What is the Program Director’s role in resident education?
Our Program Director, Dr. Jeremy Fish, has spent his career developing resident and faculty responsive family medicine education. Responsive family medicine education includes important elements such as setting transparent priorities, holding faculty and residents to perform at their highest capabilities, and building a culturally humble and inclusive teaching and learning environment.
Dr. Fish’s role in our residency includes architectural leadership, resident mentorship, workshop facilitation, and patient care. Dr. Fish will has regular group and individual contact with residents. Dr. Fish leads workshops with a focus on leadership development and family medicine transformation. There is nothing Dr. Fish enjoys more than learning with residents!
Could you describe the demographics of the Family Medicine Residency Practice (FMRP) patient population?
We serve one of the most diverse counties in California. Contra Costa county has a population of about 1.2 million, with 45% Caucasian, 25% Latino, 15% Asian, 10% African American as the primary ethnic demographics. Our Practice is in Walnut Creek. Walnut Creek is at the border of Pleasant Hill and Concord and is accessible by short walk from nearby BART.
About 50% of the FMRP are from the managed Medi-Cal (California Medicaid) Health Plan here called Contra Costa Health Plan (CCHP), which brings great diversity to our practice. About 20% of our hospitalized patients are insured through CCHP or uninsured. Resident’s inpatient services for adult medicine are primarily insured through CCHP population since that is focus of our practice. Our residents are delivering CCHP patients on OB as well, a population that is growing rapidly.
How is behavioral health integrated into the practice?
Integrated behavioral health is a core aspect of both our educational and clinical models. Medical students and residents learn the tenets of behavioral health through joint biomedical and behavioral medicine workshops. Also, a behaviorist is available for consultation during clinic times, which creates an integrated precepting environment. For example, on Wednesday afternoons we have a behavioral, psychiatric, and family medicine consultant to support learners in their care of complex patients. Learners have countless opportunities for joint visits with our interprofessional team, which facilitates comprehensive patient care and real time learning. Video observation and review is another way that we support learners in their development of patient-centered care skills and effective communication. Two afternoons per week learners’ clinics are videotaped and then reviewed with a trusted faculty and peer to encourage reflection and develop goals for change. Our behavioral health team loves working with learners and are committed to training the next generation of family medicine physicians!
How are residents longitudinal panels constructed?
Residents work with their own panel of patients from day one. Panel management is one of the foundational building blocks of high performing primary care practices, which is the evidence based framework for our FMRP. Residents already have continuity patients asking to see them specifically during appointments.
How will the residency ensure that students receive education in a variety of training environments that share the same values as the residency program?
Our program focuses on training outstanding family medicine physicians with acumen in outpatient medicine. First year residents will also receive training in important areas of family medicine, including pediatrics, musculoskeletal, women’s health, inpatient, care of the older adult, and others. Key faculty who work with residents outside the FMRP are trained in key principles of resident education and foster supportive, hand-on education in each setting that reflect the values espoused in our FMRP.
Could you describe the surgical experience?
Resident have a three week block for surgery in the second-year and residents will be giving additional procedural & peri-operative training during their musculoskeletal-sports medicine and urgent care rotations. The highest value of working and training in the operating room is for residents to familiarize themselves with surgeons and understand how they make decisions for operative interventions. Additionally, residents will learn how to appropriately determine pre-operative surgical risk based on the anticipated procedure and the patient’s known and unknown risks.
Residents perform as “first assist” on caesarean sections throughout their training and care for peri-operative patients during Adult Hospital rotations. Given our ambulatory focus on procedures, we provide additional training in the FMRP and other ambulatory centers including surgical centers.
What are the plans for community involvement for residents?
Residents are involved with community organizations and have the opportunity to build their own elective community engagement activities. Additionally, our goal is for residents to work with high school clinics for sports physicals, mentor community college students, provide community health talks, and others. Residents have the opportunity to practice in the mobile health van most Saturday mornings, which provides care to some of the most vulnerable patients in the Contra Costa community.
