In October 2017, Dr. Tara Scott, MD, was only a few short months into her role as Program Director at Sutter Santa Rosa Family Medicine Residency when a devastating re struck the community of Santa Rosa in Sonoma County, California. The sponsoring hospital of the community-based program was signicantly impacted by the res and was not opera­tional for several weeks after the re. Nearly 100,000 inhabit­ants of the county were evacuated and two out of three hospitals in Santa Rosa were evacuated. The members of the program, along with alumni and many in the medical com­munity, were instrumental in keeping medical care going in the county at emergency evacuation shelters for several weeks after the res. The residency ofces and Family Medicine Practice were severely damaged and closed for nearly 2years. The program established a small, temporary Family Medicine Practice, and many of the faculty continued to see patients in makeshift “Clinics in a Can” until the clinic site was rebuilt. In 2019, shortly after the program moved back to its ofce and Family Medicine Practice, Sonoma County experienced another large wildre that again temporarily closed the pro­gram’s hospital and forced residents of the county into evacu­ation shelters. After numerous hard- earned lessons and incorporating Emergency Preparedness into the resident ori­entation, the program was able to spring into action the sec­ond time around, quickly executing phone trees, establishing medical care in the evacuation shelters, and creating alterna­tive forms of remote work for those who were displaced. Later in 2020, when the COVID-19 pandemic struck, many of the same systems used in the res were deployed to man­age sick-calls, mass communications, and remote work.

J. Gravel et al.

Fig. 42.1 Rationale for 4years

The Length of Training Project has nevertheless yielded valuable information. Two major concerns of program direc­tors and interested parties were whether an increase in required time would harm student recruitment into family medicine and whether increasing residency training time would be nancially feasible particularly if Medicare would choose not to provide GME funding for PGY4 residents.

As far as program nances, 4-year programs did well through clinical revenue generation in the residency practice alone, assuming PGY4s had (on average) 4–5 half-day con­tinuity clinic sessions per week. The other time of the PGY4 residents’ week was spent on ACGME-required rotations, electives, time on a resident-chosen area of concentration, and other rotations required by the program to train everyone to a deeper level, such as requiring practice leadership expe­rience working with the FMP’s Medical Director for 4–6 weeks. Some 4-year programs set an internal require­ment of Family Medicine Practice continuity visits at 2500 for graduation. With an additional year of continuity in the FMP, patient no show rates, patient satisfaction, quality indi­cators, and other benets of continuity were experienced, that also had positive effects on practice nances to offset increased total resident salary and benet costs. Sustainable funding of a fourth year of training in family medicine was achievable in a variety of program models with variable payer mix. Of the 4 programs that required all residents (“all in”) to participate, all achieved nancial stability, maintain­ing or improving their contribution margins to their sponsor­ing institutions [6]. Average operational expense per resident remained stable or decreased. Optional added costs such as more global health experiences, national conference atten­dance in an area of concentration, and online training mod­ules were offset by modest amounts of institutional support.

J. Gravel et al.

J. Gravel et al.