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34 Training forRural Practice: Place-Based, Mission-Aligned, andCommunity-Engaged
Table 34.2 Resources for rural graduate medical education
The RTT Collaborative(recently renamed The Rural Medical Training Collaborative)—This national non-prot board-directed cooperative of
rural programs and urban programs with a rural focus conducts an annual meeting, offers rural faculty scholarships for registration in the
National Program Director Development (NIPDD) fellowship, coordinates a learning community of new rural-focused program directors
(Rural Program Directors University), and provides consultation and technical assistance to both established and developing rural-focused
programs. https://rttcollaborative.net
Rural PREP is an education and research collaborative that promotes rural primary care, research, education, and practice. Although no longer
grant-funded, the WWAMI Rural Health Research Center maintains an online archive of teaching kits around topics relevant to rural training
and practice. https://ruralprep.org
Rural Residency Planning and Development Technical Assistance Center (RRPD-TAC) maintains an online portal of resources for both
program development and sustainability at https://ruralgme.org (simply register for free access)
ACGME medically underserved areas and populations has developed a framework for RTP designation, an advisory group, and resources to
support new programs in these settings. https://www.acgme.org/initiatives/medically- underserved- areas- and- populations
Rural health information hub (RHIhub) provides an extensive library of information, resources, and opportunities relevant to rural health
generally, including GME. https://www.ruralhealthinfo.org
Health Resources and Services Administration (HRSA), Federal Ofce of Rural Health Policy (FORHP) Rural Health Research gateway is an
important federally supported link to the growing evidence base in rural health care and training. https://www.ruralhealthresearch.org
National Rural Health Association (NRHA) provides information, resources, and advocacy in matters relevant to rural health, including
education and training for rural practice. Become a member, attend their Policy Institute, and join the rural medical educators at their annual
preconference to the NRHA annual conference each spring. https://www.ruralhealth.us
Family medicine organizations support a variety of member groups that promote rural-focused practice, education, and research. These include
the AAFP Rural health member interest group, the STFM Rural health collaborative, and the STFM family-centered perinatal care
collaborative.
395
Fig. 34.2 A typology
segmenting the place of
training continuum
(both termed RTPs). These programs in family medicine
may include as few as 10 weeks, but less than 18months, in
an urban setting, limited only by the 24-month requirement
for continuity in the family medicine practice (FMP) of the
residency program.
An organic approach requires a thorough inventory of all
stakeholders and can be particularly complex in rural track
programs, balancing the power and inuence of the local
rural leaders and community with that of remote urban faculty and decision-makers [37, 53, 54]. Amplifying the voice
of the rural community that is likely most affected by rural
program decisions is key to both initiating and sustaining
training in rural places. Explicit governance and transparent
communication with agreed-upon outcomes and outcome
measures allow for rigorous accountability and team-based
prioritization for continuous program improvement [37].
Annual budgets, clear funds ow, and annual budget reconciliation are essential to that process.
Once a program is established, the challenge is to sustain
it, enabling the program to not only survive but indeed thrive
over time [6]. Challenges may include limited resources
(e.g., nances or personnel), poor or disruptive performance
of individual residents or faculty, transitions in leadership
and health systems, and procedure and policy changes (e.g.,
new accreditation requirements). Although adequate and
stable funding is always a concern and a necessary condition
for program sustainability, money alone is not sufcient to
assure program success.
The best rural programs in both rural and urban locations
are accountable to mission, led by a passionate team, respect-
396
Table 34.3 Tips for achieving excellence in rural training
1. Establish immediate and longer term program metrics. Measure outcomes from the onset and provide robust reports to the community of
stakeholders
2. Rural programs are generally smaller than urban ones, and the leadership team may be smaller as well. Leadership development and
succession planning are critical for long-term success
3. Effective governance must address the power differential that naturally exists between a large healthcare system and a local leadership team,
between an academic institution and a clinical enterprise, and, in the case of an RTP, the generally larger number of urban faculty and smaller
number of rural faculty [32]. This power gap must be bridged in a way that respects and utilizes local resources, including local formal and
informal leadership, and promotes functional autonomy. Decision-making responsibility must be explicit and align with individual authority
and accountability. If decision-making responsibility can’t be expressed on a mutually drawn organizational chart, it will likely not be
sustained
4. There are unique challenges for RTPs that are not separately accredited from an established program. Although easier to receive ACGME
approval, non-separately accredited programs are also easier to disband. Often the program director and/or program administrator are anchored
in the larger urban site and may not be as invested in the rural site’s survival. There may be a sole rural site director with little supporting
infrastructure and only a small cadre of volunteer faculty. This lack of investment inlocal rural leadership is an important vulnerability
5. A budgeting process that segregates educational and clinical revenue and expenses must, at least annually, explicitly outline the all-funds
ow and budget reconciliation process, including Medicare and Medicaid GME, other state or federal funding, community support and
community benet, downstream revenue, and institutional investment
6. There will always be failures to remedy and improvements to be made. Leading or directing a rural program requires the habit of reective
practice, an attitude of abundance in the face of scarcity and limits, and adaptability, all domains of competence for both rural residency
program leaders and rural physicians
7. Programs without effective community engagement, investment, and ownership will struggle to survive. A program held in high esteem and
actively supported by the community will thrive. Rural communities can have a signicant inuence on attracting and retaining healthcare
professionals through investments in social, human, and physical capital [3, 70]