What support do interns receive as they adjust to residency?
Resident well-being is a primary objective for our program. We have designed the schedule to maximize learning in a challenging environment without excessive hours or evening work. As our inaugural class, our first-year class receives additional attention in this important aspect of individual personal and professional development than they might in more traditional programs. Resident-responsiveness, like patient-responsiveness, is key to success in educational missions in healthcare. We want our patients to be well our staff to be well, our faculty to be well and our residents to be well.
What are the mentorship opportunities available to residents?
Residents both give and receive mentorship during their time at the program. We developed a ladder near- peer mentorship program with our partners at Health Occupations Student Association. Our mentorship program, CLIMB provides residents an opportunity to mentor local community college students who are pursuing careers in medicine. In turn, community college students mentor high school students who seek guidance in the college admission process and want to major in pre-med. Our CLIMB program was recognized at the STFM national conference in 2017 and we are honored to have been selected to present CLIMB during a well-attended lecture.
Resident mentorship is one of the most important and meaningful components of leadership development and a top priority for us. Core residency faculty mentor at least two residents in the first-year class. Residents receive mentorship from faculty with the opportunity for additional meetings upon request. Resident achievement of goals and professional vision is a major component of the mentorship relationship. Toward this end, we use the Individual Personal and Professional Development Worksheet to support residents in their vision for self-improvement.
Could you describe the process by which residents will be evaluated?
Resident evaluation includes both formative and summative feedback. Formative evaluation will include real-time feedback from faculty, peers, clinical staff, and others on the healthcare team. For example, if a resident collects a thoughtful and thorough history, the faculty preceptor will provide that feedback in the moment. Residents will also receive in the moment guidance and direction about areas for improvement.
Summative resident evaluation will occur every three to six weeks depending on rotation length. Professional development and communication skills require multi-perspective evaluations and feedback to help us all develop more fully. Therefore, core and key faculty will provide feedback in addition to residency staff, nurses, quality managers, community benefits employees, patients, and others. Residents will also self-assess on a regular basis. Self- assessment begins with a comprehensive evaluation across the four pillars of the New Model Full Spectrum: Clinical care (ambulatory focus), leadership & teamwork, partnership, and scholarship.
Do you foresee opportunities for students interested in pursuing clinical faculty positions after graduation?
Absolutely. Our Mentorship and Leadership Development programs also involve teaching how to teach. In addition, our 1:1 and 1:2 teaching ratios in inpatient and ambulatory settings provide excellent modelling for teaching. In addition, residents are provided formal workshops to learn teaching modalities in role-play type situations and have opportunities through co-precepting in the Residency Practice to learn how to teach other residents and medical students.
Is the John Muir Health System a 501(c)3 nonprofit organization?
Yes, the John Muir Health System is a charitable Hospital system and a 501(c)3 for tax-exempt purposes.
Does the John Muir Family Medicine Residency Program qualify for the Public Service Loan Forgiveness Program?
Yes, the John Muir Health Family Medicine Residency program meets Public Service Loan Forgiveness Program criteria. Students should ensure that they meet all other Public Service Loan Forgiveness Program criteria.
What are the best schools in the area?
Contra Costa County Office of Education website has information about the Districts in our county.
The California Department of Education has reports on the performance of each district and school.
A complete list of County Schools and a snapshot of their 3-Year Academic Performance Index averages.
How can I secure a local rental property?
What are the unique features we are most proud of at JMH FM Residency?
We put our residency practice and learners first in all major programmatic decisions, meaning your training in our residency practice is extensive starting on day one. Most programs have first year residents in one (1) clinic a week all year—making it nearly impossible to build a panel of continuity patients. Few clinics also make it seem like clinic is an intrusion on other training, rather than the most important training we can provide.
