Fifteen years ago, shortly after the Accreditation Council for Graduate Medical Education (ACGME) enacted rules restricting duty hours in residency programs, Alan David and I published an essay in Family Medicine entitled, “Is It Time for a 4-Year Family Medicine Residency?”1 We raised this question at a time when the Future of Family Medicine Project had just been completed and our discipline had committed its future to an expanded concept of primary care that came to be known as the patient-centered medical home. Our paper further suggested that the number of first-year positions could be decreased to pay for the expanded training. A letter to the editor by Tom Schwenk, published a few months later, commended us for taking on the “third rail” of family medicine education.2 He was correct; the reaction was spirited and mostly negative. Some expressed concern that a 4-year residency would be less appealing to residency applicants. Some argued that prolonging the entry time into practice would compound the problem of medical student debt. Others noted that our residencies might struggle to pay for a fourth year of training, and that shrinking the number of positions would lead to a smaller number of family physicians being produced each year. Our paper was written at a time of declining interest in family medicine among American allopathic students and the great recession of 2008 soon followed. Thus, interest cooled, and a debate never really happened.
Between 2007 and 2014, the Preparing the Personal Physician for Practice (P4) project was conducted to consider ways to reform the residency curriculum, including a case study of required 4-year training in one of the 14 programs.3 To follow up on this work, a formal length of training pilot (LOTP) experiment began in 2012. The experiment was designed as a controlled comparison of six 4-year programs with seven matched 3-year programs. In this issue of Family Medicine, we publish the first major paper from this experiment, a report from Patrice Eiff and colleagues examining the impact of length of training on residency match results.4 This is a very challenging question to study; the team working on the LOTP should be commended for trying to compare match performance during an era when change abounds in the residency education landscape. The study is not perfect. A larger sample of programs followed for a longer period of time certainly would have been desirable. But the results are clear; there was no overall difference in match performance between these two groups of residencies. Faced with a choice between 3-year and 4-year programs, students do not seem to consider the length of training to be a determining factor in their choice. This is an important finding because it directly refutes one of the primary concerns about lengthened training. It also confirms the subjective experiences of those programs that have converted to a 4-year curriculum as well as an earlier limited study that addressed the same question.5
This issue also contains commentaries from directors of the two groups of programs in the study. Directors from the control programs correctly point out that the match choices of subgroups of students, such as women and those with high student debt, might have been impacted by the length of training but could not be examined due to sample size.6 Directors from the 4-year programs correctly note that a longer residency directly addresses longstanding student concerns about the challenges of mastering a discipline as comprehensive as family medicine in less time than narrower fields require.7 Both perspectives are thoughtful and well-argued. The LOTP has already required an enormous effort and substantial resources from the participating programs. We all owe a debt of gratitude to them, to their sponsoring institutions, to the American Board of Family Medicine for funding the study, to the ACGME for authorizing it, and to the researchers who designed the study and carried out the analysis. This is the first of what will likely be a series of papers about this study with future analyses focusing on training outcomes and practice patterns among program graduates. We now know that students are not deterred from 4-year programs, but it matters far more whether or not their extra year of work is worth the effort—because the costs are substantial. An extra year of training in the face of growing community demand for family physicians and rising student debt burdens will only be worthwhile if tangible benefits outweigh these costs.
That being said, the current paper and those to follow should cause us to rethink some of our assumptions about the future of our discipline and the role of residency education in that future. Much has been written recently about changes taking place in the scope of work being done by our nation’s family physicians.8-16 Board-certified family physicians are less likely to provide pediatric,9 maternity,10 and hospital care11 than at any time in our history. This causes concern that these changes might contribute to a decline in family medicine’s economic competitiveness12 or undermine the doctor-patient relationship.13 Some have speculated that the growing demand for outpatient care might underlie these changes.14,15 Of course there is another possible explanation: maybe some of our traditional 3-year residencies are struggling to produce comprehensive family physicians in the limited time available to them. If this is the case, then future papers from the LOTP could show scope of practice differences between graduates of 3- and 4-year programs.
Family physicians understandably focus on the needs of those we serve, but maybe we need to be more concerned about what future family physicians want to be. Recent studies have associated higher burnout rates with a narrower scope of practice in family medicine16 and have suggested that graduating residents seek a broader scope of practice than family physicians in practice.11 Perhaps young physicians still want to enter a discipline that allows them to practice at the top of a physician’s license. Perhaps they are looking for residency programs that can make this dream a reality.
Family medicine has committed itself to attracting 25% of American medical students to our discipline by 2030 (25 x 2030).17 This will require us to double the share of students we attract by a decade from now. The LOTP only studies those students who have chosen to enter family medicine programs. Who are the students who might have chosen family medicine but did not, and what changes could we make that might have changed their minds? Is it possible that students seeking comprehensive generalist practice are entering other disciplines because of concerns about our future scope of practice? The LOTP will not be able to answer these questions for us.
The future of our health care system remains uncertain, with continued threats to the Affordable Care Act and growing calls for single-payer health care in America. So it is understandable that we might be risk averse, preferring to wait until the future is clearer. But our response to the length of training question should not be to bury our heads in the sand. We have heard plenty of opinions about the length of training. We need to be open minded about what can be learned from the LOTP, but we also need to be honest about what it cannot tell us. The success of 25 x 2030 lies with those students who are not choosing our current model of training; we need to know a lot more about how we look from the perspective of these students. In the 2019 match, 4,128 students chose family medicine residencies, representing 12.8% of all osteopathic and allopathic applicants. Thus, to reach 25% of the match, we will need over 8,000 students per year to choose family medicine. After 50 years, do we really think our current model can make this happen? If not, how should we proceed?