R. Longenecker et al.
fully governed, nancially enabled, committed to iterative
improvement, and community engaged. Table 34.3 lists
important tips for sustained residency program success from
our combined decades of experience in consulting with
established and developing programs.
Much is yet to be learned about achieving and sustaining
excellence in preparing physicians for rural family medicine
practice. Among areas for further study are (1) better assessing domains of competence most relevant to rural practice,
(2) determining the optimal time spent training in a rural
place, (3) designing and implementing a more effective way
to nancially sustain GME in rural places and track the training that occurs there, (4) discovering the best governance
and most efcient use of consortia as sponsoring institutions
and scholarly communities of practice, and (5) learning how
best to address rural health inequities through graduate medical education.
We can’t predict the future except to say that there will
likely always be rural places where people live and work,
and rural physicians will need ongoing support from a
resilient community of practice to ourish there. Those physicians engaged in rural education and training will benet
from peer expertise in growing their own and recruiting others. Although there have been ongoing grant-funded efforts
in rural medical education and training, particularly in the
past several decades, the future of rural training is best served
by a sustaining infrastructure and stable funding in support
of peer program director and faculty development and interaction across rural programs of all types, including opportunities for collaboration in scholarly work anchored in rural
places [71, 72].
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Part VIII
The Family Medicine Center
Managing theFamily Medicine Center
MariannaKong andCoreyLyon
35
Key Points
• Close partnership between residency program and clinic
leadership with a shared vision and aligned priorities is
important to improve the Family Medicine Center for
patients and residents.
• A core of clinic-based faculty who spend at least half of
their time in the FMC has benets for resident teaching
and role modeling, continuity, team-based care, and clinic
improvement.
• Resident scheduling in the FMC needs to be consistent,
predictable, done far in advance, and sufciently concentrated to allow continuity, access, and team stability.
• Timely, simple, and validated metrics should be tracked
and drilled down to individual clinician and team levels,
which often requires a strong partnership with an information technology or electronic health record champion.
• Create and regularly implement detailed empanelment
policies and procedures around panel assignment, validation, adjustment, and transitions, with target panel sizes
informed by the ideal panel size equation.
• Prioritize teamlet stability between clinicians and medical
assistants, facilitate partnership and communication skills
with co-location and coaching, and actively incorporate
interdisciplinary team members into patient care with
expanded team roles and a culture of sharing the care.
• Improve continuity using scheduling algorithms and
scripts, team-based strategies, and a culture of
continuity.
• Increase capacity or reduce demand to improve access,
such as by right-sizing panels, incorporating team-based
M. Kong (*)
Department of Family & Community Medicine, University of
California San Francisco, San Francisco, CA, USA
e-mail: Marianna.Kong@ucsf.edu
C. Lyon
Department of Family Medicine, University of Colorado,
Denver, CO, USA
care, minimizing no-shows, increasing clinic time, and
using appointment templates strategically.
• Create systems for coverage of resident inter-visit clinic
tasks and coordination of care.
• Incorporate residents meaningfully into the clinic through
clinic-driven quality improvement, clinic curricula with
hands-on components, and leadership opportunities.
Introduction
The Family Medicine Center (FMC) is a foundational component of family medicine residency training, where residents learn to practice in the context of a fundamental tenet
of family medicine—the continuity relationship with a
patient. However, it is also a uniquely challenging environment given the complexity of running a primary care practice
staffed by many part-time residents and faculty who usually
spend only one to two half-days per week in the clinic. This
leads to numerous difculties with maintaining continuity of
care, providing timely access of care, working well with
clinic team members, and more. These in turn frequently
give rise to chaotic and dysfunctional clinic experiences for
both patients and learners, often messaging to residents that
primary care is an unsustainable and frustrating career
option.