Putting the practice at the front of our minds does not mean we don’t believe training in the hospital, ICU, Emergency Department, Labor & Delivery isn’t vital to gaining the skills you will need to be a strong, ambulatory full-spectrum family physicians. We have focused our training at these sites to emphasize “how does this make our residents stronger, ambulatory full-spectrum family physicians?”
We also developed our Residency Curricular Group to focus on educational value in an inclusive way. We have invited our inpatient rotation leaders to the table to sort through teaching priorities across the scope of the program.
We have also made a strong commitment to provide training and development opportunities for our residents across a Practice PLUS model. What is the PLUS part of that promise?
We provide meaningful hands-on and workshop training to improve our resident’s skills in:
Could you describe didactic experiences?
We have made broad Didactic training a focus of our weekly, protected Thursday afternoon workshops - where all residents are freed from training activities to participate. Our workshops are organized by Dr. Kishore Nath and Lynn Eddleman and span a broad array of clinical activities across inpatient and ambulatory spheres - as well as procedure workshops, skills-development workshops, and programs addressing partnerships, leadership, advocacy, well-being, and scholarly improvement.
Residents also receive regular didactics as part of their clinical training at sites beyond our Practice: Inpatient Adult and Pediatric Medicine, Critical Care, Labor & Delivery, Newborn Nursery, etc. Our didactics are a blend of evidence-based and real-world practical topics to provide our residents with comprehensive working knowledge across all the areas vital to being a strong, full-spectrum family physician.
In addition, our residents are encouraged to participate in weekly Primary Care CME Didactics available in the Outpatient Center every Tuesday a lunch, which cover a wide array of clinically-relevant topics.
Will there be any opportunities to experience other clinic settings, such as Federally Qualified Health Centers (FQHC’s) or school clinics?
Our Residency Practice serves a very diverse population, with 50% of our patients covered by Medi-Cal (CA Medi-Caid), with the rest covered by Medicare, commercial insurance, and around 5% uninsured.
We received a nearly $1 million CA State Song-Brown Grant in 2018 to develop a meaningful Diabetes-Behavioral Group visit model at La Clinica (FQHC), which will be co-facilitated by our Residents during their Team-Based Care and Vulnerable Population Health rotations.
In addition, we are using this funding to advance our Mobile Health Teaching Clinic activity beyond Saturday in order to increase our residency presence in areas of highest need in East Contra Costa County.
What is the inpatient pediatrics training like? Will we have to go to a hospital outside of the John Muir Health system for inpatient pediatric training?
We have enough inpatient pediatric volume — with a variety of cases and intensity of illness – for our residents to train at our home hospital. The inpatient and emergency pediatrics rotations began in January 2017 and we are looking forward to an expanded role of our residents in our Walnut Creek Inpatient Pediatrics rotations as we grow the residency program. Our pediatric hospitalists are associated with Stanford's Lucile Packard Children's Hospital and many have extensive teaching experience. The hospital has both a NICU and a PICU, which allows our residents to care for patients with more acute and severe illness while on the pediatric wards, knowing that there are pediatric intensivists available close by if the patients require step up care.
Could you describe the residency’s approach to wellness?
We take resident well-being very seriously at John Muir Health Family Medicine Residency. We developed our innovative Modified Indianapolis schedule with resident well-being in mind. Resident expectations for work hours are clear. Because our hospital and other sites are well run by well-trained attending physicians, we have the opportunity to put resident education at the top of our priorities when developing their schedule. So, for example, our first year residents do not do service-based call in the hospital, although they gain vital training and experience through our innovative Evening Admits rotation. We made sure our inpatient residents for Adult Medicine have all-day Thursday off from rounding (patients are rounded on by attendings) so they can have their Continuity Clinic and Workshops without having to “finish on the wards first” or “go back after clinic”. We have done our best to reduce as many “double jeopardy” challenges in our program by putting our Residency Practice and Residents first when it comes to their schedules.
