Author Archives: stfmguestblogger

Pharmacists as Family Medicine Teachers

Editors Note: In honor of American Pharmacists Month, STFM Member Scott Bragg, PharmD, former STFM Member at Large, pens an essay outlining his journey as a pharmacist in family medicine education.

by Scott Bragg, PharmD, Medical University of South Carolina

My journey to teaching family physicians started in 2009 as a second-year pharmacy student at West Virginia University. The previous year, I developed late-onset type 1 diabetes, which led me to volunteer at a diabetes camp called Camp Kno Koma in West Virginia. My first night at camp, one of the nurses asked me to check blood glucose values for the campers in our cabin and treat kids for any lows they experienced. Being relatively inexperienced with making treatment decisions with patients, I was anxious but made it through the night without incident. The whole week was a crash course in following trends, learning on my feet, and trusting others on our care team. My experiences at camp and subsequent learning in pharmacy school led me to pursue pharmacy residency training, because I loved working with a diverse care team and developing autonomy as a clinician.

In pharmacy, exposure to family medicine as a discipline is uncommon, as it is not a recognized specialty for residency programs. Also, there are very few opportunities for holistic training in interprofessional education. Many pharmacist educators in family medicine stumble upon this career path after residency training when they start their first clinical job and find they have a chance to start teaching. Like my experience at diabetes camp, it can be a challenging, learn-as-you-go opportunity. I was very fortunate to complete two years of residency training at UPMC St. Margaret in Pittsburgh, Pennsylvania, where they welcome pharmacy residents into their faculty development fellowship. This is where my love for teaching and family medicine grew. I was surrounded by passionate teachers who viewed their careers as a calling to better the lives of learners and their patients. The faculty development fellowship provided opportunities to partner with family physicians to develop curricula, research collaborations, and patient care initiatives. As a family medicine pharmacist, I hope to encourage more pharmacists to pursue positions within family medicine and contribute to the next generation of family medicine educators.

Family medicine is a uniquely interprofessional discipline, and that’s something I learned when working as a family medicine educator with the Medical University of South Carolina in Charleston, South Carolina. I knew early on that I had found a home when, during my first week on inpatient, one of our attendings insisted I round on their team. I observed early on as a faculty member that pharmacists often possess skills (eg, eye for detail, focus on transitions of care, attention to patient costs) useful to family medicine teams. Many of the pharmacy students I precept are surprised at how easy it is to collaborate with our family medicine team. More than other disciplines, family medicine educators and trainees create an environment that truly values an interprofessional approach.

The nuances of providing patient care in family medicine make it consistently challenging and rewarding. Family medicine teams proactively apply evidence-based medicine, navigate an evolving health care system, practice population health management, and consider social determinants of health. Family medicine providers are often described with the phrase “jack of all trades, but a master of none.” I disagree. I like to say that family medicine teams are a jack of all trades and a master of many. Our holistic team approach helps us deliver on patient-oriented outcomes that matter, despite many of the complex issues we encounter.

So how do we continue to push for innovation and optimize patient care outcomes? One way is by including pharmacists and other interprofessional team members, such as nurses, behavioral health providers, and social workers on family medicine care teams. With the transition in focus to value-based care, building bridges to multiple interprofessional groups will only strengthen the family medicine discipline. STFM and other organizations that make up the family of family medicine continue to serve as catalysts for innovation in our practice model and inclusion of interprofessional educators.

STFM has provided me and many other pharmacists with valuable professional development opportunities. I have worked as a fellow in the Emerging Leaders Fellowship, a member at large on the board of directors, and the program assessment chair for STFM. These leadership experiences have helped me understand the complexities of medical education and advocacy for family medicine as a discipline. I also belong to STFM’s Pharmacist Faculty Collaborative where I’ve grown in my understanding of the ways pharmacists contribute to family medicine education and networked with pharmacists across the country. Despite the name, the Pharmacist Faculty Collaborative is open to all STFM members; please check us out on STFM Connect.

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.