Fortunately, with the right tools and investment, the FMC
can also be a place where the dual missions of patient care
and resident training harmonize and mutually benet one
another. Many residency practices nationwide have created
innovative strategies and solutions to meet the challenges of
the FMC, and developed clinics that provide high- functioning
care and engaging training experiences. Rather than being a
source of dread for residents, these clinics model excellence
in primary care and inspire learners to perpetuate this excellence in their future practices.
In this chapter, we will start by reviewing basic logistics
involved in running and practicing in a Family Medicine
© 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_35
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Center, focusing on operational, precepting, billing, and
funding considerations that are specic to teaching clinics.
We will then use the 10 + 3 Building Blocks of HighPerforming Teaching Clinics [1] to take a deeper look at
areas of common challenges in running the FMC, and discuss best practices to help strategically address these
challenges.
Basic Logistics
Operational Considerations
As residents gain experience in patient care and grow their
clinic skills over time, the number of patients they can see
per clinic session changes, which results in several operational considerations. For example, residents’ clinic templates will usually start in intern year with only a few patients
scheduled per session to allow ample time for interns to see
patients, formulate a plan, precept, and carry out the plan,
while learning many of the clinic’s workows for the rst
time. This number should increase as residents gain more
experience and can see more patients per session. FMCs usually have a schedule at which resident clinic templates
increase in number of appointment slots throughout each
year to reect this.
Attention should be paid to coordinate clinic resources
and staff in proportion to residents’ evolving clinic schedules. With most interns seeing a maximum of 4–6 patients in
a half-day session, two interns can be considered roughly
equivalent to one full-time attending clinician, and can possibly share the resources and exam rooms normally allocated
for one attending clinician. For example, if a faculty clinician
is normally paired with one medical assistant (MA) and three
exam rooms, two interns can share the three rooms and one
MA with staggered appointment times. As residents advance
in training, these allocations should be adjusted accordingly.
For clinic planning purposes, it is helpful if the number of
residents of each year in clinic on a given half day is generally consistent, so that stafng and room availability do not
have to be constantly reconciled with changing numbers of
residents.
Many health systems allocate support staff and other
resources based on patient visit volume. This can be a challenge in a residency FMC due to the number of patients residents see, especially early in training. Ensuring that health
system leadership understands how residents are scheduled
to see patients is important for them to accurately interpret
patient volume data. If support stafng is based on how
many full-time equivalents (FTE) of clinicians are seeing
patients, you can average how many clinic sessions the residents have based on year group to determine their clinical
FTE, and consider pro-rating based on the average number
of patients they see in a session. Resident FTE depends on
how often your residents are in clinic throughout their training. For example, two interns, two 2nd year residents, and
two 3rd year residents may add up to one-full FTE clinician.
Consider that with many part-time clinicians, there are usually higher care coordination needs since individual clinicians are often not present to actively address patient
questions, rell requests, forms, and other inter-visit needs.
Faculty Models andPrecepting
There is a spectrum of models when it comes to how faculty
are involved in the FMC [2]. Some programs, commonly
community-based residencies, have a small, focused faculty
whose members spend at least 5 half-day sessions per week
seeing patients or precepting residents in the clinic. Others,
usually those based in academic centers, have a large, dispersed faculty with many faculty physicians who each spend
only 1 or 2 half-day sessions per week in the clinic. Some
programs use an in-between hybrid model, with a small core
group of focused faculty doing several clinic sessions per
week and additional faculty members that have very little
clinic time.
Studies have shown benets of having faculty clinicians
who commit substantial amounts of their time to patient
care and teaching in the FMC [2]. Focused faculty clinicians who spend a signicant proportion of their FTE in the
FMC provide a stable presence in the clinic, know the residents’ patients and the clinic’s workows, provide greater
continuity of care, anchor clinic teams, and can help coordinate coverage for residents when they are on other rotations. Furthermore, with the FMC as their professional
home, they play an important role in championing clinic
improvement and acting as role models for residents.
Finding the right balance of precepting sessions and faculty
clinics for residency faculty is also important to ensure that
faculty are able to meet the needs of their patient panel,
maintain their clinic skills, and model clinical care for their
residents.
