Preparing the Personal Physician for Practice (P4): A National Program Testing Innovations in Family Medicine Residencies
=========================================================================================================================

* Larry A. Green
* Perry Pugno
* Gerald “Jay” Fetter, Jr
* Samuel M. Jones

“*Family physicians are committed to fostering health and integrating health care for the whole person by humanizing medicine and providing science-based, high-quality care*.”1

When the basic structure and content of family medicine residency training was defined in the 1960s, the overarching goal was to replenish the ranks of declining numbers of general practitioners with the graduates of these new residencies. As successful as this model and its key innovation, the model family medicine center, has been, one would not intuitively assume that the training template from this era would be ideal nearly a half century later. Much has changed in practice with expansion of the useful medical armamentarium, changes in what patients expect, and the stunning impact on frontline practice of information technologies. Concurrently, the health policy environment of the United States has evolved to emphasize an urgent need for revisions in the organization and delivery of health care to enhance quality and improve outcomes for the entire population at a price that the nation can afford and sustain.2

The Future of Family Medicine project concluded after careful study that a transformative change was required in frontline medical practice.1 Redesign of frontline practice for the information age while preserving the core values of personalized care in a continuing relationship over time was called for, and the hard work of implementing and testing new approaches has been joined.3–9 Although the work of practice redesign is far from complete, the leadership of the Association of Family Medicine Residency Directors and the American Board of Family Medicine concluded that there is sufficient progress in these new approaches to proceed with an active reconsideration of the structure and content of graduate medical education in family medicine10 to better prepare family physicians to be personal physicians in the new models of practice now emerging.

To define, organize, implement, and evaluate a set of educational experiments, a Steering Committee was assembled to guide what is now named P4, Preparing the Personal Physician for Practice ([www.transformed.com/p4.cfm](http://www.transformed.com/p4.cfm)). The purpose of P4 is to learn more about how to improve the graduate medical education of family physicians such that they are prepared to be outstanding personal physicians and work in new models of practice. Key assumptions, for which there is considerable evidence, include that expert primary care is foundational to sufficient, sustainable health care systems11 and that people need and want a personal physician to whom they can turn with their health concerns and who will stick with them.1

A personal physician was well characterized by T. F. Fox:

“*The doctor we have in mind, then, is no longer a general practitioner and by no means always a family practitioner. His essential characteristic, surely, is that he is looking after people as people and not as problems. He is what our grandfathers called “my medical attendant” or “my personal physician”; and his function is to meet what is really the primary medical need. A person in difficulties wants in the first place the help of another person on whom he can rely as a friend—someone with knowledge of what is feasible but also with good judgment on what is desirable in the particular circumstances, and an understanding of what the circumstances are. The more complex medicine becomes, the stronger are the reasons why everyone should have a personal doctor who will take continuous responsibility for him, and, knowing how he lives, will keep things in proportion—protecting him, if need be, from the zealous specialist. The personal doctor is of no use unless he is good enough to justify his independent status. An irreplaceable attribute of personal physicians is the feeling of warm personal regard and concern of doctor for patient, the feeling that the doctor treats people, not illnesses, and wants to help his patients not because of the interesting medical problems they may present but because they are human beings in need of help*.”12

This nearly 50-year-old articulation, refreshed to refer to both male and female physicians, characterizes the desired graduate of future family medicine residencies.

One of the initial steps taken by the P4 Steering Committee to guide and inform a set of educational experiments in and by family medicine residencies was the commissioning of 4 papers. The authors of these papers were recruited because of their insight, experience, and scope. Some are well known within family medicine, and others are better known in other disciplines and in the larger medical arena. These authors were asked to stimulate thinking about what might be important to do to improve family medicine residency training, and in particular, to align it with what is feasible and needed now to respond to the opportunities of new practice models and to the stubborn challenges besetting health care systems in the United States.

Dr. David was asked to provide an historical context and critical review of pertinent literature and to formulate some possible structures worth considering by residencies.13 Dr. Leach and Dr. Batalden were asked to help define where promising opportunities lie to improve the preparation of personal physicians for practice.14 Dr. Scherger was asked to unleash his imagination and propose what a personal physician is likely to be doing during the future workday and to suggest which critical skills will be needed.15 Dr. Whitcomb was asked to identify promising, achievable opportunities for revisions in family medicine residencies and to challenge the field to take a hard look at itself.16

These authors fulfilled their assignments. Their work was shared with residencies as they considered applying to be part of P4 and was posted on the P4 website until publication in the *Journal of the American Board of Family Medicine (JABFM)*. The P4 portfolio of innovations that eventually emerged encompasses much of what these authors suggested. The impact and quality of these manuscripts were such that they were accepted by *JABFM* for publication as a group. It is the hope of the P4 Steering Committee that these manuscripts, an important part of the record of the continuing development of family medicine, will inspire, annoy, encourage, and challenge the readers of *JABFM* to engage and enable a period of reconsideration and innovation in family medicine residency education. We invite your comments on these manuscripts through the Rapid Response system on the *JABFM* website. Please go to [www.jabfm.org](http://www.jabfm.org), select the desired manuscript, click the “Rapid Response: Submit a response” link located in the right menu, and then make your contributions to this important dialogue.

