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16 International Medical Graduates inFamily Medicine Education
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Holistic reviews are dened by the AAMC as “exible, individualized ways of assessing an applicant’s capabilities by
which balanced consideration is given to experiences, attributes, and academic metrics.” [8] Holistic reviews have been
recommended by the AAMC for medical school applicants
for over 15years [9] and for selecting academic medical faculty [10]. As a group, family medicine has long been a proponent of “looking beyond the numbers” and endorsing a
comprehensive review of residency applicants that includes
the identication of characteristics that are important to the
program, the sponsoring institution, the community, and the
specialty in general. An example of an approach to a holistic
review can be found in the Program Director toolbox of the
Association of Family Medicine Residency Directors
(AFMRD) website (www.afmrd.org).
IMG candidates have often displayed determination, perseverance, exibility, and ingenuity throughout their journey,
all characteristics which are highly valuable in family physicians. With an increased emphasis on master adaptive learners by the family medicine community [11], IMG candidates
are ideally suited to enter training and excel in this model,
beneting themselves, their patients, and the community at
large.
Work Visas forIMGs
A particular consideration for programs hiring non-US citizen IMGs is the issue of work visas. There are two main
types of work visas for resident physicians, the J-1 and the
H-1B.Visa status should be discussed during the interview
process and is easily found on the main page of the ERAS
application. The decision to sponsor a resident who requires
a work visa is a complex one that should be discussed with
the designated institutional ofcial (DIO) and the sponsoring
institution prior to the interview season. If a candidate is
matched who requires a work visa, the process should begin
as soon as possible following Match Day. Often, using an
immigration lawyer can be worth the expense to the resident
and the hospital.
A J-1 work visa is dened as “(a work visa that) is authorized for those who intend to participate in an approved program for the purpose of teaching, instructing or lecturing,
studying, observing, conducting research, consulting, demonstrating special skills, receiving training, or to receive
graduate medical education or training [12].” It is considered
a nonimmigrant visa and allows for up to 7years of training.
It must be renewed annually and there are travel restrictions
after visa stamp expiration. Passing the USMLE Step 3 is not
required for a J-1 visa. At the conclusion of training, the physician must either return to their country of residence for a
period of 2 years or obtain a J-1 waiver to remain in the
United States [13].
In contrast, an H-1B visa allows employers “to hire nonimmigrant aliens as workers in specialty occupations [14].”
While classied as a nonimmigrant work visa, it does allow
for the possibility of obtaining permanent residency in the
United States. It allows for up to 6years of training and the
USMLE Step 3 examination must be passed as a requirement
of obtaining an H-1B.While a J-1 visa is sponsored by the
ECFMG, an H-1B is sponsored by the training program and
can have signicant cost associated with this sponsorship.
Prior to 2013, programs had the option to prematch candidates outside of the National Residency Match Program
(NRMP), which allowed for additional time for visa processing for candidates. With the current “all in” policy for the
NRMP [15], the time frame for completing the required
documentation has been compressed. This, together with the
cost of sponsoring an H-1B visa, has resulted in many programs prioritizing US citizens and permanent residents for
positions over non-US citizen IMGs.
Onboarding andAcclimation
For many candidates who successfully match with a residency program, the transition from medical student to resident physician is lled with feelings of anticipation,
excitement, and an appropriate amount of apprehension. For
IMGs who are US citizens or permanent residents, the experience of transition is often very similar to that of US allopathic or osteopathic graduates. Although some US citizen
IMGs will have graduated off cycle or not matched during
their rst year of eligibility, many will experience similar
events to their non-IMG colleagues following Match Day:
completing rotations, graduation, and relocation to the residency program location. In general, the support that they will
need will be comparable to the onboarding and orientation
processes of residents who graduated from a US medical
school.
With non-US citizen IMGs, however, the process may differ in several aspects. These physicians may need to coordinate relocation from another country, may be leaving well
developed family and friend support networks, and may
experience nancial pressures beyond those of their classmates. Many non-US citizen IMGs are older and have children, which may make them feel isolated and different
compared to the rest of their class. If they were living in
another country prior to starting residency, they may also
require time during the beginning of training to complete
tasks such as obtaining a driver’s license, attending immigration appointments, establishing daycare or schooling for
children, and moving into housing. Perhaps the most important thing a program can do for their non-US citizen IMGs is
to create a safe and open environment where questions can
be asked without fear of looking foolish. Programs with pre-
162
R. C. Langan
vious residents who were non-US citizen IMGs may have
more experience with common issues and concerns and be
able to frankly but supportively discuss these issues with
newly matched residents. Similarly, assigning a current resident as a mentor to a non-US citizen IMG during the transition phase can also have a benecial effect, especially if the
mentor is a non-US citizen IMG themselves.
