Category Archives: Education

Get to Know Incoming STFM President Renee Crichlow, MD, FAAFP

Posted on March 23, 2023 by | 1 comment

As the 2022-2023 term comes to a close, we sat down with incoming STFM President Renee Crichlow, MD, FAAFP to learn about her journey to family medicine education, her plans for the presidency, the importance of good conference snacks, and her love of Audible.

“We are a community of learners and teachers from and for each other. STFM never stops working for Family Medicine or our learners, teachers, and patients. From clinical teaching through the ranks of academia, the bureaucracy of medical schools, and amid policymakers, STFM is working for you and with you. We are you; together, we are thoughtful, strong, and persistent.”

Renee Crichlow, MD, FAAFP

When you were a child, what did you want to be when you grew up?

As a child, the first job I wanted growing up was to be a rodeo rider. I don’t know why, but I remember writing about it in my journal when I was six. Then I wanted to be an oceanographer because Jacques Cousteau was one of my heroes in the 70s, then I fell in love with rocks. As a kid, I could probably name every rock or crystal you could find. My favorite was feldspar. Then came the point in my life when someone I respected a great deal asked me what I wanted to be when I grew up. I was 12. I was pretty good at science, and people liked to talk to me, so I said I would like to be a doctor. Mrs. Rutherford said I would be an excellent doctor. She was a nurse and someone I admired, so I figured if she said I could be a doctor, I could probably be a doctor. My first job in healthcare was as a phlebotomist in Boston. It was there I worked side-by-side with doctors. I appreciated that they supported and encouraged me to attend medical school. So, I left Boston and went to UC Santa Cruz as an undergraduate. After that, I went to UC Davis, which had a strong family medicine focus.

What drew you to medicine and family medicine education in particular as you grew?

The people I admired were the family docs that worked and taught at UC Davis. The specialists at UC Davis were very kind, compassionate people, but the folks that were doing the kind of work that I thought the doctor was supposed to do (take care of people from the time they were born till the time they die and everything in between) were the family docs. The department Chair at the time, Dr Klea Bertakis invited me to interview after she heard my Grand Rounds in my chief resident year. She asked me to consider becoming an attending at the UC Davis Dept of Family and Community Medicine. I’ve always enjoyed teaching, tutoring, and mentoring. I come from an academic family, so the thought of teaching at the graduate level sounded like an excellent way to continue learning and growing as a physician and a person, so I jumped in and never looked back.

When you’re not revolutionizing family medicine education, how do you like to spend your time?

I like to spend my time traveling with my family and reading books or having books read to me. My wife and I have three teenagers, and they are each fantastic in their own way; traveling the country with them has been filled with surprising and wonderful adventures. Also, I am quite likely emotionally dependent on Audible.com in ways that others might consider unhealthy; what do you mean you can’t listen to books in the shower? Why else would one have waterproof earbuds?

What do you wish all members and non-members knew about STFM?

The Society of Teachers of Family Medicine is shaped by and shapes the specialty of Family Medicine. We are a community of learners and teachers from and for each other. STFM never stops working for Family Medicine or our learners, teachers, and patients. From clinical teaching through the ranks of academia, the bureaucracy of medical schools, and amid policymakers, STFM is working for you and with you. We are you; together, we are thoughtful, strong, and persistent. That’s what I’d want them to know. Also, they should know that when I’m typing, my autocorrect flags “STFM,” which always suggests “storm” instead.

If you could impart your past self with any wisdom from the future, what would it be and why?

I would tell past Renee that loving who you are now is a path to becoming who you can be. It may not be the only or easiest path, but it will sustain you. I would tell her that building joy is courageous and starts with me. I would look her straight in the eye and say, “Stillness is the ground, fear is the noise, and Love is both the signal and receiver.” Past Renee would then look at me, think I was a little eccentric, and then she would go out and make the same mistakes I made in the past that I have now learned from, allowing me to become who I am today. That is the other path; experience plus reflection equals wisdom.

