Longitudinal Residency Training: A Survey of Family Practice Residency Programs

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1 740 November-December 2001 Family Medicine Special Series: Longitudinal Residency Training Longitudinal Residency Training: A Survey of Family Practice Residency Programs Carin E. Reust, MD Background and Objectives: Most family practice residency training consists of 2 4-week block rotations in specific curricular areas, supplemented by training in the family practice center. An alternative model, longitudinal residency training, emphasizes training in curricular areas over a 3-year time period. This study determined the frequency of longitudinal training in family practice residency programs. Methods: We conducted a survey of 477 residency program directors listed in the American Academy of Family Physicians 2000 Directory of Family Practice Residency Programs. Results: Sixtyeight percent (n=320) of program directors responded to the survey. A total of 3.6% of program directors described their program as mostly longitudinal, and 14.2% described their program as half block/half longitudinal. An additional 15% of program directors indicated interest in adopting or moving toward a longitudinal program in the next 2 years. Responses suggest some inconsistencies in program directors understanding of what constitutes a longitudinal curriculum. Conclusions: Longitudinal residency training is reported in 18% of family practice residency programs. Further work is needed to develop a definition of longitudinal residency training. (Fam Med 2001;33(10):740-5.) Family medicine education has modeled its training programs around a rotating internship format; the content of family medicine is taught through participation in block rotations. Block rotations are taught in specified time frames, usually 2 4 weeks, during which residents spend the majority of time working with health care professionals in their specialties, providing care to the patients of those health care professionals. The primary site for these educational experiences is outside of the family practice center (FPC), and the primary teachers of the family practice residents are not family physicians. This block-based model is the standard in most family practice residency programs. In the 1990s, an alternative educational model for family practice residency training reemerged the longitudinal residency model. This model was initially proposed in the early 1970s, when two programs, the Sparrow program in Lansing, Mich, and the Fairfax, Va, program, developed nonrotational or longitudinal models to more closely approximate the work environment From the Department of Family and Community Medicine, University of Missouri-Columbia. of the practicing family physician. 1 Noting that family practice residents were being trained with little resemblance to the day-to-day experience of physicians in family practice, 1 the nonrotational or longitudinal programs emphasize the FPC as the center of residents training experience, providing not only training in continuity but training in the content of family practice. Outside rotations were developed to supplement residents training in specific areas but not as the primary source of education. Family physicians were identified as the primary teachers of resident physicians, supplemented by other health care professionals as necessary. Resident physicians were seen as capable of determining their own educational needs through critical selfreflection and the practice of lifelong learning skills. Finally, practicing in the FPC group setting offered what was perceived to be an optimal professional and personal lifestyle experience. 1-8 Resident physicians learned continuity and content by caring for their own patients in settings in which the family physician practices, ie, clinic, hospital, labor and delivery, and nursing home. The proposed advantages of the longitudinal model include role modeling and supervision by family physician faculty, improved opportunities to provide

2 Special Series: Longitudinal Residency Training Vol. 33, No continuity of care, management and decision making about problems in primary care settings, and the practice of lifelong learning skills and lifestyles by resident physicians. Barriers to development of the model have been the emphasis on hospital-based training, 2 accreditation requirements emphasizing the need for training in specialty areas outside of the FPC, 5 and the lack of proven educational benefit when compared to the traditional model. There is a spectrum of residency program organization from a standard block-based model to a half block/ half longitudinal model, and finally to a longitudinal model. But, it is unknown how many family practice residency programs are implementing or developing any type of longitudinal residency training. To evaluate the effectiveness of a longitudinal model for training, however, it is important to identify programs using the model, describe the components of the model, and develop measures of comparison between each model. This study was designed to identify programs that are using a longitudinal model and to describe the structure of their longitudinal curricula and training. Methods Approval for the study was obtained through the University of Missouri s Institutional Review Board. The study included a survey mailed in the fall of 2000 to 477 residency program directors listed in the American Academy of Family Physicians (AAFP) 2000 Directory of Family Practice Residency Programs. 9 A follow-up survey was sent in 1 month to nonrespondents. Survey Instrument The two-page survey was developed and pilot tested through the use of two electronic listserves (FAMILY-L and the STFM Group on Residency Education listserve). The first question of the survey, based on a consensus opinion regarding the definition of longitudinal residency training, was A longitudinal family practice residency is one that has limited block rotations, with most of resident education supervised by the family medicine faculty in the FPC. How would you describe your residency program? Additional questions in the survey were designed to determine the current status of the program (all or mostly block, half block/half longitudinal, all or mostly longitudinal); interest in future development of a longitudinal program at their site (yes or no); average estimated number of half days per week in the FPC for each residency class; number of immersion weeks in the FPC (weeks spent in the FPC in which half days in clinic were higher than usual); and a description of how (mostly block, half and half, mostly longitudinal), where (mostly outside FPC, half and half, mostly FPC) training occurs for a variety of curricula, and by whom (mostly others, half and half, mostly family physicians). Supplemental information regarding the geographic location of the program and the structure of program was obtained from the AAFP 2000 Directory of Family Practice Residency Programs. Geographical regions were categorized as East North Central, East South Central, Middle Atlantic, Mountain, New England, Pacific, South Atlantic plus Puerto Rico, West North Central, West South Central. Programs were classified, based on information in the directory, as community based, community based and medical school affiliated, community based and medical school administered, medical school based, or military. Data Analysis Data were entered into Microsoft Excel and analyzed using SAS Systems for Windows V8. Standard statistical methods used included descriptive analysis (means + standard deviation, percentages), chi-square for ordinal data, and ANOVA to determine differences between sample means, followed by post-hoc pair-wise comparisons (Tukeys). Missing data was considered as a nonresponse. To determine if a representative sample of programs had responded, respondents were compared to nonrespondents based on geographical location and structure of program. Table 1 Respondents Versus Nonrespondents, Based on Residency Structure and Location Respondent Nonrespondent Community based 14 (4.3%) 11 (7.1%) Community based, medical school affiliated 194 (60.2%) 83 (53.5%) Community based, medical school administrated 64 (19.9%) 35 (22.6%) Medical school based 39 (12.1%) 23 (14.8%) Military program 11 (3.4%) 3 (1.9%) Location 1. East North Central 65 (20.4%) 32 (20.6%) 2. East South Central 18 (5.6%) 9 (5.8%) 3. Middle Atlantic 47 (14.7%) 27 (17.4%) 4. Mountain 19 (6.0%) 10 (6.5%) 5. New England 12 (3.8%) 7 (4.5%) 6. Pacific 41 (12.9%) 17 (11.0%) 7. South Atlantic + Puerto Rico 48 (15.0%) 25 (16.1%) 8. West North Central 30 (9.4%) 14 (9.0%) 9. West South Central 39 (12.2%) 14 (9.0%)

