadership Development Program at GW, named to medical school committees, chosen to direct the senior capstone course, and promoted to clinical associate professor. These professional opportunities were the result of hard work and dedication along with the influences of key mentors along the way. Recognizing the voids in my past student experiences motivated me to think of creative ways to combine my passion and interests with my career goals. My life was busy and full as I juggled my work with my roles as a mother of two young children, a wife, and a daughter.

Although I felt respected from my adjunct teaching position, I began to feel that I could have a bigger impact at a university level as a full-time faculty member. Years of student and faculty advocacy for FM at GW caught momentum and I was asked to join the leadership of a small new Division of Family Medicine. This switch necessitated that I get firmly on a full-time academic track. But on the other hand, I loved my FQHC patients, families who I had cared for for generations. I struggled with how to advocate for them, full of angst as I announced my decision to leave. Several cards and letters of gratitude poured in from my patients and friends.  However, one from a teenage patient I have cared for since she was in kindergarten left a permanent mark on my heart.  In her adolescent script she said:

Don’t worry about me, Dr Anderson, I will achieve my dreams. I appreciate you so much.  But I know it is time for you to move on, time to make new stars. Many students will appreciate your hard work so they can light up their dreams as well.”

So this year at commencement, I will walk in my academic regalia, this time with the other full-time faculty. When I hear those bagpipes I am again reminded how proud I am to be an African American woman in academic medicine. In the spirit of those who have mentored me along the way, I march proudly and cheer for my students. As URM faculty, our presence says that we are still here and you can be here too. We are contributing, shaping the scholarly discourse of primary care, medicine, and public health for years to come. I nod to everyone, but especially to all those grandmothers and parents and aunties and uncles of color who have sacrificed, sweated, and prayed so that their loved ones could achieve their dreams. That nod that says I see you, and I am standing up here for you. I think of my own grandmother, a proud, smart, and beautiful woman who missed out on her college and career dreams, so eventually I could realize mine. I think of my former immigrant patients and how it is my responsibility to speak up for them. I think of the theme song played as I accepted my STFM Advocate Award, “Girl on Fire” by Alicia Keys.  STFM is a place where we are reminded that as family medicine educators, we are all on fire to create, as my teen patient and Brian Andreas would agree, Fierce New Stars. Let’s keep our torches burning brightly to do just that.