We have also embedded reflective care into many of our rotations, most importantly into our Team-Based Care and Vulnerable Population Health rotations, which ensures that residents can process complex cases in real- time with preceptors. In addition to this “real-time” well-being focused activities, we will have regular Personal & Professional Development & Support sessions by class to ensure all residents have a safe forum to share ongoing stressors and challenges with adapting to residency and the large responsibility of becoming a family physician.
Additionally, we blocked out the “high-risk” month of December with elective and project time which will allow for down-time and vacation during this busy holiday month. Our primary models for wellness will be Positive Psychology, Mindfulness, Personal & Professional Development & Support, and reflective practice. We believe this powerful combination, along with real structural support, will make our program a strong example of putting well-being ahead of exhaustion as a training priority.
What do you envision in terms of resident moonlighting opportunities? Would those hours be subject to the 80 hour cap?
We will not be encouraging moonlighting for two reasons.
This may reduce or eliminate the graduating resident’s ability to receive substantial signing bonuses if/when a resident chooses to work for John Muir Health after graduation. Graduating resident physicians can receive “recruitment incentives” if they have not been on the Medical Staff for John Muir Health. Moonlighting will likely make residents ineligible for such incentives.
Are there opportunities for policy and innovation mentorship during the residency? Would working directly with John Muir Medical Group CEO, Dr. Ahn, be an option?
Dr. Ahn is a remarkable family physician leader who has expansive working knowledge of Health Policy, leadership, and business of medicine. For example, Dr. Ahn was chair of Health Policy at California Academy of Family Physicians for many years. Dr. Ahn is part of our residency faculty and teaches third year medical students in primary care, when his schedule allows. He is helping us develop our Residency & Faculty Leadership Development Program and has offered to participate in facilitating leadership workshops when time permits. He has been very generous with his time to help mentor students and faculty alike. We have made leadership, partnership, and scholarship part of our mantra here in large part to ensure our residents receive comprehensive and useful leadership development training.
How will the residency prepare graduates for the competitive job market?
Our training centers leadership and team-based care as integral parts of a resident’s approach to medicine. When physicians are versed in how to lead healthcare teams, they are well-positioned to change the landscape of medicine through clinical, policy, and scholarship endeavors. Physicians who are competitive on the job market also have diverse clinical experiences.
Very few family medicine programs provide training experience for residents with a broad array of payer mixes. Fifty percent of our patient population mirrors that of an FQHC, managed medi-cal, which provides an opportunity for our graduates to be effective across a wide array of settings. This experience will make our graduates attractive to many health systems, whether in a PCMH, ACO, HMO, PPO or other payment model.
Although our graduates will be well prepared for any practice setting, such as FQHC, private physician group or private practice, the number of graduates of all family medicine programs going into private practice is dropping rapidly. Our residency is in a Primary Care Employed Physician model, which is what is used in most FQHC’s, Kaiser, Sutter, Group Health, Mayo Clinic and many other health systems.
Do you foresee any opportunities for PGY-1’s or PGY-2’s that are interested in teaching later in their careers (faculty development)?
Absolutely. Our Mentorship and Leadership Development programs will also involve learning how to teach, as teaching is an important component of mentorship and leadership. In addition, our 1:1 and 1:2 teaching ratios in inpatient and ambulatory setting provide excellent modelling for teaching. Residents will be provided formal workshops to learn teaching modalities in role-play situations and have opportunities through co-precepting in the FMRP to learn how to teach other residents and medical students.
Is there training in practice management?
We believe that training in practice management is important for giving our residents the tools necessary to have a sustainable career in any setting. In addition to our Team Based Care rotation, where residents will learn how an inter-disciplinary team can provide better patient care and help prevent physician burn-out, we will also be teaching coding, billing, and clinic efficiency. The efficiency training will focus on creating effective clinic workflows, organizing and managing the patient visit, and learning EMR tips to place orders, document, refill medications, respond to patient messages, and review charts in a streamlined way.