A exible orientation schedule can help non-US citizen
IMGs with the time to address some of the appointments
they need without forcing them to miss experiences and
opportunities that their classmates attend. Programs should
consider in-person or virtual sessions to explain the fundamentals of payment and documentation for the US health
system, which is likely very different from the system is
which they practiced or were trained. Simulation sessions
involving common patient scenarios can be a great way for
non-US citizen IMGs to practice common interactions with
immediate, formative feedback from their faculty. Programs
can host gatherings where residents share food and stories
from their heritage as a way of facilitating camaraderie
among the classes and sponsor tours of the community to
help them understand the communities and dynamics where
they are practicing [16]. Regularly scheduled meetings with
their advisors should focus on acclimation to the United
States and US healthcare in addition to the usual residency
assessments. Behavioral medicine faculty can also assist new
residents with the behavioral and psychological effects of the
transition to residency.
Education of faculty is another key component for programs that want to help IMGs succeed in their transition to
residency and beyond. Current faculty who are themselves
IMGs are a wonderful resource for programs. They can assist
with planning faculty development sessions, and they can
serve as mentors both for incoming IMG residents and other
non-IMG faculty. However, programs should avoid a “one size
ts all” approach, as many IMGs want a US-trained faculty
member to serve as their mentor. Talking to current and former
IMG residents is another potential source of information for
helping them make the transition, as programs may not realize
the challenges that their new residents are facing. Finally, utilizing information from other programs in a learning collaborative or from national organizations such as the AFMRD can
provide a useful framework to help with onboarding.
Programs should be aware of bias and discrimination that
may occur toward IMGs from patients, staff, fellow residents, faculty, or off service rotations. IMGs bring a depth
and breadth of experience that enhances the quality of the
program, but program directors need to work to create environments that are welcoming and inclusive of residents from
a variety of backgrounds. This must be a commitment shared
by the sponsoring institution and the DIO, and policies must
be in place to provide adequate education and condential
means of addressing concerns.
Conclusion
IMGs are a heterogeneous group of physicians who represent a signicant portion of the family medicine residency
positions lled and a signicant portion of practicing physicians in the United States. Programs should be aware of the
unique circumstances surrounding an individual physician’s
journey to residency training, and the opportunities to assist
with their transition to practice in the United States. The
rewards of such a relationship for the individual, the program, and the community at large are great. Family medicine
can only be stronger with everyone having a seat at the table.
References
1. 2021 Physician Specialty Data Report. Association of American
Medical Colleges. https://www.aamc.org/data- reports/workforce/
data/active- physicians- international- medical- graduates- imgsspecialty- 2021. Accessed 11 Aug 2023.
2. 2023 Match Results for Family Medicine. American Academy
of Family Physicians. https://www.aafp.org/students- residents/
residency- program- directors/national- resident- matching- programresults.html. Accessed 11 Aug 2023.
3. NRMP Match 20-year data for Family Medicine. American
Academy of Family Physicians. https://www.aafp.org/dam/AAFP/
documents/medical_education_residency/the_match/NRMPMatch- 20- Year- Data- 2023.xlsx&wdOrigin=BROWSELINK.
Accessed 11 Aug 2023.
4. History of the ECFMG. Educational Commission for Foreign
Medical Graduates. https://www.ecfmg.org/about/history.html.
Accessed 11 Aug 2023.
5. ECFMG Recognized Accreditation Policy. World Federation for
Medical Education https://wfme.org/recognition/ecfmg- 2023/.
Accessed 11 Aug 2023.
6. Work to relaunch USMLE Step 2 CS discontinued. United States
Medical Licensing Examination. https://www.usmle.org/work-
relaunch- usmle- step- 2- cs- discontinued. Accessed 11 Aug 2023.
7. Assessment of communication skills including English language prociency. Educational Commission for Foreign Medical
Graduates. https://www.ecfmg.org/certication- pathways/oet.html.
Accessed 11 Aug 2023.
