A Voice of Their Own
Putting their indelible stamp on these newly developing programs were the directors. In the early days, some even brought their own patients into the model family medicine center to establish a patient base for the residents.
Part clinician, part administrator, part teacher, these individuals had -- and still have -- a unique position within their medical communities. Perry Pugno, MD, MPH, has described some of the challenges:
- A director's job is a lonely one. Physician colleagues see the director as a representative of the administration; to management, he or she is a physician. There are few peers within the hospital with whom to talk.
- The role has parenting dynamics. Directors guide the residents through the educational process, while also teaching teambuilding, decision making, resource development, and other skills commonly associated with parent-child coaching.
- Directors are "on call" practically 24 hours a day with regard to the residents under their charge.
- The relationship with the residents is intense, lasting three years during which they are often undergoing major life changes such as marriage and family.
- Directors have to model being a good physician. They are called on to constantly maintain their clinical credibility in a job in which a good portion of the time is spent in non-clinical work.
- Directors are required to be both educators and managers, but few have formal training in either the education process or management skills.
- While the gratification is significant, it tends to be delayed until residents have established their own practices within their communities.
- These challenges and the unique nature of the job were significant factors in the directors' need for an organization of their own and led to the formation of the Association of Family Practice Residency Directors (AFPRD).
"Hospitalization" has become a part of the orientation for family medicine resident at the Long Beach program. Rosa Solorio, MD, and Stephen Brunton, MD, Program Director, are attending to Susan Jung, MD, resident "patient."
Like family medicine certification, the idea of a special association took a while to find its moment. Its roots are in Indiana, where Alvin J. Haley, MD, was president of the Indiana Academy of General Practice (later Family Physicians) in 1969. At that time, as the specialty was getting its official start, he suggested creating a liaison committee between family medicine program directors in Indiana and the Academy.
Open discussion forums were held during 1987 and 1988 Family Practice Program Directors Workshops. The American Academy of Family Physicians (AAFP) Division of Education formally surveyed program directors in 1988. The response was strong -- over three quarters of directors returned the surveys and over 70% of these supported the idea of a separate organization.
The reasons for starting the program directors group remain clear to those involved in the early discussions.
"It was a confluence of timing that the directors group needed a separate voice," says Richard L. Layton, MD. "We sought to form a nucleus to focus on tasks that needed to be done."
"Directors represent a fairly specific constituency with specific interests," Dr. Pugno points out. "There was no structure for assuring program directors' priorities were expressed."
Those priorities that needed a voice included representation on the RRC-FP, a strong presence in Washington, DC, and communication among directors and within the "family" of family medicine organizations.
Inevitably, not everyone favored creation of another organization. Even Dr. Layton, who would be elected the group's first president, originally advised against yet another group. "I and others originally felt we didn't need to duplicate what was being done."
Concerns were also expressed about the burden of another meeting to attend and the potential impact the new group would have on the existing family of organizations.
Nevertheless, none of the objections seemed powerful enough to stand against the building momentum of support. In early June 1989, just prior to the Program Directors Workshop, a special session was convened with 150 directors on hand. Dr. Layton, as chair of the AAFP Commission on Education planning committee for the Workshop, chaired this discussion. As a result, a steering committee was formed, comprised of Alvin J. Haley, M.D.; Norman B. Kahn, Jr, M.D.; Richard L. Layton, M.D.; and Charles Payton, M.D., with Jane Murray, M.D., AAFP division director of education, serving as facilitator.
Within two days this group, along with Roland Goertz, M.D., and Elizabeth A. Burns, M.D., met and established a set of six goals for the prospective organization. These were:
- A voice in existing organizations
- A voice in the RRC-FP
- Lobbying in Washington, DC
- Preservation of ties with the AAFP
- Communication among program directors to establish what they wanted from such an organization, and
- Membership for all program directors, one vote each, with a proxy mechanism.
A core group of program directors met frequently and worked to create AFMRD, including (left to right): Richard L. Layton, MD, Alvin J. Haley, MD, Norman B. Kahn, Jr., MD, and Charles Payton, MD. Credit: AFMRD
Following a July 1989 meeting with the AAFP Commission on Education where AAFP support for the new organization was reaffirmed, the planning committee set to work on the nuts and bolts of creating a functional organization. In a November meeting, they reviewed bylaws from similar groups. Committee members selected three names to be put to a vote at the June 1990 Program Directors Workshop: (a) Association of Family Medicine Residency Directors; (b) Association of Residency Directors in Family Practice; and (c) Family Practice Residency Directors Association.
The committee also devised an organization structure that resulted in several of the group's continuing strengths. All program directors -- and only directors -- would be eligible for membership, with one vote for each member.
"The group is profoundly democratic," emphasizes past president John W. Saultz, M.D. "Officers are elected by the members and policies are established by members. This gives the president significant power as she or he is speaking for the entire membership."
This power is enhanced by the single membership category, which includes directors from all types of programs, as Mary Willard, M.D., points out.
"Representing only program directors is an asset because it gives focus to the organization's activities and policies. The group composition gives validity to comments and stands on issues."
By the time of the June 1990 workshop, the planning committee had also worked up a budget, a slate of officers, and an agenda for the attendees' approval. One issue they needed to resolve was the group's relationship to AAFP. The academy would provide administrative support as it had done in the early years of the STFM. The program directors surveyed in 1989 had overwhelmingly supported a group that "related within the AAFP structure." Yet this left considerable latitude.
AFMRD Founders (front): Jane L. Murray, MD; Alvin J. Haley, MD; (back) Norman B. Kahn, Jr., MD; Richard L. Layton, MD; Charles Payton, MD. Credit: AFMRD
Ultimately, the directors were given several choices, including an independent organization, a constituent chapter of AAFP with resolutions going to its House of Delegates, a forum of the Commission on Education, or the status quo. The choice was an independent organization.
The first board of directors were elected at the Program Directors Workshop in 1990 and included:
President: Richard L. Layton, M.D.
President-elect: Stephen Brunton, M.D.
Immediate past president: Alvin J. Haley, M.D.
Secretary / treasurer: Penelope K. Tippy, M.D.
Members at large: Elizabeth A. Burns, M.D.; Norman B. Kahn, Jr, M.D.; and Mary Willard, M.D.
"The election of an immediate past president set the tone for AFMRD," suggests Dr. Layton. "This was a working group that didn't stand on titles!"
On August 31, 1990, articles of incorporation were filed in Missouri for the Association of Family Medicine Residency Directors. Program directors had a voice; they now had to work to make it be heard.