3 742 November-December 2001 Family Medicine Table 2 Type of Program, Based on Structure and Location of Program for Responding Programs Block Half and Half Longitudinal Structure Community based 10 (4.0%) 2 (4.7%) 2 (18.2%) Community based, medical school affiliated 151 (60.1%) 27 (62.8%) 6 (54.5%) Community based, medical school administrated 51 (20.3%) 7 (16.3%) 2 (18.2%) Medical school based 29 (11.6%) 6 (13.9%) 1 (9.1%) Military program 10 (4.0%) 1 (2.3%) 0 0 Location 1. East North Central 48 (19.1%) 11 (25.6%) 4 (36.4%) 2. East South Central 14 (5.6%) 3 (7.0%) Middle Atlantic 37 (14.7%) 5 (11.6%) 3 (27.3%) 4. Mountain 18 (7.2%) (9.1%) 5. New England 8 (3.2%) 3 (7.0%) Pacific 31 (12.4%) 6 (13.9%) South Atlantic + Puerto Rico 41 (16.3%) 7 (16.3%) 1 (9.1%) 8. West North Central 25 (10.0%) 2 (4.7%) West South Central 29 (11.6%) 6 (13.9%) 2 (18.2%) Location is: East North Central IL, IN, MI, OH, WI; East South Central AL, KY, MS, TN; Middle Atlantic NJ, NY, PA; Mountain AZ, CO, ID, MT, NM, NV, UT, WY; New England CT, DE, MA, ME, NH, RI, VT; Pacific AK, CA, HI, OR, WA; South Atlantic + Puerto Rico DC, FL, GA, MD, NC, PR, SC, VA, WV; West North Central IA, KS, MN, MO, ND, NE, SD; West South Central AR, LA, OK, TX. Results The response rate was 68% (322/477) after two requests to participate in the study, though not all respondents answered all questions. Percentages of respondents for each geographic region and for each structure type of program were similar to percentages for all residency programs listed in the AAFP directory. (Table 1) Of the 305 program directors who responded to the question about program structure, 11(3.6%) described their program as all or mostly longitudinal, and 43 (14.2) described their program as half block, half longitudinal. A total of 46 (15%) indicated that they were considering adopting or moving toward a longitudinal Table 3 Half Days in Clinic Per Week for Each Type of Residency Program Half Traditional, Overall Traditional Half Longitudinal Longitudinal P Value First-year residents Second-year residents * Third-year residents * * From post-hoc analysis (Tukey), the difference occurs between traditional and half and half program program in the next 2 years. The remainder of program directors described a block format for their program (Table 2). There was no statistical difference between traditional, half and half, and longitudinal programs in the amount of time first-year residents are reported to spend in the FPC (Table 3). However, for second- and third-year residents, there was a trend toward an increasing number of half days in clinic per week moving from traditional to longitudinal programs. In fact, a significant difference was seen between traditional and half and half programs, with second-year residents spending 2.7 and 3.0 half days per week in clinic, respectively, and thirdyear residents spending 3.8 and 4.3 half days in clinic per week, respectively. Human behavior, geriatrics, and practice management are the curricula most commonly taught in a longitudinal manner (Table 4). Geriatrics, practice management, and community medicine are the curricula mostly taught by family physicians. The curricula mostly taught in the FPC are practice management, human behavior, and community medicine. Block programs are more likely to teach a curriculum in a block fashion than half and half programs or longitudinal programs. Discussion This is the first survey of longitudinal residency training in family practice. A total of 3.6% of program directors described their programs as longitudinal and 14.2% as half block, half longitudinal. Another 15% of programs are considering incorporating longitudinal elements into their curriculum. The findings are similar to an unpublished study performed in 1998 and reported by Michael Stehney, MD, at the 1998 STFM Annual Spring Conference, in which 2.3% of programs answered that they were primarily longitudinal, and 20% of programs without longitudinal elements were interested in further development of longitudinal experiences. It appears that second- and third-year residents in longitudinal programs may spend