8. Coleman AL, etal. Roadmap to diversity and educational excellence: key legal and educational policy foundations for medical schools. Washington, DC: A Report for the Association of
American Medical Colleges; 2014.
9. Conrad SS, Addams AN, Young GH. Holistic review in medical school admissions and selection: a strategic, mission-driven
response to shifting societal needs. Acad Med. 2016;91:1472–4.
10. Harris TB, Thomson WA, Moreno NP, et al. Advancing holistic review for faculty recruitment and advancement. Acad Med.
2018;93:1658–62.
11. Edje L, Price DW. Training future family physicians to become
master adaptive learners. Fam Med. 2021;53(7):559–66.
12. Exchange Visitors. US Citizenship and Immigration Services.
https://www.uscis.gov/working- in- the- united- states/students- andexchange- visitors/exchange- visitors. Accessed 11 Aug 2023.
13. Waiver of the exchange visitor two-year home-country physical presence requirement. US Department of State. https://travel.
state.gov/content/travel/en/us- visas/study/exchange/waiver- of- theexchange- visitor.html/. Accessed 11 Aug 2023.
16 International Medical Graduates inFamily Medicine Education
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14. H-1B Program. US Department of Labor. https://www.dol.gov/
agencies/whd/immigration/h1b. Accessed 11 Aug 2023.
15. Main Residency Match All in Policy. National Residency Match
Program. https://www.nrmp.org/policy/main- residency- match- all-
in- policy/#:~:text=Under%20the%20NRMP%20All%20In%20
Policy%2C%20any%20program,of%20positions%20for%20
which%20the%20program%20is%20accredited. Accessed 11 Aug
2023.
16. Chang AY, Bass TL, Duwell M, etal. The impact of “see the City
you serve” eld trip: an educational tool for teaching social determinants of health. J Grad Med Educ. 2017;9(1):118–22.
Resident Evaluation, Advancement,
andProgram Completion
WandaCruz-Knight andMiriamWhiteley
17
Key Points
• Comprehensive, standardized, multifaceted evaluations
promote continuous learning, professional development
and the acquisition of skills necessary to provide high
quality patient care.
• A collaboratively developed Individual Learning Plan
provides a framework for self directed learning.
• The Clinical Competency Committee (CCC) plays a pivotal role in the resident evaluation process.
Graduate medical education has undergone a dramatic evolution from a time-based process to a competency-based system, aiming to produce a physician workforce to further the
quadruple aim in healthcare [1]. The goal of family medicine
residency education, in particular, is to produce physicians
who can deliver patient-centered individual, community, and
population-based care that advances health equity is costeffective and enhances the joy in practice. Resident evaluation in a competency based system is grounded on workplace
assessment of a resident in the authentic clinical environments in which day-to-day resident education occurs.
The Accreditation Council for Graduate Medical
Education (ACGME) has created a framework for workplace
assessment of resident performance using the ACGME milestones [2]. Milestones are composed of competencies and
sub-competencies, which set out progressive benchmarks,
measured as observable behaviors, by which residency faculty mark the progress of their trainees toward independent
W. Cruz-Knight (*)
Department of Family Medicine, Endeavor Health,
Evanston, IL, USA
Department of Family Medicine, University of Chicago Pritzker
School of Medicine, Chicago, IL, USA
e-mail: WCruz-Knight@northshore.org
M. Whiteley
University of Chicago Pritzker School of Medicine,
Chicago, USA
practice [3]. For residents, the milestones provide a transparent and descriptive roadmap for developing the skills
expected for independent practice. Milestones encourage
informed self-assessment and self-directed learning and help
to facilitate meaningful feedback to the resident. These milestones collectively encompass the essential competencies
and skills required for the practice of family medicine, ensuring that residents are well-prepared to practice independently
upon program completion [3].
The ACGME milestones provide a standardized approach
to evaluate resident competencies across six core areas:
patient care, medical knowledge, practice-based learning
and improvement, interpersonal and communication skills,
professionalism, and systems-based practice [3]. Each core
area is further divided into sub-competencies that reect specic skills and behaviors expected of residents at different
stages of their training. The milestones are used to evaluate
residents by providing a standardized and objective framework for assessing their performance. They offer clear
expectations and benchmarks against which program directors and faculty can measure residents’ progress. Evaluators
use the milestones to evaluate the residents’ level of prociency in each sub-competency, providing a comprehensive
and detailed account of their abilities.
