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Excellence in Medical Education
Rick Kellerman Gretchen Irwin
Editors
Graduate Medical Education in Family Medicine
From Basic Processes to True Innovation
Excellence in Medical Education
Volume 2
Series Editors
L.JoyHouston, Neuroscience Institute, Springeld,USA MarkKinzie, Portland,USA MatthewMacaluso, Mountain Brook,USA DeborahCowley, Seattle,USA
e Excellence in Medical Education series helps readers understand the requisite structure and programming to ensure a highly functioning and innovative medical education program across levels of educational training and medical specialties. is includes key content areas, such as program administration and teaching methodology. Each book covers basic and advanced principles to help readers meet accreditation requirements, develop clinical and didactic curricula, ensure equitable assessment and evaluation, promote learner and faculty wellness, and implement novel educational approaches.
Rick Kellerman • Gretchen Irwin
Editors
Graduate Medical Education in Family Medicine
From Basic Processes toTrue Innovation
Editors
Rick Kellerman Department of Family and Community Medicine University of Kansas School of Medicine Wichita, KS, USA
Gretchen Irwin Department of Family and Community Medicine University of Kansas School of Medicine Witchita, KS, USA
ISSN 2731-9148 ISSN 2731-9156 (electronic) Excellence in Medical Education ISBN 978-3-031-70740-7 ISBN 978-3-031-70741-4 (eBook)
https://doi.org/10.1007/978-3-031-70741-4
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specic statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
If disposing of this product, please recycle the paper.

