Fostering a passion for primary care remains an opportunity for improvement in Internal Medicine (IM) residency programs. Residents spend limited time in the outpatient setting and face unique challenges in developing confidence and competence during the relatively short training time of IM residency.1 Thus, it is important to make training in the ambulatory setting a priority, especially within primary care tracks (PCTs). Currently, opportunities within our PCT for education delivered to the group of PC-bound residents are limited to elective evening get-togethers that attract a few residents at a time due to call schedules and other responsibilities. The COVID-19 pandemic added to the challenge of primary care education by taking the focus away from ambulatory medicine given the need to care for the critically ill. The intense focus on COVID-19 led to a sense of isolation, increased physician burnout and decreased bandwidth to participate in non-required learning.2 We recognized the need for a stronger primary care focus and, despite pandemic challenges, developed an annual PCT workshop for our residents that has allowed us to rekindle connection and passion for primary care among residents and teachers.
In early 2019, we began working with program leadership to plan the inaugural PCT workshop. We reviewed our current curricula for individual PCT rotations and developed a survey for current residents, program graduates and faculty to determine our biggest areas of need. All groups requested additional training in musculoskeletal exam, general procedures, dermatology, and women’s health. There was agreement that including topics on efficiency, difficult conversations, and boundary setting would help develop resiliency skills. Residents requested career specific information related to addiction medicine, policy and advocacy, and public health. After reviewing the survey and reflecting on our mission statement, we decided on the following objectives to frame our workshop:
- expand knowledge, attitudes, and skills useful for primary care
- build a sense of a primary care community and mentorship within our PCT
- recognize varied career paths within primary care
- promote primary care and general internal medicine as a career
- demonstrate leadership skills and resiliency strategies to promote career sustainability.
Based on these goals, we designed a three-year workshop curriculum that includes hands-on procedural skills sessions, an annual career panel of recent graduates and community leaders, and medical improv sessions to help us work through common challenges in primary care communication and embrace ambiguity. In addition, we include an annual narrative medicine activity to promote sharing of joys and challenges in primary care and a series of knowledge boosters focused on enhancing knowledge of historically marginalized populations and topics in which residents in the PCT requested additional training.
We planned for our inaugural workshop to take place in March 2020 entirely in-person; however, we had to cancel the event that year due to the COVID pandemic. In 2021, we hosted the workshop with a half day of virtual events followed by an in-person skills session, and in 2022 the entire workshop was in-person with appropriate COVID precautions. Eleven to 12 PCT residents participated in the workshop each year. The workshop sessions were consistently rated as moderately to extremely helpful to professional growth and development. Overall, the workshop made 95% of the residents indicate they felt more excited about primary care. After three years of planning and two years of execution, our PCT workshop serves as an example of how to foster professional development and excitement about careers in General Internal Medicine and Primary Care.
We will highlight several innovations in this PCT Workshop curriculum including having both a virtual and in-person component, focusing on hands-on procedural skills, and debuting a medical improvisational curriculum.
The mixed virtual and in-person format was required to abide by social distancing measures but also provided additional benefits. While still having time for essential skills practice during our in-person sessions, we were able to include a variety of speakers from across the state who may not have all been able to attend an in-person event. The virtual session allowed residents a more relaxed morning and an opportunity to participate in self-reflection from the comfort of their homes with the ability to share their pets and children with their peers. Despite the above benefits, the virtual session did decrease opportunities for one-on-one interpersonal interaction and discussion between residents which contributed to our decision to have the second workshop all in person.
A major objective of the workshop was to increase trainee exposure to common outpatient procedures. In general residents feel less comfortable performing outpatient procedures compared to inpatient, and faculty expertise is often a major limiting factor in learning these skills.1 Based on our survey results, we decided to focus on ultrasound, basic MSK, dermatology, and women’s health procedures. Hands-on procedure training was completed using simulation models for joint injections and women’s health procedures (including certification in Nexplannon placement); while pigs’ feet were used for skin biopsies and trigger point injection practice. We also incorporated point of care ultrasound teaching related to the outpatient MSK exam and divided into small groups whenever possible to encourage active participation. Residents requested additional time for ultrasound and procedure training, which we will incorporate in the future workshops.
One final innovative session that we will highlight is “medical improv” where basic theater improvisational strategies were used in medical scenarios. The goal is to promote effective communication strategies and to build relationships by harnessing teamwork. Studies looking at the use of medical improv in medical students showed improvements in student wellbeing, engagement with studies, and communication skills.3 For our 2021 workshop, we invited an outside improv facilitator to lead foundational activities focused on teamwork and understanding the hierarchy of status in health care. The following year our improv activities involved patient cases surrounding difficult conversations including a “worried well” patient, a patient with chronic pain seeking opioids as first line therapy, and a patient frustrated with previous doctors. For these sessions, volunteers were asked to try a series of communication strategies with standardized patients including a “too passive” approach and a “too aggressive” approach to start. We then facilitated a discussion as a group and crafted responses that struck a balance before practicing a “just right” final version. Resident noted that the “improv session was actually more helpful than I realized” and that “the instructor did a good job at getting us out of our comfort zones in a very structured way that made it feel less anxiety provoking.” Given the initial success, we plan to continue to explore creative ways to involve improv in our primary care learning.
Our annual primary care workshop has been an immensely positive experience for our residents. This dedicated time for procedural training, career planning, knowledge boosters, communication strategies, and time for reflection has added value to our trainees’ education. We look forward to continuing these workshops and further refining our three-year curriculum in the future. We would love to hear from others about their positive experiences or challenges in primary care training as well.
- Bowen J, Salerno S, Chamberlain J, et al. Changing habits of practice: Transforming internal medicine residency education in ambulatory settings. J Gen Intern Med. 20, no. 12 (2005):1181-1187.
- Kannampallil T, Goss C, Evanoff B, et al. Exposure to COVID-19 patients increases physician trainee stress and burnout. PloS One. 15, no. 8 (2020):e0237301.
- Neel N, Maury J-M, Heskett K, et al. The impact of a medical improv curriculum on wellbeing and professional development among pre-clinical medical students. Med Educ Online. 2021 Dec;26(1):1961565. doi:10.1080/
Career Development, Clinical Practice, COVID-19, Medical Education, SGIM, Wellness
Drs. Keyserling (email@example.com) and Kehaya (firstname.lastname@example.org) are assistant professors at Oregon Health & Science University (OHSU) and primary care physicians at the Portland VA. Dr. Terndrup (email@example.com) is an assistant professor and primary care physician at OHSU. Dr. Iossi (firstname.lastname@example.org) is an associate professor at OHSU and primary care physician at the Portland VA
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