Impact of a Residency Family Systems Curriculum on the Postresidency Practice of Family Physicians

Family systems training is considered important by a majority of family medicine residency program directors and chief residents, yet family systems topics are not consistently incorporated into the curriculum. ¹ Though demonstrated infrequently, research on family-oriented training has shown that family-oriented attitudes and skills become stronger after such training. ² Like pediatrics, family medicine needs a family-centered approach as a component of clinical care. Concluding that family function and structure are important for children’s outcomes, the American Academy of Pediatrics recommended that family content be part of resident training and continuing education for practitioners. ³ A family systems approach by health providers also has been suggested in palliative care. ⁴ Evidence has shown that in addition to resident training, undergraduate medical education training in family-oriented care approaches benefits medical students. For example, an interactive workshop with medical students revealed improvement in understanding complex families, greater confidence in working with families, and better understanding of interactions between medical systems and families. ⁵

In 2016, we introduced a family systems curriculum ⁶ for third-year residents. Residents learned family systems concepts and how to apply these concepts in assessing their own family of origin and that of their patients. They also learned to apply family-oriented skills in clinical practice. Our 2019 study of the same curriculum indicated that a family systems curriculum may have improved the level of empathy of a small group of residents. ⁷ That research was based on an objectively rated video assessment of residents’ interaction with patients after participating in a 10-month curriculum. The aim of our present study was to determine the postresidency impact on the practice of the family medicine physicians who participated in the third-year family systems seminar from 2016 to 2021.

We asked all 60 residents who participated in the family systems training and completed residency between 2016 and 2021 to complete an email survey on the curriculum’s effect on their clinical practice. We sent two follow-up reminders to encourage completion of the survey. The survey included 12 Likert-scale questions and narrative options for respondents to describe their thoughts about the curriculum and its influence on their practice. We used Qualtrics XM (Qualtrics, LLC) to summarize the responses to the questionnaire. The questionnaire was accompanied by an informed consent. This study was approved by the Oregon Health & Science University’s Institutional Review Board.

Thirty-five graduates (58.3%) returned completed questionnaires. Overall, 74.3% of the respondents felt that the family systems curriculum helped them a fair amount or a great deal in the care of their patients. In particular, 82.9% felt that the curriculum helped them a fair amount or a great deal in maintaining empathy (Table 1). When asked how the family systems curriculum compared to other longitudinal courses, 91.4% indicated that they liked it somewhat or a great deal (Table 2).

Overall, most respondents found the curriculum valuable. Several participants commented on the curriculum’s influence on their understanding of themselves and their relationship to work, as well as the utility of the curriculum in direct clinical care.

Despite many positive assessments of the curriculum, a portion of the residents felt that the curriculum helped minimally with their care of patients and did not find value in reflecting on their own family of origin. Several residents found the concepts difficult to implement in the care of patients while others noted that earlier introduction may have helped them develop the relevant skills.

Family-oriented care, a defining principle of family medicine, has been written about extensively by early leaders in the field. ^8-10 Over the last 20 years, our colleagues have offered practical and comprehensive approaches to the field of family medicine and integrated behavioral health care.¹¹ Two ongoing challenges within family medicine behavioral science teaching are inconsistencies in how behavioral science topics are taught and the limited exposure trainees have to working with couples and families. ¹² As one respondent noted, “[Family-oriented care] seems disconnected from the lived experience of health care delivery,” demonstrating the difficulty residents have operationalizing family systems thinking.

Supplementing the Accreditation Council for Graduate Medical Education’s program requirements, Newton et al developed core outcomes for family medicine residency training. ¹³ We believe that having a background in family systems helps trainees attain the core outcomes relevant to managing and coordinating complex medical care, diagnosing and managing mental health conditions, and helping patients with undifferentiated symptoms. At a minimum, this training may help practitioners develop and maintain empathic interactions with their patients.

Our study had some limitations. The small number of respondents did not allow us to generalize our data to a residency population. The nature of our survey relied on self-reported knowledge and skills; although some respondents reported changes to their practice behaviors, they were not observed. Some selection bias may have influenced the participants’ responses. Residents who completed the curriculum more recently may have been more likely to respond or to report using family-oriented skills. Those who were willing to respond to the questionnaire may have viewed their experience as more positive. However, even within this group, some respondents indicated critical reactions to some elements of the curriculum.

The results from our study will be used to improve our curriculum and further research. We are considering introducing the curriculum earlier in residency training and exploring how to better show the connection between reflection on one’s own family of origin and improved skill in working with complicated patients and their families. Some possible activities are weekly family-centered rounds and family-oriented precepting blocks. Apart from programmatic changes, continued research is needed in this area. Randomized controlled trials across several residencies could help in developing elements for more standardized curriculum in family-oriented care training.