4 Special Series: Longitudinal Residency Training Vol. 33, No Table 4 Curriculum Description: How Is the Curriculum Taught? Who Teaches? Where? Where Is the Curriculum Primarily Taught, FPC or Outside of FPC How Is Who Teaches the Curriculum? (Hospital, Nursing Home, Curriculum Taught? Family Physicians Versus Others Other Ambulatory Office)? Half Half Mostly Mostly Half Mostly and Mostly Mostly and Family Outside and Mostly Curriculum Block Half Longitudinal Others Half Physicians of FPC Half FPC Adult Medicine Traditional model Half and half model Longitudinal model Pediatrics ** Traditional model Half and half model Longitudinal model Obstetrics Traditional model Half and half model Longitudinal model Gynecology Traditional model Half and half model Longitudinal model Human behavior ** Traditional model Half and half model Longitudinal model Geriatrics *** Traditional model Half and half model Longitudinal model Practice management Traditional model Half and half model Longitudinal model Community medicine *** Traditional model Half and half model Longitudinal model Dermatology ** *** Traditional model Half and half model Longitudinal model Cardiology ** *** Traditional model Half and half model Longitudinal model Surgery ** Traditional model Half and half model Longitudinal model (continued on next page)

5 744 November-December 2001 Family Medicine Table 4 (continued) Where Is the Curriculum Primarily Taught, FPC or Outside of FPC How Is Who Teaches the Curriculum? (Hospital, Nursing Home, Curriculum Taught? Family Physicians Versus Others Other Ambulatory Office)? Half Half Mostly Mostly Half Mostly and Mostly Mostly and Family Outside and Mostly Curriculum Block Half Longitudinal Others Half Physicians of FPC Half FPC Orthopedics ** *** Traditional model Half and half model Longitudinal model Ear, nose, and throat Traditional model Half and half model Longitudinal model Emergency room Traditional model Half and half model Longitudinal model Intensive care unit * ** Traditional model Half and half model Longitudinal model FPC Family Practice Center * P>.05, indicating there is no relationship between how ICU is taught (block, half and half, longitudinal) and whether program is described as traditional, half and half, or longitudinal. For all other curriculum, how curriculum is taught is related to model of program. ** P<.05, indicating there is a relationship between who is teaching in these curricula (pediatrics, human behavior, dermatology, cardiology, surgery, orthopedics, ICU) and whether program is described as traditional, half and half, or longitudinal *** P<.05 indicating there is a relationship between where curricula is taught (geriatrics, community medicine, dermatology, cardiology, orthopedics) and whether program is described as traditional, half and half, or longitudinal more time in the FPC than residents in traditional programs, though the relationship is not consistent. In fact, two programs, one of which is a block program and one of which is half and half, reported their residents to be in the clinic every day in their first, second, and third years. In terms of how the curriculum is taught, there is a relationship between model of program and whether the individual curricula are being taught in a block, half and half, or longitudinal manner, except for ICU. Inconsistent relationships were found in whether longitudinal and block programs do more or less teaching in the FPC and whether most teaching is by family medicine faculty. Limitations This study has several limitations that may explain some of the aforementioned inconsistencies. First, although responding programs are representative of all family practice residency programs in terms of structure and geographic location, 32% of programs did not respond to the survey. Thus, it is possible that some programs with longitudinal programs were missed by this survey. However, based on word of mouth, contact with the Residency Review Committee, and discussions with known longitudinal programs, all programs with significant longitudinal components appear to have responded. A second limitation is that program directors were asked their perceptions regarding their own program in terms of longitudinal components and description of curriculum. No attempt was made to validate these perceptions, and it is possible that program directors underestimated or overestimated the level of longitudinal training, primary faculty for each curricula, or where curricula is primarily taught. A third, and perhaps most important, limitation of this study was the lack of a standard definition for longitudinal residency training. Through pilot testing of

