Sailing the 7C’s: Starfield Revisited as a Foundation of Family Medicine Residency Redesign

Abstract

Amidst a pandemic that has acutely highlighted longstanding failings of the US health care system and the graduate medical education (GME) enterprise that serves it, educators prepare to embark on another revision of the program requirements for family medicine GME. We propose in this article a conceptual framework to guide this endeavor, built on a foundation of the core functions that Barbara Starfield suggested might explain primary care’s salutary effects. We first revisit these “4C’s”—first Contact, Continuity, Comprehensiveness, and Coordination—and how they might inform design thinking in primary care GME guideline revision. We also propose the addition of Community engagement, patient-Centeredness, and Complexity. Training residents to deliver on these “7C’s,” functions critical to the delivery of high-performing primary care, is essential if family medicine residency graduates are to serve the clearly articulated, but unrealized, quadruple aim for US health care: improved patient experience and population health at lower costs while preserving clinician well-being. Finally, we highlight and illustrate examples of four critical enablers of these 7C core functions of primary care that must be accommodated in training guidelines and reform, suggesting a need for resident competencies in Team-based, Tool- and Technology-enabled, Tailored (“4T’s”) care of patients and populations.

Brief on Primary Care Part 2: Factors Affecting Primary Care Capacity in Ontario for Pandemic Response and Recovery

“…Health systems with stronger primary care have better population health outcomes, and evidence indicates this is likely facilitated by a core set of mechanisms commonly termed "the Four C's": first contact, continuity, comprehensiveness, and coordination. 33 Models of care, or the way in which health services are organized and delivered, are important for realizing these "Four C's". Although there is limited research available, this Brief discusses how patient enrolment models (PEMs) that formally attach patients to a regular source of primary care, patient attachment to team-based models of care, and inter-physician practice variations, have been important determinants of access, continuity, and outcomes throughout the COVID-19 pandemic, with implications for primary care capacity moving forward.…”

“…53 The mechanism is likely the enhancement of the "comprehensiveness" described in the "four C's". 33 Prior to the pandemic, these benefits were contested in some Ontario models. While an early evaluation of team-based care (the FHT model) suggested few benefits, 54 a more recent review conducted by a third party for the Ministry of Health found that FHTs improved patient and clinician experience and improved quality of care (better afterhours access, better quality, and cost neutral).…”

Brief on Primary Care Part 1: The Roles of Primary Care Clinicians and Practices in the First Two Years of the COVID-19 Pandemic in Ontario

“…[1][2][3] Primary care offers a critical entry point into both COVID-19-and non-COVID-19-related care by providing people with the "Four C's" of first contact, continuity, comprehensiveness, and coordination. 4 The international community has therefore repeatedly called for a focus on strengthening primary health care both in general, and in particular to support COVID-19 pandemic response and recovery. [5][6][7][8] In Canada 9 and internationally, [10][11][12][13][14][15] PCCs often support upstream efforts to address health disparities with an equity-lens that considers the social determinants of health.…”

Core Outcomes of Residency Training 2022 (Provisional)

“…The new ACGME FM residency requirements double down on the Starfield 4 C's-first contact care, comprehensiveness, continuity, and care coordination-and extend them to the community. 5 We assert that exposure does not equate to competence: a family medicine resident is not competent in the care of children just because she has completed 5 months of rotations! We expect residents to co-create their education and believe that this will attract the best medical students.…”