Being prepared

What does it mean to train practice-ready primary care physicians?

Primary care residency program leaders have nuanced views on the meaning of the phrase practice-ready physicians.

Graduate medical education programs must train physicians to become not just skilled clinicians but also savvy business professionals who can thrive in the contemporary health care climate. Trainees also need the tools to adapt to whatever changes and challenges lie ahead.

Among leaders of primary care residency programs, the phrase practice-ready physicians has been gaining traction. But educators have nuanced views as to what this means.

“To me, being a practice-ready physician means having all the skills needed to practice on your own, unsupervised, do everything that your specialty requires, and not harm patients,” says Jeremy J. Fischer, DO, who directs the osteopathic family medicine residency at Henry Ford Macomb in Clinton Township, Mich. “It also means understanding when to refer the patient out and when to take care of a problem yourself.”

Practice-ready physicians, first and foremost, are “clinically competent safe practitioners—physicians we would trust our family with,” says Richard Terry, DO, the chief academic officer of the Lake Erie Consortium for Osteopathic Medical Training. Second in importance, according to Dr. Terry, residency graduates must be able to manage patients confidently and efficiently in today’s production-driven environment.

“By their third year of residency, family medicine residents should be able to see at least 20 to 25 patients a day because that is what is required in the health system they are about to enter,” Dr. Terry says.

Time management is typically a bigger challenge for residents than the acquisition of medical knowledge, according to Dr. Fischer.

“The medicine part is pretty straightforward because it builds on what the residents have learned already,” Dr. Fischer explains. “The hardest thing they have to master is dealing with patients who present with a lot of problems. Sometimes patients will come in with six or seven issues they’ve had for a long time that they’d like to discuss during a 20-minute office visit. That’s just not possible.

“Residents need to be able to navigate that visit so the patient feels satisfied with the care provided but they still have time to see the rest of their patients.” This involves zeroing in on any potentially life-threatening and other major complaints and asking patients to make a follow-up visit to address less-significant issues.

Understanding the many obstacles faced by underserved patients is another challenge residents struggle with, Dr. Fischer notes. “When you have patients with low financial resources, how are you able to deliver what the patient needs? We have to find out what community resources are available and tell patients about Medicaid and,” he says. Residents need to realize that low-income patients are frequently noncompliant because they can’t afford their medications, they lack a safe, inexpensive venue for cardiovascular exercise, and they live in “food deserts” without access to fresh fruits and vegetables.

In addition, physicians new to practice need to have rigorous problem-solving skills, stresses Robyn Dreibelbis, DO, who directs the osteopathic family medicine residency at Good Samaritan Regional Medical Center in Corvallis, Ore. “Accordingly, our expectations of residents are very high,” she says. “We are constantly questioning their reasoning—asking them to explain why they ordered a particular test or prescribed a particular medication. And they are exposed to multiple perspectives.”

As the patient-centered medical home concept has taken hold, residents need to master the art of team leadership and care coordination. In Dr. Dreibelbis’ program, residents are being trained in a clinic that is recognized as a Level 3 medical home by the National Committee for Quality Assurance. Among other criteria, Level 3 medical practices engage in performance reporting and quality improvement, systematically track clinical referrals, communicate electronically with patients, and emphasize patient education and self-management of chronic diseases. “Because they are being trained inside of this system, they will be very comfortable leading a medical home when they get out into practice,” Dr. Dreibelbis says.

Preparing for the future

Beyond handling the present-day demands of practice, residents must be prepared to become nimble lifelong learners, say GME leaders.

“In my mind, practice-ready is one step beyond what we’ve considered to be a standard competent physician,” says Harald Lausen, DO, the president of the Association of Osteopathic Directors and Medical Educators. “What we’re talking about is someone who is prepared to practice not only in the current medical system but also in what the health care system of the future.”

For example, he notes that the federal government has been pressing for outcomes-based reimbursement, which would reward physicians for positive health outcomes in specific patient populations.

“Even though we don’t currently practice in a system that reimburses physicians based on population health, it is likely that our residents today will practice in such a system,” says Dr. Lausen, the director of medical education and quality initiatives at the Southern Illinois University School of Medicine in Springfield. “So we need to make sure that residents understand how to manage populations. To impact population health, you need to have an understanding of such topics as health disparities and health literacy evaluation.

“We need to be talking to our residents about these things because of the rapid transitions that will be occurring in health care.”

No trainee can learn all that he or she needs to know during residency. “As I tell my residents,” Dr. Fischer says, “ ‘My goal is not to give you nuts-and-bolts medical knowledge. Medicine is not static. It’s about my giving you the skills to acquire knowledge on your own, whether it be new techniques or an understanding of health care reform.’

“I want my residents go out in practice and survive for many years to come.”

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