6 Special Series: Longitudinal Residency Training Vol. 33, No the survey, a consensus definition of longitudinal training was reached that emphasized teaching by family physicians in the family practice setting and in a longitudinal manner. In looking at specific curricula described by respondents as longitudinal, however, only teaching in a longitudinal manner ( how the curriculum is taught ) was consistently reported by longitudinal programs. Teaching by family physicians and/or in the FPC was not consistently reported by longitudinal programs. These inconsistencies point out the need for a more clear definition of longitudinal training. Conclusions This study has provided information on the spectrum of longitudinal family practice residency training. By identifying longitudinal programs, this survey will aid in further clarifying the nature and definition of longitudinal residency training so that the educational effectiveness of the longitudinal model can be studied. Before outcome studies or evaluation of the educational effectiveness of longitudinal residency training can be done, a clearer understanding of the nature or definition of a longitudinal residency training program is necessary. Acknowledgments: I thank and acknowledge John Hewett, PhD, for statistical advice and insight and Michael Stehney, MD, MPH, and Josh Freeman, MD, for their enthusiasm and support. Correspondence: Address correspondence to Dr Reust, 501 Route B, Hallsville, MO Fax: missouri.edu. REFERENCES 1. Radke KF, Crow HE, Carley WC. The nonrotational model. Family Practice Recertification 1982;4(6):31-2, Frey JJ. Time for change. Fam Med 1990;22(6): Carley WC, Radke KF, Smith GF, Rohrer MM, Burgess HJ. Nonrotational residency training. J Fam Pract 1983;17(5): Crow HE, Rohrer MM, Carley WC, Radke KF, Holden DM, Smith GF. Nonrotational teaching of obstetrics in a family practice residency. J Fam Pract 1980;10(5): Crow HE, Gifford WP. Is there anybody out there who would like to change from a content curriculum to a functional curriculum? Fam Med 1991;23(8): Rodney WM. Further support for the nonrotational system. Fam Med 1992;24(4): Leibert BA. The birth of the blended curriculum. Fam Med 1998; 30(6): Reust CE, Stehney M, eds. Models of innovation: longitudinal curriculum in family practice residency education. (monograph). Leawood, Kan: Society of Teachers of Family Medicine, American Academy of Family Physicians directory of family practice residency programs. Leawood, Kan: American Academy of Family Physicians, 2000.

7 740 November-December 2001 Family Medicine Special Series: Longitudinal Residency Training Longitudinal Residency Training: A Survey of Family Practice Residency Programs Carin E. Reust, MD Background and Objectives: Most family practice residency training consists of 2 4-week block rotations in specific curricular areas, supplemented by training in the family practice center. An alternative model, longitudinal residency training, emphasizes training in curricular areas over a 3-year time period. This study determined the frequency of longitudinal training in family practice residency programs. Methods: We conducted a survey of 477 residency program directors listed in the American Academy of Family Physicians 2000 Directory of Family Practice Residency Programs. Results: Sixtyeight percent (n=320) of program directors responded to the survey. A total of 3.6% of program directors described their program as mostly longitudinal, and 14.2% described their program as half block/half longitudinal. An additional 15% of program directors indicated interest in adopting or moving toward a longitudinal program in the next 2 years. Responses suggest some inconsistencies in program directors understanding of what constitutes a longitudinal curriculum. Conclusions: Longitudinal residency training is reported in 18% of family practice residency programs. Further work is needed to develop a definition of longitudinal residency training. (Fam Med 2001;33(10):740-5.) Family medicine education has modeled its training programs around a rotating internship format; the content of family medicine is taught through participation in block rotations. Block rotations are taught in specified time frames, usually 2 4 weeks, during which residents spend the majority of time working with health care professionals in their specialties, providing care to the patients of those health care professionals. The primary site for these educational experiences is outside of the family practice center (FPC), and the primary teachers of the family practice residents are not family physicians. This block-based model is the standard in most family practice residency programs. In the 1990s, an alternative educational model for family practice residency training reemerged the longitudinal residency model. This model was initially proposed in the early 1970s, when two programs, the Sparrow program in Lansing, Mich, and the Fairfax, Va, program, developed nonrotational or longitudinal models to more closely approximate the work environment From the Department of Family and Community Medicine, University of Missouri-Columbia. of the practicing family physician. 1 Noting that family practice residents were being trained with little resemblance to the day-to-day experience of physicians in family practice, 1 the nonrotational or longitudinal programs emphasize the FPC as the center of residents training experience, providing not only training in continuity but training in the content of family practice. Outside rotations were developed to supplement residents training in specific areas but not as the primary source of education. Family physicians were identified as the primary teachers of resident physicians, supplemented by other health care professionals as necessary. Resident physicians were seen as capable of determining their own educational needs through critical selfreflection and the practice of lifelong learning skills. Finally, practicing in the FPC group setting offered what was perceived to be an optimal professional and personal lifestyle experience. 1-8 Resident physicians learned continuity and content by caring for their own patients in settings in which the family physician practices, ie, clinic, hospital, labor and delivery, and nursing home. The proposed advantages of the longitudinal model include role modeling and supervision by family physician faculty, improved opportunities to provide