Preface

It’s easy to run a family medicine residency program. All you need is:
• residents
• faculty who teach
• patients to see
• and a place to see them
• support staff
• accreditation
• and money to pay everybody who needs to be paid.
Truth be told, family medicine residency programs are complex adaptive learning organiza­tions. They involve people, processes, procedures, buildings, budgets, high stakes, mistakes, mission statements, strategies, schedules, curricula, learners who are called residents, and learners who are called faculty.
Let’s rephrase that introductory sentence. It is deceptively easy to run a family medicine residency program. In fact, the job of the family medicine residency director might be called the most difcult job in all of medicine.
At their best, residency programs are characterized by trust, teaching, learning, mentoring, coaching, feedback, evaluation, continuous quality improvement, and young family physicians working toward competency with an aim of autonomous and independent clinical practice. During this process, residency programs must try to protect patients, the public, and learners.
Day to day, those who run residency programs are challenged by a matrix of overlapping, complex—and sometimes contradictory—laws, rules, regulations, requirements, policies, pro­cedures, and cultures, sometimes resulting in an operational Gordian Knot. For example, the funding of residency education is nearly incomprehensible and most program directors will tell you that the resources at their disposal to optimally run their programs are not sufcient. Family medicine education, in particular, is susceptible to the vagaries of public GME funding. The primary driver of graduate medical education in the United States is the federal Medicare program that gives money to hospitals to train residents. Hospitals thrive on patient admis­sions. An inherent conict is apparent since family medicine, as a medical specialty, tries to keep people healthy and out of the hospital.
The medical school environment is not immune from criticism. Medical schools thrive on approaching problems with a reductionistic mental model. Indeed, the pursuit of research dol­lars and care provided in tertiary care centers (where most medical education occurs) supports a reductionist philosophy. No doubt, this approach to research and the diagnostic process have contributed greatly to scientic progress during the last century. The human genome program and the rapid development of COVID-19 vaccines are recent examples. But reductionism has limitations, as we learned during the COVID-19 pandemic, and family medicine with its broad biopsychosocial mental model, whole-person approach to personalized patient care, and com­munity orientation makes for an imperfect t in traditional post-Flexnerian medical schools.
Family medicine faculty must share a common vision of their goals and their work. They must think systemically and work as a team. Faculty must master clinical medicine, the
v
vi
biopsychosocial model of patient care, and educational andragogy. They must demonstrate leadership, interpersonal skills, and administrative abilities on a daily basis. They must negoti­ate and they must communicate. They must comfort and empathize and, sometimes, they must enforce. They must be comfortable with uncertainty. They must adapt. They must use all of their medical, clinical, leadership, and business management skills. They must wear many hats.
Residency program faculty answer to many people. On any given day a faculty member may deal with a resident who is depressed or who has made a medical mistake or who hasn’t been getting their chart documentation done on time, a patient (or family member) who is upset with the care they received from the inpatient team, a hospital administrator who is reporting that one of the quality of care indicators in the program is running low, a university department chair who asks why the program’s average in-training examination score isn’t higher and what you are going to do about it, a policy-maker who demands to know why your program doesn’t produce more doctors who practice in rural communities, a nancial ofcer concerned about not making budget, a nurse manager who reports that two nurses turned in resignation letters and the X-ray equipment is on the fritz, a program coordinator who tells you the noon conference speaker just canceled and asks if you can give an impromptu lecture, a medical student who asks you to write a letter of recommendation, and a group of residents who complain about the food at morning report. All the while, you wish you had an extra part­ner to share the on-call load.
And those are just the problems that have come up before noon!
Let’s rephrase that introductory sentence again. It is not easy at all to run a family medicine residency program. Running a family medicine residency program is incredibly hard! Running a family medicine residency program is the most difcult job in all of medicine!
At the same time, being a family medicine faculty member is the most important job in medicine. Faculty train family physicians who will care for us, our families, and our neighbors in the future. Faculty develop lifelong relationships with their residents. Some residency grad­uates will call their faculty for clinical, personal, and professional advice years after they leave residency. And there are some residents who will never consult their faculty again, but who remember consciously and subconsciously the lessons their faculty taught them, who imitate the care their faculty role modeled, and who are driven and inspired by something their faculty said.
We all have our stories from residency. Our stories are about our patients. Our stories are about our resident colleagues. Our stories are about the nurses and other healthcare profession­als we worked with on a daily basis. The most enduring stories, though, are about our faculty. The faculty we looked up to. The faculty we wanted to emulate. The faculty who showed us the way when we were confused, lost, scared, or discouraged. When one of us (RK) had a clini­cal dilemma in practice, he would ask himself, “What would Ron Brown (his residency faculty team leader) do in this situation?” We remember the heuristic insights of our program directors and faculty.
While the impact individual faculty have on residents is profound and lifelong, the multi­plier effect on patient care amplies the critical role of each faculty member. Every resident has a professional lifespan of 35years and will care for thousands of patients. Faculty mem­bers will never meet these patients, but they vicariously contribute to their care.
And there is no doubt that the contributions of facultymake a difference. Everyone agrees that the US healthcare system performs sub-optimally. Yet, the evidence is clear that the broad­based services provided by family physicians improve care and health outcomes. Family medi­cine is foundational to a well-functioning healthcare system. International, national, state-by-state, and county-by-county evidence has shown that healthcare systems with a robust generalist workforce (which in the United States translates into family physicians) have better mortality rates, better morbidity rates, better preventive care, better care of chronic illness, improved access, higher quality of care, better cost-effectiveness, fewer health care disparities, and patients like it more! [1–7].
Preface
Preface
vii
Therein lies the vexed question. For all the benets of family medicine, why is the invest­ment in family medicine education—let alone the practice of family medicine—under­resourced and undervalued?
This book won’t answer each of the multitude of day-to-day questions that arise in a busy family medicine residency program. What it will do is give residency program faculty and oth­ers who are interested or involved in residency programs a solid foundation in the underpin­nings of graduate medical education. We asked the authors of each chapter to answer the following question: “What do you want a residency program director and their faculty to know about your subject?” All authors have been family medicine residency program directors or faculty or have been intimately involved in residency program education. They have “been there and done that.”
When we started the process of putting together this book as the COVID-19 pandemic was winding down, we were worried that we might not be able to get enough expert faculty authors to write the variety of chapters we had planned. As it turns out, we were unnecessarily concerned. After putting out a call for authors through the Association of Family Medicine Residency Directors, the Society of Teachers of Family Medicine, and the Association of Departments of Family Medicine and making some personal contacts, we were delighted with the number of program directors and faculty who volunteered to write chapters. Take a moment to read the biographies of the authors of this book. They represent years of experience, expertise, skill, and knowledge in family medicine residency education. They are some of family medicine’s top educators, experts, and leaders. We are gratied by the extra time and effort the authors devoted to their chapters and their willingness to share their knowledge, advice, and wisdom.
We would like to dedicate this book to patients. They teach us and they allow us to learn. Our educational opportunities derive from their vulnerabilities, illnesses, fears, and anxieties. Residency education is not book-learning. It cannot be done in the classroom. Residency edu­cation is the ultimate in on-the-job training. It occurs in the real world with real live patients. There is little room for error in an imperfect system that demands high standards as well as skilled, conscientious, hard-working, and dedicated faculty and residents. To sum it all up, graduate medical education is what the future of family medicine—and the care millions of patients receive from their family physicians each year—is all about.
Witchita, KS, USA RickKellerman GretchenIrwin