What accomplishment are you most proud of in life, and why?

My children are kind and courageous. My learners are innovative and bold. I can, have, and will be a catalyst for systems change, and I have learned to lead from love and help unleash people to claim their own power.

What drives you to show up every day?

Black Jeep with seat warmers and remote starter…just kidding. I show up. I understand that change is the only constant, and we must help shape that change. But that was a journey; first, I showed up because I wanted to survive, and if I didn’t, only bad things would happen. Then, I started realizing I needed more than survival. I wanted to live, which meant showing up for myself too. Then, I understood that I needed more than just survival and more than just to live. I want to thrive, which means showing up for myself and showing up for and with others. I show up to shape change.

What is your most used STFM resource?

My colleagues, this community of learners is my most useful STFM resource. Other than the members, I would say STFM Connect, which helps me stay connected with those colleagues.

What would you tell medical students and residents about their journey ahead?

Family Medicine is THE FUTURE of Healthcare. Machines or Artificial Intelligence can never replace us. We are a critical component in a compassionate and functional healthcare system. We need to build that compassionate and functional healthcare, and together we can.

Has a lesson you’ve learned stuck with you your whole life?

Be kind. Be kind to me and others.

What do you most look forward to most in your term as STFM president?

I look forward to shaking the US medical and educational system to its core, reshaping it into a model for the world, and choosing snacks at conferences.

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Exploring Burnout and Resiliency Using the Photovoice Experience

Posted on October 20, 2022 by | Leave a comment

Background:  

Understanding physician burnout is an area of intense research. Commonly cited studies by Mayo Clinic and Medscape indicate levels of physician-reported burnout continue to rise.  Traditional ways of measuring burnout include questionnaires and surveys.  While these are popular and validated ways to assess burnout, they do not allow providers to self-define burnout and use scripted words that limit individual expression.  The movement to discuss burnout and its causes is welcome. However, perhaps more important is the shift that has occurred in the conversation from problem to solution.  Increasingly, the focus has been on the study of resiliency and how systematic changes can impact burnout rates.  

This exercise uses photography as a way for individuals to connect with and express what burnout and resilience mean to them.  Individuals will have the opportunity to self-express and process the experience of burnout or distress with others. Participation in the group experience will allow for perspective-taking and recognizing commonalities with peers. The shared experience gives participants the opportunity to be exposed to new strategies for resilience building by learning from their peers. Additionally, the outcome from the collective experience can lay the groundwork for systematic change.   

Photovoice is a qualitative method generally used in community-based participatory research.  It is action-oriented and meant to give a voice to people that are considered disempowered.  The aim of this research method is to evoke dialogue and create movement on social issues.  In this curriculum, the residents are empowered to use photography to create a shared experience which can lead to bolstering personal resilience and promotion of systematic change.   

Objectives: 

After participating in the experience residents will … 

  1. Use photography to express their personal views on burnout and how to combat burnout 
  2. Enhance personal resiliency skills as a result of the shared experience  
  3. Create a collective dialogue that can be used to influence systemic change 

Photovoice Assignment Participants Guide

Take two photographs*, one to answer each of the following questions. 

  • What is burnout? 
  • How do I prevent or overcome burnout? 

With each image, write a brief statement describing why you chose the image. 

*photographs should be taken personally by the participant, not images found on the internet  

Instructions regarding photographs: 

Do not take photographs that: 

  • Include people who can be identified (you can see their faces clearly) 
  • Include people’s body parts in a dehumanizing way 
  • Are sexually explicit 
  • Include protected health information

You are allowed to edit photos, but don’t spend a lot of time on this. The purpose of the exercise is not the photographs themselves, but the experience of reflection. 

Take a photo that you are comfortable sharing with your group.  

The photos will be part of a group discussion. 