8 Special Series: Longitudinal Residency Training Vol. 33, No continuity of care, management and decision making about problems in primary care settings, and the practice of lifelong learning skills and lifestyles by resident physicians. Barriers to development of the model have been the emphasis on hospital-based training, 2 accreditation requirements emphasizing the need for training in specialty areas outside of the FPC, 5 and the lack of proven educational benefit when compared to the traditional model. There is a spectrum of residency program organization from a standard block-based model to a half block/ half longitudinal model, and finally to a longitudinal model. But, it is unknown how many family practice residency programs are implementing or developing any type of longitudinal residency training. To evaluate the effectiveness of a longitudinal model for training, however, it is important to identify programs using the model, describe the components of the model, and develop measures of comparison between each model. This study was designed to identify programs that are using a longitudinal model and to describe the structure of their longitudinal curricula and training. Methods Approval for the study was obtained through the University of Missouri s Institutional Review Board. The study included a survey mailed in the fall of 2000 to 477 residency program directors listed in the American Academy of Family Physicians (AAFP) 2000 Directory of Family Practice Residency Programs. 9 A follow-up survey was sent in 1 month to nonrespondents. Survey Instrument The two-page survey was developed and pilot tested through the use of two electronic listserves (FAMILY-L and the STFM Group on Residency Education listserve). The first question of the survey, based on a consensus opinion regarding the definition of longitudinal residency training, was A longitudinal family practice residency is one that has limited block rotations, with most of resident education supervised by the family medicine faculty in the FPC. How would you describe your residency program? Additional questions in the survey were designed to determine the current status of the program (all or mostly block, half block/half longitudinal, all or mostly longitudinal); interest in future development of a longitudinal program at their site (yes or no); average estimated number of half days per week in the FPC for each residency class; number of immersion weeks in the FPC (weeks spent in the FPC in which half days in clinic were higher than usual); and a description of how (mostly block, half and half, mostly longitudinal), where (mostly outside FPC, half and half, mostly FPC) training occurs for a variety of curricula, and by whom (mostly others, half and half, mostly family physicians). Supplemental information regarding the geographic location of the program and the structure of program was obtained from the AAFP 2000 Directory of Family Practice Residency Programs. Geographical regions were categorized as East North Central, East South Central, Middle Atlantic, Mountain, New England, Pacific, South Atlantic plus Puerto Rico, West North Central, West South Central. Programs were classified, based on information in the directory, as community based, community based and medical school affiliated, community based and medical school administered, medical school based, or military. Data Analysis Data were entered into Microsoft Excel and analyzed using SAS Systems for Windows V8. Standard statistical methods used included descriptive analysis (means + standard deviation, percentages), chi-square for ordinal data, and ANOVA to determine differences between sample means, followed by post-hoc pair-wise comparisons (Tukeys). Missing data was considered as a nonresponse. To determine if a representative sample of programs had responded, respondents were compared to nonrespondents based on geographical location and structure of program. Table 1 Respondents Versus Nonrespondents, Based on Residency Structure and Location Respondent Nonrespondent Community based 14 (4.3%) 11 (7.1%) Community based, medical school affiliated 194 (60.2%) 83 (53.5%) Community based, medical school administrated 64 (19.9%) 35 (22.6%) Medical school based 39 (12.1%) 23 (14.8%) Military program 11 (3.4%) 3 (1.9%) Location 1. East North Central 65 (20.4%) 32 (20.6%) 2. East South Central 18 (5.6%) 9 (5.8%) 3. Middle Atlantic 47 (14.7%) 27 (17.4%) 4. Mountain 19 (6.0%) 10 (6.5%) 5. New England 12 (3.8%) 7 (4.5%) 6. Pacific 41 (12.9%) 17 (11.0%) 7. South Atlantic + Puerto Rico 48 (15.0%) 25 (16.1%) 8. West North Central 30 (9.4%) 14 (9.0%) 9. West South Central 39 (12.2%) 14 (9.0%)