Family medicine residency programs can use the ACGME
milestones as a guide to ensure that residents receive comprehensive and standardized evaluations [2]. Residency programs can use these milestones to create evaluation criteria
and rating scales to evaluate formative and summative performance and achievement of family medicine core competencies. Table 17.1 is an example of a rating scale used to
evaluate residency performance.
This evaluation process promotes continuous learning,
professional development, and the acquisition of the skills
and knowledge necessary to provide high-quality patient
care in family medicine. The evaluation process typically
involves multiple assessment methods. Direct observation
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_17
165
166
W. Cruz-Knight and M. Whiteley
Table 17.1
Competency Evaluation criteria Rating scale
Clinical knowledge Demonstrates a solid understanding of
Diagnostic skills Effectively collects and analyzes patient
Treatment planning Develops comprehensive and individualized
Evaluation of residency performance
medical concepts and evidence-based
guidelines
Applies clinical knowledge to make
appropriate diagnostic and treatment decisions
information
Formulates accurate differential diagnoses
Orders appropriate diagnostic tests
treatment plans based on patient factors and
evidence-based medicine
Considers patient preferences and shared
decision-making
Not observed: The resident’s performance in
clinical knowledge was not observed or could
not be assessed
Developing: The resident has a basic
understanding of medical concepts but
requires further development and supervision
Competent: The resident consistently
demonstrates prociency in clinical
knowledge
Procient: The resident consistently exceeds
expectations in clinical knowledge,
demonstrating advanced understanding and
application of medical concepts
Expert: The resident consistently demonstrates
exceptional performance in clinical
knowledge, exceeding the level of prociency
expected of a graduating resident
Not observed: The resident’s performance in
diagnostic skills was not observed or could
not be assessed
Developing: The resident demonstrates basic
skills in data collection, formulation of
differential diagnoses, and ordering diagnostic
tests but requires further development and
supervision.
Competent: The resident consistently
demonstrates prociency in diagnostic skills
Procient: The resident consistently exceeds
expectations in diagnostic skills,
demonstrating advanced ability in data
collection, formulation of differential
diagnoses, and ordering appropriate diagnostic
tests
Expert: The resident consistently demonstrates
exceptional performance in diagnostic skills,
exceeding the level of prociency expected of
a graduating resident
Not observed: The resident’s performance in
treatment planning was not observed or could
not be assessed
Developing: The resident demonstrates basic
skills in developing treatment plans but
requires further development and supervision.
Competent: The resident consistently
demonstrates prociency in treatment
planning
Procient: The resident consistently exceeds
expectations in treatment planning,
demonstrating advanced ability in developing
comprehensive and individualized treatment
plans
Expert: The resident consistently demonstrates
exceptional performance in treatment
planning, exceeding the level of prociency
expected of a graduating resident
(continued)
17 Resident Evaluation, Advancement, andProgram Completion
Table 17.1 (continued)
Competency Evaluation criteria Rating scale
Procedural skills Demonstrates prociency in performing
common procedures within the scope of
family medicine
Adheres to proper technique and safety
protocols
Chronic disease management Effectively manages chronic diseases,
including monitoring patients’ progress and
adjusting treatment plans
Provides patient education and selfmanagement support
Acute care management Promptly assesses and manages acute medical
conditions
Triages, stabilizes, and initiates appropriate
interventions
Preventive care Emphasizes preventive care by promoting
health screenings, immunizations, and
lifestyle modications
Not observed: The resident’s performance in
procedural skills was not observed or could
not be assessed
Developing: The resident demonstrates basic
procedural skills but requires further
development and supervision
Competent: The resident consistently
demonstrates prociency in procedural skills
Procient: The resident consistently exceeds
expectations in procedural skills,
demonstrating advanced prociency and
adherence to safety protocols
Expert: The resident consistently demonstrates
exceptional performance in procedural skills,
exceeding the level of prociency expected of
a graduating resident
Effectively manages chronic diseases,
including monitoring patients’ progress and
adjusting treatment plans
Provides patient education and selfmanagement support
Not observed: The resident’s performance in
acute care management was not observed or
could not be assessed
Developing: The resident demonstrates basic
skills in acute care management but requires
further development and supervision.