References

1. Institute of Medicine (US) Committee on the Future of Primary Care. In: Donaldson MS, Yordy KD,
Lohr KN, Vanselow NA, editors. Primary care: America’s health in a new era. Washington, DC: National
Academies Press (US); 1996. PMID: 25121221.
2. Stareld B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q.
2005;83(3):457–502. https://doi.org/10.1111/j.1468- 0009.2005.00409.x. PMID: 16202000; PMCID:
PMC2690145.
3. Friedberg MW, Hussey PS, Schneider EC.Primary care: a critical review of the evidence on quality and
costs of health care. Health Aff. 2010;29(5);766–72. https://doi.org/10.1377/hlthaff.2010.0025.
4. Shi L.The impact of primary care: a focused review. Scientica (Cairo). 2012;2012:432892. https://doi.
org/10.6064/2012/432892. Epub 2012 Dec 31. PMID: 24278694; PMCID: PMC3820521.
5. Ofce of Disease Prevention and Health Promotion. Social determinants of health. Healthy People 2030.
Access to Primary Care Literature Review. U.S.Department of Health and Human Services. https://health.
gov/healthypeople/priority- areas/social- determinants- health/literature- summaries/access- primary- care
6. National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division; Board on
Health Care Services, Committee on Implementing High-Quality Primary Care. In: Robinson SK, Meisnere
M, Phillips RL Jr, McCauley L, editors. Implementing high-quality primary care: rebuilding the foundation
of health care. Washington, DC: National Academies Press (US); 2021. PMID: 34251766.
7. Jabbarpour Y, Petterson S, Jetty A, Byun H.The health of US primary care: a baseline scorecard tracking
support for high-quality primary care. The Milbank Memorial Fund and The Physicians Foundation, 22 Feb
2023.

Contents

Part I Important Specialty Organizations for Family Medicine
Graduate Medical Education
1 American Academy of Family Physicians: Growing Family
Medicine’s Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Karen B. Mitchell
2 American Board of Family Medicine’s Commitment to Residency
Education: Advancing Excellence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Gerald Fetter and Warren Newton
3 American College of Osteopathic Family Physicians: Osteopathic
Postgraduate Medical Education in Family Medicine . . . . . . . . . . . . . . . . . . . . . . 15
Thomas N. Told, Rob Danoff, Kenneth A. Heiles, and Shirley L. Sharp
4 Association of Departments of Family Medicine: Assisting
Family Medicine Graduate Medical Education Programs to Reach
Their Full Potential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
F. David Schneider
5 Association of Family Medicine Administration and the Key Role
of the Residency Program Coordinator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Katherine Kellerman
6 Association of Family Medicine Residency Directors: A Collective
Voice for Family Medicine Residency Program Directors . . . . . . . . . . . . . . . . . . 29
Deborah Clements
7 The North American Primary Care Research Group: Unlocking
Scholarship Through A Network of Support for Family Medicine
Residency Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Stephen K. Stacey, Wendy B. Barr, and Diane M. Harper
8 The Society of Teachers of Family Medicine: The Professional
Home for Family Medicine Educators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Heather L. Paladine
Part II Infrastructure for a Successful Family Medicine Residency Program
9 Family Medicine Residency Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Grant S. Hoekzema, Colleen K. Cagno, and Shantie Harkisoon
10 Graduate Medical Education Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Kenton I. Voorhees, Daniel Burke, Louis Sanner, and Alan B. Douglass
ix
x
Part III Curriculum Design and Assessment
11 Designing Assessment to Meet the Challenge of Competency-Based
Medical Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
Drew Keister and Veronica Brohm
12 Core Competencies, Milestones, and Entrustable Professional Activities . . . . . . . 107
KrisEmily McCrory
13 A Practical Approach to Curriculum Development . . . . . . . . . . . . . . . . . . . . . . . 121
Bethany D. Panchal and Ericka Bruce
Part IV Resident Issues
14 Recruitment of Residents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
P. T. Dooley and M. P. Williams
15 Resident Integration: Orientation and Onboarding . . . . . . . . . . . . . . . . . . . . . . . . 149
Bharat Gopal and Tina Kenyon
16 International Medical Graduates in Family Medicine Education . . . . . . . . . . . . 159
Robert C. Langan
17 Resident Evaluation, Advancement, and Program Completion . . . . . . . . . . . . . . 165
Wanda Cruz-Knight and Miriam Whiteley
Contents
18 Addressing Medical Resident Performance Issues: Strategies
for Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Stephen M. Carek, John F. Emerson, and Peter J. Carek
Part V Faculty Issues
19 Faculty Recruitment: Best Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187
Rebecca Martin, Shantie Harkisoon, and London Muse
20 Faculty Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 197
John F. Emerson, Stephen M. Carek, and Peter J. Carek
21 Faculty Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205
Julie A. Blaszczak and Karl T. Rew
Part VI The Learning Environment
22 Promoting Diversity, Equity, Inclusion and Anti-oppression (DEIA) . . . . . . . . . 219
Diana Coffa, Kirsten Y. Day, Randy Jackson, Lydia Leung, Megan Mahoney, Manuel Tapia, and Sharon Washington
23 Developing a Healthy Learning Environment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
Kimberley Miller, Erin O’Connor, and Barbara Wolf
24 Resident and Faculty Well-Being and Burnout . . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Lauren Brown-Berchtold and Caitlin Matthis
25 Interprofessional Education and Teamwork . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Ashley R. Wilk