9 742 November-December 2001 Family Medicine Table 2 Type of Program, Based on Structure and Location of Program for Responding Programs Block Half and Half Longitudinal Structure Community based 10 (4.0%) 2 (4.7%) 2 (18.2%) Community based, medical school affiliated 151 (60.1%) 27 (62.8%) 6 (54.5%) Community based, medical school administrated 51 (20.3%) 7 (16.3%) 2 (18.2%) Medical school based 29 (11.6%) 6 (13.9%) 1 (9.1%) Military program 10 (4.0%) 1 (2.3%) 0 0 Location 1. East North Central 48 (19.1%) 11 (25.6%) 4 (36.4%) 2. East South Central 14 (5.6%) 3 (7.0%) Middle Atlantic 37 (14.7%) 5 (11.6%) 3 (27.3%) 4. Mountain 18 (7.2%) (9.1%) 5. New England 8 (3.2%) 3 (7.0%) Pacific 31 (12.4%) 6 (13.9%) South Atlantic + Puerto Rico 41 (16.3%) 7 (16.3%) 1 (9.1%) 8. West North Central 25 (10.0%) 2 (4.7%) West South Central 29 (11.6%) 6 (13.9%) 2 (18.2%) Location is: East North Central IL, IN, MI, OH, WI; East South Central AL, KY, MS, TN; Middle Atlantic NJ, NY, PA; Mountain AZ, CO, ID, MT, NM, NV, UT, WY; New England CT, DE, MA, ME, NH, RI, VT; Pacific AK, CA, HI, OR, WA; South Atlantic + Puerto Rico DC, FL, GA, MD, NC, PR, SC, VA, WV; West North Central IA, KS, MN, MO, ND, NE, SD; West South Central AR, LA, OK, TX. Results The response rate was 68% (322/477) after two requests to participate in the study, though not all respondents answered all questions. Percentages of respondents for each geographic region and for each structure type of program were similar to percentages for all residency programs listed in the AAFP directory. (Table 1) Of the 305 program directors who responded to the question about program structure, 11(3.6%) described their program as all or mostly longitudinal, and 43 (14.2) described their program as half block, half longitudinal. A total of 46 (15%) indicated that they were considering adopting or moving toward a longitudinal Table 3 Half Days in Clinic Per Week for Each Type of Residency Program Half Traditional, Overall Traditional Half Longitudinal Longitudinal P Value First-year residents Second-year residents * Third-year residents * * From post-hoc analysis (Tukey), the difference occurs between traditional and half and half program program in the next 2 years. The remainder of program directors described a block format for their program (Table 2). There was no statistical difference between traditional, half and half, and longitudinal programs in the amount of time first-year residents are reported to spend in the FPC (Table 3). However, for second- and third-year residents, there was a trend toward an increasing number of half days in clinic per week moving from traditional to longitudinal programs. In fact, a significant difference was seen between traditional and half and half programs, with second-year residents spending 2.7 and 3.0 half days per week in clinic, respectively, and thirdyear residents spending 3.8 and 4.3 half days in clinic per week, respectively. Human behavior, geriatrics, and practice management are the curricula most commonly taught in a longitudinal manner (Table 4). Geriatrics, practice management, and community medicine are the curricula mostly taught by family physicians. The curricula mostly taught in the FPC are practice management, human behavior, and community medicine. Block programs are more likely to teach a curriculum in a block fashion than half and half programs or longitudinal programs. Discussion This is the first survey of longitudinal residency training in family practice. A total of 3.6% of program directors described their programs as longitudinal and 14.2% as half block, half longitudinal. Another 15% of programs are considering incorporating longitudinal elements into their curriculum. The findings are similar to an unpublished study performed in 1998 and reported by Michael Stehney, MD, at the 1998 STFM Annual Spring Conference, in which 2.3% of programs answered that they were primarily longitudinal, and 20% of programs without longitudinal elements were interested in further development of longitudinal experiences. It appears that second- and third-year residents in longitudinal programs may spend

10 Special Series: Longitudinal Residency Training Vol. 33, No Table 4 Curriculum Description: How Is the Curriculum Taught? Who Teaches? Where? Where Is the Curriculum Primarily Taught, FPC or Outside of FPC How Is Who Teaches the Curriculum? (Hospital, Nursing Home, Curriculum Taught? Family Physicians Versus Others Other Ambulatory Office)? Half Half Mostly Mostly Half Mostly and Mostly Mostly and Family Outside and Mostly Curriculum Block Half Longitudinal Others Half Physicians of FPC Half FPC Adult Medicine Traditional model Half and half model Longitudinal model Pediatrics ** Traditional model Half and half model Longitudinal model Obstetrics Traditional model Half and half model Longitudinal model Gynecology Traditional model Half and half model Longitudinal model Human behavior ** Traditional model Half and half model Longitudinal model Geriatrics *** Traditional model Half and half model Longitudinal model Practice management Traditional model Half and half model Longitudinal model Community medicine *** Traditional model Half and half model Longitudinal model Dermatology ** *** Traditional model Half and half model Longitudinal model Cardiology ** *** Traditional model Half and half model Longitudinal model Surgery ** Traditional model Half and half model Longitudinal model (continued on next page)

11 744 November-December 2001 Family Medicine Table 4 (continued) Where Is the Curriculum Primarily Taught, FPC or Outside of FPC How Is Who Teaches the Curriculum? (Hospital, Nursing Home, Curriculum Taught? Family Physicians Versus Others Other Ambulatory Office)? Half Half Mostly Mostly Half Mostly and Mostly Mostly and Family Outside and Mostly Curriculum Block Half Longitudinal Others Half Physicians of FPC Half FPC Orthopedics ** *** Traditional model Half and half model Longitudinal model Ear, nose, and throat Traditional model Half and half model Longitudinal model Emergency room Traditional model Half and half model Longitudinal model Intensive care unit * ** Traditional model Half and half model Longitudinal model FPC Family Practice Center * P>.05, indicating there is no relationship between how ICU is taught (block, half and half, longitudinal) and whether program is described as traditional, half and half, or longitudinal. For all other curriculum, how curriculum is taught is related to model of program. ** P<.05, indicating there is a relationship between who is teaching in these curricula (pediatrics, human behavior, dermatology, cardiology, surgery, orthopedics, ICU) and whether program is described as traditional, half and half, or longitudinal *** P<.05 indicating there is a relationship between where curricula is taught (geriatrics, community medicine, dermatology, cardiology, orthopedics) and whether program is described as traditional, half and half, or longitudinal more time in the FPC than residents in traditional programs, though the relationship is not consistent. In fact, two programs, one of which is a block program and one of which is half and half, reported their residents to be in the clinic every day in their first, second, and third years. In terms of how the curriculum is taught, there is a relationship between model of program and whether the individual curricula are being taught in a block, half and half, or longitudinal manner, except for ICU. Inconsistent relationships were found in whether longitudinal and block programs do more or less teaching in the FPC and whether most teaching is by family medicine faculty. Limitations This study has several limitations that may explain some of the aforementioned inconsistencies. First, although responding programs are representative of all family practice residency programs in terms of structure and geographic location, 32% of programs did not respond to the survey. Thus, it is possible that some programs with longitudinal programs were missed by this survey. However, based on word of mouth, contact with the Residency Review Committee, and discussions with known longitudinal programs, all programs with significant longitudinal components appear to have responded. A second limitation is that program directors were asked their perceptions regarding their own program in terms of longitudinal components and description of curriculum. No attempt was made to validate these perceptions, and it is possible that program directors underestimated or overestimated the level of longitudinal training, primary faculty for each curricula, or where curricula is primarily taught. A third, and perhaps most important, limitation of this study was the lack of a standard definition for longitudinal residency training. Through pilot testing of