Competent: The resident consistently
demonstrates prociency in acute care
management
Procient: The resident consistently exceeds
expectations in acute care management,
demonstrating advanced ability in assessing
and managing acute medical conditions
Expert: The resident consistently demonstrates
exceptional performance in acute care
management, exceeding the level of
prociency expected of a graduating resident
Not observed: The resident’s performance in
preventive care was not observed or could not
be assessed
Developing: The resident demonstrates basic
skills in promoting preventive care but
requires further
167
allows faculty members to assess residents’ clinical skills,
such as history-taking, physical examination, and procedural
competence. It also provides an opportunity to evaluate residents’ ability to communicate effectively with patients, families, and the healthcare team.
Likewise, multisource feedback from attending physicians, colleagues, patients and other healthcare team members is critical to provide a complete view of residents’ skills,
strengths, and areas for improvement. The milestones provide a common language and framework for communication
and feedback among evaluators, residents, and program
directors. They facilitate meaningful discussions about the
residents’ strengths, areas for improvement, and progress
toward achieving the desired competencies. The milestones
also help identify areas where additional support, guidance,
or educational interventions may be needed to help the residents reach the expected level of prociency. Documentation
is an essential component of any evaluation process.
The evaluation process is comprehensive and multifaceted, ensuring a well-rounded assessment of the resident’s
performance. It allows faculty members to identify the resident’s strengths, provide constructive feedback, and address
any areas of concern. The evaluation process also serves as
an opportunity for residents to reect on their performance
and identify areas for growth [1]. Residents should be
encouraged to actively engage in their evaluation process by
reecting on their performance, identifying areas for
improvement, and developing strategies to enhance their
168
W. Cruz-Knight and M. Whiteley
skills and knowledge. The use of an independent learning
plan (ILP) will engage residents in reection and selfevaluation, creating a process for lifetime learning [4].
The Individual Learning Plan (ILP) is a personalized roadmap that outlines each FM resident’s learning objectives and
goals [2, 5]. It is developed collaboratively between the resident and their faculty advisor or program director. The ILP
considers the resident’s prior experience, strengths, areas for
improvement, and career aspirations. It serves as a guide to
ensure the resident receives a well-rounded and comprehensive training experience. The ILP helps residents identify their
learning needs and set specic goals to address those needs. It
provides a framework for residents to explore various clinical
areas, procedural skills, research opportunities, and other
aspects of FM practice. By tailoring the ILP to the individual
resident, it promotes self-directed learning and encourages
residents to take ownership of their educational journey.
The ILP and resident evaluation are closely linked. The
ILP serves as a guide for residents to identify their learning
needs and set goals, while the evaluation process provides
feedback on their progress toward those goals. The ILP is
periodically reviewed and updated based on the evaluation
outcomes, ensuring that the resident’s educational plan
remains relevant and aligned with their evolving needs.
The ILP and resident evaluation are crucial for the resident’s professional development and program accreditation.
These tools provide evidence of the resident’s progress, competency, and adherence to the required standards. They also
serve as a foundation for mentoring and career planning, as
residents can use the feedback and evaluation outcomes to
identify areas for improvement and plan their future learning
opportunities.
The Individual Learning Plan and resident evaluation are
integral to the FM training program. The ILP supports personalized learning and goal setting, while the evaluation process provides ongoing feedback and assessment of the
resident’s progress. Together, these tools promote continuous learning, professional development, and the acquisition
of the necessary skills for successful FM practice.
Data points may include performance evaluations from
attending physicians, feedback from nurses, other team
members, patients, colleagues, and the residents’ selfassessments. By thoroughly examining these assessments,
the CCC can comprehensively understand each resident’s
strengths and areas for improvement.
Based on the assessment data, the CCC engages in a dialogue to discuss and determine each resident’s progress.
Such dialogue is enhanced when members of the CCC represent diverse perspectives and expertise. Through this discussion, the CCC aims to provide an accurate and well-rounded
evaluation of the resident’s clinical competency. The CCC
also plays a crucial role in identifying and addressing any
potential concerns or areas of deciency in a resident’s performance. If a resident is struggling in a particular aspect of
their training, the CCC can recommend targeted interventions and educational plans to help the resident improve and
meet the required competencies. This personalized approach
ensures that each resident receives the necessary support and
guidance to excel in their training.