Photovoice Assignment Facilitator’s Guide 

(for virtual learning experience) 

Pre-Group Session:  

  1. Send out the assignment 1-2 weeks before the planned group session. 
  2. Give instructions for participants to email the photos and their descriptions to you several days before the group session. 
  3. Prior to the session, create a virtual visual display of the images and captions.
    1. Consider creating a PowerPoint or Google Slide presentation. 
    2. Place one picture on a slide and the caption on the following slide.
    3. The pictures and captions should be grouped with burnout images together and resiliency images together.
  4. Send out a link to an online meeting platform.
  5. Depending on the number of participants, 1-2 hours will be needed. 
  6. The recommended group size for online learning is no greater than 10 people

During the Session: 

  1. Create a safe space and discuss possible trigger warnings with the option for individuals to take a break if needed. 
  2. Share the presentation with participants
    1. The presentation, because it is full of images, will likely be too large to mail.  Consider posting it as an online secure link (Example – Google slide file that has access through invitation only)
      1. Give the participants dedicated time to review the images and captions:
      2. 20 minutes is a good estimate but more time may be needed depending on the number of participants. 
  3. Instruct participants to view each photo and answer the questions on a notes page:
    1. What do you see in the picture?  
    2. With which images do you connect and why? 
  4. Transition to a group discussion.
    1. Group discussions on online platforms can be challenging due to a loss of normal conversational cues and conversational flow
    2. Facilitators may need to be more direct to evoke conversation
    3. Consider having a way to go through each image so they can be discussed (for example, using screen sharing of the presentation).  
    4. Consider going through each slide and asking for comments- either ad hoc or round robin style
  5. Facilitator’s role in the discussion:  
  6. Ask open-ended and follow-up questions to allow the dialogue to flow from the participants. 
  7. Identify themes or highlight differing perspectives (for example, if there are similar images in both the burnout and resiliency categories). 
  8. Help participants understand how their own context influences their perception of the images. 
  1. Look for opportunities to highlight and normalize shared experiences (debunk the “I thought it was just me” myth). 
  2. End the session with a conversation about how this exercise might spark individual or system-level change and what that could look like. 

Photovoice Assignment Facilitator’s Guide 

(for in-person learning experience) 

Pre-Group Session:  

  1. Send out assignment 1-2 weeks prior to planned group session. 
  2. Give instructions for participants to email the photos and their descriptions to you several days before the group session. 
  3. Prior to the session, create a visual display of the images and captions.   
  4. Think of this as a gallery walk experience- all the images should be on display at the same time in the space. 
  5. This could be done by simply printing the pictures and captions and fixing them to large post notes on the walls of the room. 
  6. The pictures and captions should be grouped with burnout images in one area and resiliency images in another. 
  7. Depending on the number of participants, 1-2 hours will be needed. 

During the Session: 

  1. Create a safe space and discuss possible trigger warnings with the option for individuals to take a break if needed. 
  2. Give the participants dedicated time to walk through the images and captions:
    1. 20 minutes is a good estimate but more time may be needed depending on the number of participants. 
  3. Instruct participants to view each photo and answer the questions on a notes page:
    1. What do you see in the picture?  
    2. With which images do you connect and why? 

**Consider having a handout with the above questions and space for note-taking.  

  1. Transition to a group discussion- consider having a way to go through each image so they can be discussed- you may want to use a PowerPoint of the images to facilitate the discussion. 
  2. Go through each image asking participants to share their thoughts and reactions.
  3. Facilitator’s role in the discussion:
    1. Ask open-ended and follow-up questions to allow the dialogue to flow from the participants. 
    2. Identify themes or highlight differing perspectives (for example, if there are similar images in both the burnout and resiliency categories). 
    3. Help participants understand how their own context influences their perception of the images. 
    4. Look for opportunities to highlight and normalize shared experiences (debunk the “I thought it was just me” myth). 
    5. End the session with a conversation about how this exercise might spark individual or system-level change and what that could look like.  

Download the Resiliency Photos

Download the Burnout Images

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

Posted on June 21, 2022 by | Leave a comment

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

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