12 Special Series: Longitudinal Residency Training Vol. 33, No the survey, a consensus definition of longitudinal training was reached that emphasized teaching by family physicians in the family practice setting and in a longitudinal manner. In looking at specific curricula described by respondents as longitudinal, however, only teaching in a longitudinal manner ( how the curriculum is taught ) was consistently reported by longitudinal programs. Teaching by family physicians and/or in the FPC was not consistently reported by longitudinal programs. These inconsistencies point out the need for a more clear definition of longitudinal training. Conclusions This study has provided information on the spectrum of longitudinal family practice residency training. By identifying longitudinal programs, this survey will aid in further clarifying the nature and definition of longitudinal residency training so that the educational effectiveness of the longitudinal model can be studied. Before outcome studies or evaluation of the educational effectiveness of longitudinal residency training can be done, a clearer understanding of the nature or definition of a longitudinal residency training program is necessary. Acknowledgments: I thank and acknowledge John Hewett, PhD, for statistical advice and insight and Michael Stehney, MD, MPH, and Josh Freeman, MD, for their enthusiasm and support. Correspondence: Address correspondence to Dr Reust, 501 Route B, Hallsville, MO Fax: missouri.edu. REFERENCES 1. Radke KF, Crow HE, Carley WC. The nonrotational model. Family Practice Recertification 1982;4(6):31-2, Frey JJ. Time for change. Fam Med 1990;22(6): Carley WC, Radke KF, Smith GF, Rohrer MM, Burgess HJ. Nonrotational residency training. J Fam Pract 1983;17(5): Crow HE, Rohrer MM, Carley WC, Radke KF, Holden DM, Smith GF. Nonrotational teaching of obstetrics in a family practice residency. J Fam Pract 1980;10(5): Crow HE, Gifford WP. Is there anybody out there who would like to change from a content curriculum to a functional curriculum? Fam Med 1991;23(8): Rodney WM. Further support for the nonrotational system. Fam Med 1992;24(4): Leibert BA. The birth of the blended curriculum. Fam Med 1998; 30(6): Reust CE, Stehney M, eds. Models of innovation: longitudinal curriculum in family practice residency education. (monograph). Leawood, Kan: Society of Teachers of Family Medicine, American Academy of Family Physicians directory of family practice residency programs. Leawood, Kan: American Academy of Family Physicians, 2000.

13 740 November-December 2001 Family Medicine Special Series: Longitudinal Residency Training Longitudinal Residency Training: A Survey of Family Practice Residency Programs Carin E. Reust, MD Background and Objectives: Most family practice residency training consists of 2 4-week block rotations in specific curricular areas, supplemented by training in the family practice center. An alternative model, longitudinal residency training, emphasizes training in curricular areas over a 3-year time period. This study determined the frequency of longitudinal training in family practice residency programs. Methods: We conducted a survey of 477 residency program directors listed in the American Academy of Family Physicians 2000 Directory of Family Practice Residency Programs. Results: Sixtyeight percent (n=320) of program directors responded to the survey. A total of 3.6% of program directors described their program as mostly longitudinal, and 14.2% described their program as half block/half longitudinal. An additional 15% of program directors indicated interest in adopting or moving toward a longitudinal program in the next 2 years. Responses suggest some inconsistencies in program directors understanding of what constitutes a longitudinal curriculum. Conclusions: Longitudinal residency training is reported in 18% of family practice residency programs. Further work is needed to develop a definition of longitudinal residency training. (Fam Med 2001;33(10):740-5.) Family medicine education has modeled its training programs around a rotating internship format; the content of family medicine is taught through participation in block rotations. Block rotations are taught in specified time frames, usually 2 4 weeks, during which residents spend the majority of time working with health care professionals in their specialties, providing care to the patients of those health care professionals. The primary site for these educational experiences is outside of the family practice center (FPC), and the primary teachers of the family practice residents are not family physicians. This block-based model is the standard in most family practice residency programs. In the 1990s, an alternative educational model for family practice residency training reemerged the longitudinal residency model. This model was initially proposed in the early 1970s, when two programs, the Sparrow program in Lansing, Mich, and the Fairfax, Va, program, developed nonrotational or longitudinal models to more closely approximate the work environment From the Department of Family and Community Medicine, University of Missouri-Columbia. of the practicing family physician. 1 Noting that family practice residents were being trained with little resemblance to the day-to-day experience of physicians in family practice, 1 the nonrotational or longitudinal programs emphasize the FPC as the center of residents training experience, providing not only training in continuity but training in the content of family practice. Outside rotations were developed to supplement residents training in specific areas but not as the primary source of education. Family physicians were identified as the primary teachers of resident physicians, supplemented by other health care professionals as necessary. Resident physicians were seen as capable of determining their own educational needs through critical selfreflection and the practice of lifelong learning skills. Finally, practicing in the FPC group setting offered what was perceived to be an optimal professional and personal lifestyle experience. 1-8 Resident physicians learned continuity and content by caring for their own patients in settings in which the family physician practices, ie, clinic, hospital, labor and delivery, and nursing home. The proposed advantages of the longitudinal model include role modeling and supervision by family physician faculty, improved opportunities to provide