For faculty precepting, the Center of Medicare and
Medicaid Services (CMS) rules [3] require a 1:4 ratio of faculty to residents. This is the lowest allowed ratio, and residencies may increase this ratio to match their needs. A 1:3
ratio helps with efciency in clinic ow, and due to the time
needed to precept a new intern, interns may require an even
higher ratio to avoid precepting bottlenecks. Some programs
have enough faculty in their clinic to cover precepting needs.
Many other residencies may rely on community preceptors
to assist with precepting coverage. Community preceptors
are physicians that are not a part of the residency faculty, and
may primarily work at an outside clinic. Such community
preceptors may be less familiar with the FMC’s workows,
35 Managing theFamily Medicine Center
405
but bring valuable expertise from other clinic systems or
patient populations to teach residents.
Precepting schedules should be made to balance exposure
to different styles of practice and areas of expertise with
resident- preceptor continuity. Residents often prefer working with the same preceptors over time, and residentpreceptor continuity is necessary to obtain helpful feedback
on resident skills in clinic. It is most effective to collect evaluations right after precepting, with something written that
can be easily compiled and reviewed for patterns. The FMC
is also a good site to incorporate feedback from clinic staff
for resident evaluations.
Billing Requirements
Residents bill for their visits under an attending’s license.
The following describes clinic oversight and billing rules for
Medicare-insured patients. Even though private payors may
not have these same billing requirements, clinics and health
system compliance ofces often apply these same rules to
billing for all payors to avoid Medicare billing fraud if these
CMS rules are accidentally not followed. It’s important to
become familiar with the specic FMC and health system’s
billing and coding expectations, as details may vary between
local health settings.
Unless covered by a primary care exception, Medicare
regulations require attending physicians to have physically
seen the patient for the resident to bill. To be eligible for the
primary care exception, the patient care must be provided in
the outpatient department of a hospital or another ambulatory care entity in which the patient care activities by the
resident are included in determining direct GME payments
to a teaching hospital. Programs granted a primary care
exception by CMS may have residents bill Medicare for
lower-complexity services provided in the absence of a faculty preceptor physically present, though the preceptor must
still be in enough proximity to be immediately available.
Only evaluation and management (E/M) codes of 9921199213 or 99201-99203 and annual preventive visit codes
can be used under the primary care exception. At this time,
only medical decision making, and not time, can be used
when billing for outpatient E/M visits under the primary
care exception. Residents in their rst 6months of training
are not able to use this exception and the faculty preceptor
must be present for critical or key portions of the services
provided to the patient. After the rst 6 months, residents
may bill the visit without the physical presence of faculty
preceptor at any part of the visit. If residents have made the
expected progress in their clinical skills, second or third
year residents’ patients may physically leave the FMC
before precepting cases in batches with the faculty
attending.
The faculty preceptor must review the patients’ medical
history, the resident’s ndings on exam, diagnosis, and treatment plan during or immediately after the visit. Typically,
electronic health record (EHR) systems are set up to route
the resident’s completed note for the faculty to review, provide an attestation statement and sign the note. For the primary care exception, an example of attestation language is:
I reviewed the care provided for this patient by Dr…… during/
after the visit. I reviewed the patient’s medical history and the
resident’s description of their physical exam ndings. The
patient was treated today for……. Please see the resident’s note
for the details of the assessment and plan.
Outpatient CPT procedure codes require faculty preceptors to be present during all portions of the procedure in order
to be billed. Many residents may be competent to perform
procedures independently, however, in order to bill Medicare,
the faculty needs to be present during the procedure. Faculty
preceptors must provide a written attestation stating that they
were present during the entire procedure. While simpler procedures may make sense to include into routine primary care
clinics, those involving extensive setup and supervision may
be logistically preferable to be scheduled into a designated
procedure clinic half-day within the FMC.
Depending on the patient’s insurance, order forms for
medical items such as durable medical equipment and oxygen usually need to be signed by attending clinicians.
Additional Funding Considerations
Depending on the FMC’s setting, there may be other important funding considerations to be aware of based on the local
health system, state rules and programs, or the local GME
arrangement. FMCs that are also Federally Qualied Health
Centers (FQHCs) or FQHC Look-Alikes are eligible for
enhanced reimbursement rates from Medicare and Medicaid
based on visit codes as well as certain grants. Health systems
that use capitation or are part of accountable care organizations often use risk adjustment methodology to provide
weighted payments per patient empaneled to the clinic or
organization. Many states have various Medicaid programs
for pay for performance, where nancial incentives are given
for high performance on quality metrics, such as those
related to hypertension, cancer screening, disparity reduction, etc. There are also some innovative state-based
Medicaid programs to support screening and addressing
social determinants of health (SDH) such as food insecurity,
behavioral health integration, providing care through community health workers, and other wraparound services.