Furthermore, the CCC is responsible for documenting
and reporting the evaluation outcomes. These reports are
essential for program accreditation, as they provide evidence
of the resident’s progress and the effectiveness of the training
program [6]. The CCC’s documentation also serves as a
valuable resource for the residents, highlighting their
achievements and areas of growth and helping them in their
career development.
Overall, the CCC plays a pivotal role in the resident evaluation process in family medicine. The CCC ensures that
residents receive comprehensive evaluations and the necessary support to become competent and successful family
medicine practitioners by reviewing assessment data, engaging in dialogue, addressing concerns, and documenting outcomes [2].
Attestation ofProgram Completion inFamily
Medicine
Understanding theRole oftheClinical
Competency Committee (CCC) inResident
Education
The Clinical Competency Committee (CCC) plays a crucial
role in the resident evaluation process in Family Medicine
(FM). The CCC is a dedicated group of faculty members
responsible for assessing and evaluating the clinical competence of FM residents throughout their training program [4].
One of the primary functions of the CCC is to review and
analyze the assessment data collected on each resident [4].
The attestation of program completion in family medicine is
an essential step in residency training, as it signies that a
resident has completed all the requirements set forth by the
Accreditation Council for Graduate Medical Education
(ACGME) and is eligible for family medicine board certication [2, 7]. A robust residency evaluation is at the core of
evaluating and attesting that the residents have met the
requirements needed for program promotion. These requirements are designed to ensure that residents receive comprehensive training in all aspects of family medicine, including
clinical knowledge, patient care, procedural skills, professionalism, and communication.
17 Resident Evaluation, Advancement, andProgram Completion
169
Once a resident has completed all the ACGME requirements, the program director attests to program completion.
Such attestation should take the form of a nal summary that
is provided to the resident and is available for future verication purposes. Many programs utilize the Verication of
Graduate Medical Education Training Form that was created
through collaboration of the National Association Medical
Staff Services, American Hospital Association, Accreditation
Council of Graduate Medical Education and Organization of
Program Director Associations [5]. The nal summary document indicates that the resident has met the necessary criteria
for graduation from the family medicine residency program.
It is an important credential required for licensure and credentialing purposes.
The American Board of Family Medicine (ABFM)
requires residency program directors to attest to the following for each resident graduate within the Resident Training
Management Software. Each graduate must have completed
36 full calendar months of training with 12months each at
the PGY-1, PGY-2, and PGY-3 levels [8]. Further, the nal
2years of training must be completed at the same accredited
program to fulll requirements for a continuity of care experience. Unless a waiver is granted by the ABFM in extraordinary circumstances, residents who transfer programs after
the start of the PGY-2year will be required to extend training
to complete 24months in the new program [8].
Historically, program directors needed to attest only that a
resident had completed all ACGME requirements in order to
verify a candidate to complete the ABFM certication examination. However, starting in June 2024, residency program
directors will be asked to attest that residents have completed
residency and are competent in all core outcomes. Eventually,
program directors will be asked to attest that each graduate is
competent in fteen core outcomes. To implement the core
outcome attestation, ve core outcomes will be added to the
attestation for each graduating class from June 2024 through
June 2026. When complete, the fteen core outcomes will
include the following [5]:
• Practice as personal physicians, providing rst contact,
comprehensive and continuity care, to include excellent
doctor-patient relationships, excellent care of chronic dis-
ease and routine preventive care and effective practice
management.
• Diagnose and manage acute illness and injury for people
of all ages in the emergency room or hospital.
• Provide comprehensive care of children, including diag-
nosis and management of the acutely ill child and routine
preventive care.
• Develop effective communication and constructive rela-
tionships with patients, clinical teams, and consultants.
• Model Professionalism and be trustworthy for patients,
peers, and communities.
• Practice as personal physicians, to include care of women,
the elderly, and patients at the end of life, with excellent
rate of continuity and appropriate referrals.
• Provide care for low-risk patients who are pregnant, to
include management of early pregnancy, medical
problems during pregnancy, prenatal care, postpartum
care and breastfeeding, with or without competence in
labor and delivery.
• Diagnose and manage of common mental health problems in people of all ages.
• Perform the procedures most frequently needed by
patients in continuity and hospital practices.
• Model lifelong learning and engage in self-reection.
• Practice as personal physicians, to include musculoskeletal health, appropriate medication use and coordination
of care by helping patients navigate a complex health
system.
• Provide preventive care that improves wellness, modies
risk factors for illness and injury, and detects illness in
early, treatable, stages for people of all ages while supporting patients’ values and preferences.