14 Special Series: Longitudinal Residency Training Vol. 33, No continuity of care, management and decision making about problems in primary care settings, and the practice of lifelong learning skills and lifestyles by resident physicians. Barriers to development of the model have been the emphasis on hospital-based training, 2 accreditation requirements emphasizing the need for training in specialty areas outside of the FPC, 5 and the lack of proven educational benefit when compared to the traditional model. There is a spectrum of residency program organization from a standard block-based model to a half block/ half longitudinal model, and finally to a longitudinal model. But, it is unknown how many family practice residency programs are implementing or developing any type of longitudinal residency training. To evaluate the effectiveness of a longitudinal model for training, however, it is important to identify programs using the model, describe the components of the model, and develop measures of comparison between each model. This study was designed to identify programs that are using a longitudinal model and to describe the structure of their longitudinal curricula and training. Methods Approval for the study was obtained through the University of Missouri s Institutional Review Board. The study included a survey mailed in the fall of 2000 to 477 residency program directors listed in the American Academy of Family Physicians (AAFP) 2000 Directory of Family Practice Residency Programs. 9 A follow-up survey was sent in 1 month to nonrespondents. Survey Instrument The two-page survey was developed and pilot tested through the use of two electronic listserves (FAMILY-L and the STFM Group on Residency Education listserve). The first question of the survey, based on a consensus opinion regarding the definition of longitudinal residency training, was A longitudinal family practice residency is one that has limited block rotations, with most of resident education supervised by the family medicine faculty in the FPC. How would you describe your residency program? Additional questions in the survey were designed to determine the current status of the program (all or mostly block, half block/half longitudinal, all or mostly longitudinal); interest in future development of a longitudinal program at their site (yes or no); average estimated number of half days per week in the FPC for each residency class; number of immersion weeks in the FPC (weeks spent in the FPC in which half days in clinic were higher than usual); and a description of how (mostly block, half and half, mostly longitudinal), where (mostly outside FPC, half and half, mostly FPC) training occurs for a variety of curricula, and by whom (mostly others, half and half, mostly family physicians). Supplemental information regarding the geographic location of the program and the structure of program was obtained from the AAFP 2000 Directory of Family Practice Residency Programs. Geographical regions were categorized as East North Central, East South Central, Middle Atlantic, Mountain, New England, Pacific, South Atlantic plus Puerto Rico, West North Central, West South Central. Programs were classified, based on information in the directory, as community based, community based and medical school affiliated, community based and medical school administered, medical school based, or military. Data Analysis Data were entered into Microsoft Excel and analyzed using SAS Systems for Windows V8. Standard statistical methods used included descriptive analysis (means + standard deviation, percentages), chi-square for ordinal data, and ANOVA to determine differences between sample means, followed by post-hoc pair-wise comparisons (Tukeys). Missing data was considered as a nonresponse. To determine if a representative sample of programs had responded, respondents were compared to nonrespondents based on geographical location and structure of program. Table 1 Respondents Versus Nonrespondents, Based on Residency Structure and Location Respondent Nonrespondent Community based 14 (4.3%) 11 (7.1%) Community based, medical school affiliated 194 (60.2%) 83 (53.5%) Community based, medical school administrated 64 (19.9%) 35 (22.6%) Medical school based 39 (12.1%) 23 (14.8%) Military program 11 (3.4%) 3 (1.9%) Location 1. East North Central 65 (20.4%) 32 (20.6%) 2. East South Central 18 (5.6%) 9 (5.8%) 3. Middle Atlantic 47 (14.7%) 27 (17.4%) 4. Mountain 19 (6.0%) 10 (6.5%) 5. New England 12 (3.8%) 7 (4.5%) 6. Pacific 41 (12.9%) 17 (11.0%) 7. South Atlantic + Puerto Rico 48 (15.0%) 25 (16.1%) 8. West North Central 30 (9.4%) 14 (9.0%) 9. West South Central 39 (12.2%) 14 (9.0%)

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