Getting to know the rules and funding specics of the
local health setting and state is important to understand the
clinic’s nancial sustainability priorities and how to advocate accordingly for clinic resources [4]. It also helps faculty
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identify what should be taught to residents about the billing
and reimbursement, including what may differ in other practice settings. Mapping out how funds ow from the payor or
health plan, to the health organization, to the front-line budget and care delivery team in the FMC, goes a long way in
understanding the specics of the local funding context. For
example, for one clinic system, Medicaid payments may be
distributed through one or more managed care plans, which
pay based on capitation to form the clinic system’s budget;
the clinics themselves may not be capitated but negotiate
their budget with the local health system separately, in which
salaries are negotiated for clinic stafng based on FTEs.
Understanding the various funding ows and what payment
system they use, whether it be fee-for-service, pay for performance, capitation, risk-sharing, or some combination
thereof, allows faculty to better understand and navigate
overall demands and pressures on the FMC.State Academy
of Family Physicians chapters can be a helpful resource for
understanding local rules and reimbursement issues. It’s also
important to look beyond the FMC’s current funding sources
for alternative funding opportunities, such as state-specic
Medicaid or payor-specic programs, that can support
expanding team-based care or special initiatives for the
FMC.
Lastly, many FMCs serve a large population of patients
with limited nancial resources, including uninsured
patients, requiring training and modeling for residents on
how to work with patients facing disproportionate health
inequities and barriers to care. Strong skills in patientcentered communication with patients with limited health
literacy and/or English language capacity, as well as tools for
addressing social determinants of health and care navigation
are needed. Learning to work with such populations is helpful for workforce retention into underserved settings [5], but
likely only if the clinic experience is overall positive, versus
dysfunctional and prone to highlighting burnout. Poor care
experiences and clinic operations in a teaching clinic where
limited-resource patients are disproportionately served can
become an equity issue if a lower standard of care is felt to
be inevitable; thus, it is important to strive for a highfunctioning FMC despite challenges faced by underserved
patients.
The 10+3 Building Blocks ofHighPerforming Teaching Clinics
Now that we’ve covered basic logistics, we’ll next turn our
attention to how to work toward a high-functioning FMC.To
tackle the overwhelming work of improving the FMC, we’ll
use the 10+3 Building Blocks of High-Performing Teaching
Clinics [1] as an organizing framework (Fig. 35.1). The
Building Blocks are based on best practices gathered from
teaching clinics nationwide, and represent core areas in the
clinic to target for improvement. The lower rows of blocks
(including resident scheduling and empanelment) represent
foundational elements that need to be operationalized well in
order to make progress on higher-level blocks (such as access
and continuity).
In the remainder of this chapter, we will highlight selected
blocks with particularly important considerations for the
FMC. For each block, we’ll describe important basic concepts, common challenges, and strategies and best practices
for improvement. We will begin with the Engaged Leadership
and Scheduling blocks as these have crucial implications for
every other block, advance sequentially from the basic to
more advanced building blocks, and then conclude with discussing resident engagement and worklife.
Engaged Leadership
The FMC-Residency Partnership
The degree to which leadership is engaged and invested in
positive change sets the stage for any type of improvement
work. In the context of the FMC, this requires close partnership between the residency program leadership and the clinic
leadership. In some programs, the two leadership teams may
work in relative silos, with separate goals and agendas, rarely
communicating except when conicts arise. In others, the
clinic and residency leadership teams are in close collaboration, with aligned missions and frequent communication and
coordination.
Key questions to reect on the state of this partnership in
your program include:
• Who is on the residency program management team and
the clinic management team?
• How often do the management teams meet together?
• How often are priorities between the two teams conict-
ing, and how are these conicts resolved?
• Does the clinic leadership have a vision with concrete
objectives and goals for improving the FMC? Does the
residency leadership team have its own vision for the
FMC?
Furthermore, it’s important to know which other leaders
in the FMC’s health system have inuence on decisions
affecting the FMC (e.g., department heads, CEOs/CMOs,
deans, leaders of inpatient or specialty services). Having an
understanding of the stakeholders and their priorities will be
important to secure their support as changes are designed
and implemented.