• Assess priorities of care for individual patients across the
continuum of care—in-ofce visits, emergency, hospital,
and other settings, balancing the preferences of patients
and medical priorities.
• Evaluate, diagnose, and manage patients with undifferentiated symptoms, chronic medical conditions, and multiple comorbidities.
• Effectively lead, manage, and participate in teams that
provide care and improve outcomes for the diverse populations and communities they serve.
Innovations inFamily Medicine Resident
Evaluation andProgram Completion
As the eld of family medicine continues to evolve, there is
a need for innovation in the methods used to evaluate residents and ensure that they are competent to practice medicine without direct supervision. There is a need for residency
programs to engage in ongoing exploration of innovative
approaches and advancements in resident evaluation and
program completion within the realm of family medicine.
From incorporating technology to promoting holistic assessments, these innovations aim to enhance the learning experience, provide more accurate evaluations, and better prepare
residents for independent practice [9, 10].
Advancements in technology have revolutionized the way
residents are evaluated. Traditional evaluation methods, such
as written exams and subjective assessments, are now being
supplemented or replaced by digital tools and platforms.
Online platforms allow real-time feedback, self-assessment
170
W. Cruz-Knight and M. Whiteley
modules, and interactive case-based evaluations.
Additionally, virtual reality simulations and telemedicine
experiences provide residents hands-on training and evaluation opportunities, even remotely.
The shift toward competency-based education has led to
innovations in resident evaluation. Instead of relying solely
on time-based assessments, programs now focus on evaluating specic competencies required for independent practice.
These competencies are assessed through direct observation,
multisource feedback, and objective structured clinical
examinations (OSCEs). This approach ensures that residents
are evaluated on their ability to perform essential tasks and
skills rather than simply completing a predetermined number
of rotations [11].
There is a growing emphasis on the holistic evaluation of
residents beyond medical knowledge and technical skills.
Innovations in resident evaluation now include assessing
communication skills, cultural competency, empathy, and
professionalism. Tools such as standardized patient encounters and patient satisfaction surveys provide valuable insights
into residents’ interpersonal skills and ability to provide
patient-centered care.
Traditionally, resident evaluations have been conducted at
specic intervals or the end of rotations. However, there is a
shift toward longitudinal assessments that provide a more
comprehensive view of residents’ progress over time. This
approach allows for ongoing feedback, identication of areas
for improvement, and tailored learning opportunities
throughout the residency program. Longitudinal assessments
also promote self-reection and self-directed learning,
empowering residents to take ownership of their professional
development [1].
Innovative programs now incorporate mentorship and
coaching as integral components of the evaluation process
[12]. Mentors provide residents guidance, support, and personalized feedback, helping them navigate challenges and
optimize their learning experience. This approach fosters a
culture of continuous improvement and creates a supportive
environment for residents to thrive.
Innovation in family medicine resident evaluation and
program completion is crucial for preparing residents to
meet the evolving healthcare needs of their patients. By
leveraging technology, embracing competency-based assessments, promoting holistic evaluations, implementing longi-
tudinal assessments, and fostering mentorship and coaching,
family medicine residency programs can ensure that residents are well-prepared for independent practice. These
innovations enhance the learning experience and contribute
to the overall quality of care provided by family physicians.
References
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2021;34(6):1268–71.
2. American Board of Family Medicine. Resident evaluation in family medicine. 2021. Retrieved from https://www.theabfm.org/
residency/evaluation.
3. Milestones Guidebook for Residents and Fellows. 2020.
https://www.acgme.org/globalassets/PDFs/Milestones/
MilestonesGuidebookforResidentsFellows.pdf.
4. American Academy of Family Physicians. Clinical competency
committees in family medicine: a resource guide. 2021. Retrieved
from https://www.aafp.org/clinical- competency- committees/
family- medicine- resource- guide.
5. Newton W, Magill M, Barr W, Hoekzema GS, Karuppiah S,
Stutzman K. Implementing competency based ABFM board eligibility. J Am Board Fam Med. 2023;36(4):703–7. https://doi.
org/10.3122/jabfm.2023.230201R0.
6. Accreditation Council for Graduate Medical Education. Clinical
competency committees. 2020. Retrieved from https://www.acgme.
org/globalassets/acgmeclinicalcompetencycommitteeguidebook.
pdf.