## Acknowledgments

This manuscript was prepared at the request and with the support of the P4 Steering Committee, whose members are listed below: Erika Bliss, MD, Carolyn Downs Family Medical Center; Marguerite R. Duane, MD, Department of Family Medicine, Georgetown University; Larry A. Green, Department of Family Medicine, University of Colorado; Samuel M. Jones, MD, VCU-Fairfax Family Practice Center; Terry Kane, MD, Department of Community and Family Medicine, Duke University; Stanley M. Kozakowski, MD, Hunterdon Medical Center; Janice Nevin, MD, MPH, Christiana Care Health System; Perry Pugno, MD, MPH, CPE, American Academy of Family Physicians; John Saultz, MD, School of Medicine, Oregon Health and Science University; James C. Puffer, MD (ex officio), President, American Board of Family Medicine; Terry McGeeney, MD, MBA (ex officio), Chief Executive Officer, TransforMED.

## Notes

*   This article was externally peer reviewed.

*   *Funding:* American Board of Family Medicine Foundation and Association of Family Medicine Residency Directors.

*   *Conflict of interest:* none declared.

*   The URL for the P4 project is: [http://www.transformed.com//p4.cfm](http://www.transformed.com//p4.cfm).

*   Received for publication March 14, 2007.
*   Revision received April 30, 2007.
*   Accepted for publication May 1, 2007.

## References

1.  Future of Family Medicine Project Leadership Committee. The future of family medicine: a collaborative report of the family medicine community. Ann Fam Med 2004; 2 Suppl 1: S3–32.
    
    

2.  Davis K, Schoen C, Schoenbaum SC, et al. Mirror, mirror on the wall: an update on the quality of American health care through the patient's lens. New York: The Commonwealth Fund; 2006 April [cited 2007 March 1]. Available from: [http://www.commonwealthfund.org/usr\_doc/Davis\_mirrormirror\_915.pdf](http://www.commonwealthfund.org/usr_doc/Davis_mirrormirror_915.pdf).
    
    

3.  Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996; 74: 511–44.
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=8941260&link_type=MED&atom=%2Fjabfp%2F20%2F4%2F329.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1996VU47200004&link_type=ISI) 

4.  Glasgow RE, Goldstein M, Ockene J, Pronk JP. Translating what we have learned into practice: principles and hypotheses for addressing multiple behaviors in primary care. Am J Prev Med 2004; 27: 88–101.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/j.amepre.2004.04.019&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=15275677&link_type=MED&atom=%2Fjabfp%2F20%2F4%2F329.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000222967600010&link_type=ISI) 

5.  TransforMED [homepage on the Internet]. [cited 2007 March 1]. Available from: [www.transformed.com](http://www.transformed.com).
    
    

6.  Institute for Health Care Improvement [homepage on the Internet]. [cited 2007 March 1]. Available from: [www.IHI.org](http://www.IHI.org).
    
    

7.  Cifuentes M, Fernald DH, Green LA, et al. Prescription for health: changing primary care practice to foster healthy behaviors. Ann Fam Med 2005; 3 Suppl 2: S4–12.
    
    

8.  Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002; 288: 1175–779.
    
    

9.  Edsall R. Sinking toward a fertile chaos. Fam Pract Manag 2006; 13: (7)14.
    
    

10. Bucholtz JR, Matheny SC, Pugno PA, et al. Task Force 2. Report of the task force on medical education. Ann Fam Med 2004; 2 Suppl 1: S51–64.
    
    

11. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83: 457–502.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1111/j.1468-0009.2005.00409.x&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=16202000&link_type=MED&atom=%2Fjabfp%2F20%2F4%2F329.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=000232231200005&link_type=ISI) 

12. Fox TF. The personal doctor and his relation to the hospital. Lancet 1960; 1: 743–60.
    
    [CrossRef](http://www.jabfm.org/lookup/external-ref?access_num=10.1016/S0140-6736(60)90632-2&link_type=DOI) 
    
    [PubMed](http://www.jabfm.org/lookup/external-ref?access_num=13824267&link_type=MED&atom=%2Fjabfp%2F20%2F4%2F329.atom) 
    
    [Web of Science](http://www.jabfm.org/lookup/external-ref?access_num=A1960WB59500019&link_type=ISI) 

13. David AK. Preparing the Personal Physician for Practice (P4): Residency training in family medicine for the future. J Am Board Fam Med 2007; 20: 332–341.
    
    [FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjAvNC8zMzIiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzIwLzQvMzI5LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

14. Leach DC, Batalden PB. Preparing the Personal Physician for Practice (P4): Redesigning family medicine residencies: new wine, new wineskins, learning, unlearning, and a journey to authenticity. J Am Board Fam Med 2007; 20: 342–347.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjAvNC8zNDIiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzIwLzQvMzI5LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

15. Scherger JE. Preparing the Personal Physician for Practice (P4): Essential skills for new family physicians: how residency programs may provide them. J Am Board Fam Med 2007; 20: 348–355.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjAvNC8zNDgiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzIwLzQvMzI5LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

16. Whitcomb ME. Preparing the Personal Physician for Practice (P4): Meeting the needs of patients: redesign of residency training in family medicine. J Am Board Fam Med 2007; 20: 356–364.
    
    [Abstract/FREE Full Text](http://www.jabfm.org/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NToiamFiZnAiO3M6NToicmVzaWQiO3M6ODoiMjAvNC8zNTYiO3M6NDoiYXRvbSI7czoyMDoiL2phYmZwLzIwLzQvMzI5LmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==)