Duke retooling, reopening family medicine training

In a phoenix-like rebirth, Duke's family medicine residency is rising from the ashes.

Duke University Medical Center in Durham, N.C., announced in May that it plans to re-open its family medicine program in July 2008. The school closed the program in 2006 because of a lack of applicants.

The revitalized program has jettisoned its former hospital-based curriculum for one that focuses on clinical care at community sites. Training will have a heavy emphasis on team-based care, leadership skills and quality improvement. When residents finish the three-year program, there will be a fellowship option for a master's degree in clinical leadership.

"Morale here is fantastic," said Brian Halstater, MD, Duke's family medicine program director. "We are alive and well and stronger than ever."

Such optimism is in contrast to some family medicine numbers. In six years the specialty has seen 10% of its residencies close, said Perry Pugno, MD, MPH, director of medical education for the American Academy of Family Physicians. Not only does this generation of medical students favor subspecialties over primary care, but family medicine does not generate big revenues for teaching hospitals. Low reimbursements and a disproportionate number of poor and uninsured patients often make these programs a drain on sponsoring institutions.

So why Duke's change of heart? It may be the tenacity of family physicians themselves. Physicians from around the country and those within Duke's halls voiced concern over the decision to shutter the residency.

Then, roughly a month after the program closed, the AAFP announced its initiative to transform family medicine residencies and called for applications. Titled "Preparing the Personal Physician for Practice," or the P4 project, the six-year effort aims to encourage schools to develop new family medicine training models.

Duke decided to apply. Although the school did not make the final cut, the redesigned program gained support from all levels in Duke's administration, including those at the top. With the backing of Victor J. Dzau, MD, chancellor for health affairs for Duke University and president and CEO of Duke University Health System, the family medicine residency was back in the budget.

"It has been a little bit of a rollercoaster ride," Dr. Halstater said.

Beginning in 2008, the program plans to accept four first-year interns a year. Here's what they will experience under the new curriculum:

• First-year interns will rotate through hospital departments while attending continuity clinic weekly.
• Second-year residents will do some hospital rotations, but most of their time will be spent at outpatient settings in the community, including clinics in underserved areas and school clinics where residents can learn pediatric and adolescent care. They will learn geriatrics through a home care program for the elderly.
• Third-year residents' schedules will include a health care leadership course on how to partner with communities and set up projects that address community needs.

Chief resident Erik Butler, DO, was shocked when the hospital announced it would not accept new family medicine interns and his program would be phased out. Now he is excited and is using his enthusiasm to recruit medical students.

After a recruitment fair in May, Dr. Butler said, "There's a lot of curiosity about the program. People have heard things on the news and want to know what's changed."