7. Christopher J, Wehner P, Dailey C, O’Connor N, Kleshinski J,
Shapiro JI.Information within residency monthly evaluation forms
at two institutions. Med Educ Online. 2019;24:1. https://doi.org/10
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8. American Board of Family Medicine. Family medicine training requirements 2024. Retrieved from https://www.theabfm.org/
become- certied/initial- training- requirements.
9. Stern D. Measuring medical professionalism. Oxford University
Press; 2005. Competencies: professionalism and interpersonal and
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10. Garvin RD, Carney PA.Residency education redesign: the interplay
of innovation and standardization. Fam Med. 2021;53(7):611–7.
https://doi.org/10.22454/FamMed.2021.862031.
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JT, Co JPT, Weinstein DF, Pusic MV. Reimagining the clinical competency committee to enhance education and prepare
for competency-based time-variable advancement. J Gen Intern
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022- 07515- 3. Epub 2022 Apr 20. PMID: 35445932; PMCID:
PMC9021365. Retrieved from https://pmc.ncbi.nlm.nih.gov/
articles/PMC9021365
12. Galke CL, Swoyer JW. Mentoring in family medicine education.
Ann Fam Med. 2020;18(2):182. https://doi.org/10.1370/afm.2527.
Addressing Medical Resident
Performance Issues: Strategies
forImprovement
StephenM.Carek, JohnF.Emerson, andPeterJ.Carek
18
Key Points
• As stewards of medical education, our commitment to
fostering a culture of continuous improvement ensures
that residents not only overcome challenges but also
emerge as skilled, compassionate, and competent physicians who positively impact patient care and the broader
healthcare landscape.
• Our objective is to align selection and assessment systems
with the desired outcomes and graduate qualities, with the
aim of developing independent, high-quality family physicians who can meet the needs of their communities.
• In our study, we collected relevant performance data from
a variety of individuals that the resident worked with in
both clinical and nonclinical situations.
• Identifying a root etiology or cause of concerning behaviors or problems is important to correctly identify and
remediate resident performance with the goal of developing a high-functioning, independent, and high-quality
family physician.
• When creating a remediation plan or strategy, one should
avoid simply “giving more time” to repeat the resident’s
previous experience, offering general or vague advice, or
merely “teaching to the test;” rather, one should provide
support and develop goals for future assessment.
• Program director responsibilities include providing clear
expectations for performance, laying out a timeline to
meet expectations and explaining consequences if expectations are not met, documenting concerns, and organizing reassessment after remediation is concluded to assess
the effectiveness of the intervention.
• Trainees in remediation should undergo intensive, longitudinal tutoring with emphasis on study skills, collabora-
S. M. Carek (*) · J. F. Emerson · P. J. Carek
University of South Carolina School of Medicine Greenville,
Greenville, SC, USA
e-mail: Stephen.Carek@prismahealth.org
tively designed performance plans, frequent high-quality
feedback, and individualized assessment.
• It is necessary to explore the multiple potential causes of
learner struggle beyond education or workplace issues.
• Proactive interventions should be staged with struggling
residents—one should not rely on them to take the
initiative.
• By approaching dismissal with transparency, fairness,
and a commitment to support residents’ well-being,
training programs can balance the need to uphold high
standards of patient care and professionalism with the
responsibility to guide residents toward successful
careers in medicine.
Introduction
Family medicine residency is a demanding and transformative phase in a physician’s education, marked by rigorous
training, clinical exposure, and skill development. As it
relates to patient care, a physician must understand the
pathophysiology of a condition and available treatment
options in the context of the individual patient, their family,
and community. They must use that knowledge to treat the
patient and communicate effectively. Over time, through repetition, feedback, success, and failure, the learner should garner a level of autonomy such that they are capable of
practicing medicine independently in a manner that is both
safe and effective for the patients and community they serve.
Resident performance can be inuenced by numerous factors, such as job satisfaction, quality of life, personality
traits, learning habits, and personal health. Aresidentwho is
struggling can present challenges and performance issues
that require careful attention and intervention. The program
director and other residency faculty members have a duty to
maintain not only an environment that is safe and supportive
for education and patient care but also a climate of profes-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
R. Kellerman, G. Irwin (eds.), Graduate Medical Education in Family Medicine, Excellence in Medical Education 2,
https://doi.org/10.1007/978-3-031-70741-4_18
171