Shaping Future of Family Medicine Training

“This year, it’ll be a big topic,” said Hoekzema, who will be a mainstage speaker during the March 3-5 event that draws hundreds of program directors, coordinators and faculty to Kansas City, Mo.

In October, the ACGME issued new program requirements for family medicine that will take effect July 1. The first major revisions for the specialty’s training programs in a decade include replacing the standard 1,650 face-to-face visits with metrics related to managing a patient panel.

“There are such major changes coming this summer,” said Hoekzema, chair of the Department of Family Medicine at Mercy Hospital in St. Louis. “Hearing first-hand about those changes and ideas from others for implementing them is the best way to know your program is going to be prepared.”

When the 2023-24 academic year begins, the new program requirements will have been three years in the making. Hoekzema, who has been a member of the RC-FM since 2016, has been deeply involved throughout the process, serving on the planning committee for Starfield Summit IV: Re-Envisioning Family Medicine Residency Education in 2020 and as a member of the writing group that drafted the new requirements in the year that followed.

The ACGME did not adopt all of the review committee’s proposals in its final requirements, including limits on administrative time for program leaders and faculty. The AAFP and six other family medicine organizations have urged the ACGME Board of Directors to reconsider that issue.

Hoekzema, who served six years on the board of the Association of Family Medicine Residency Directors, including a term as president, said chairing the review committee has been the most challenging role of his career. He took the role right as the COVID-19 pandemic hit.

“It’s been a wild ride,” he said. “Everything shut down, and we went into crisis management for medicine in general, but residency training in particular. That was an interesting experience, trying to decide what we needed to do as an accrediting body while programs were under such stress from the pandemic.”

The new requirements were made with input from the AAFP, the American College of Osteopathic Family Physicians, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group and the Society of Teachers of Family Medicine, and included a public comment period.

Hoekzema, who served more than 20 years as either associate program director or program director at Mercy’s family medicine residency, said that early in his career, the review committee was “seen as an adversarial body that wanted to catch you doing things wrong.”

He said that approach doesn’t work.

“Even before the pandemic, the mood on the committee was that we did not want to be seen as an adversarial body, and especially during the process of revising requirements,” he said. “It was going to be important to get input from the rest of the family medicine community about what we need to do with training going forward. It would be better for all of us if we did that in collaboration.

“The culture of the committee is now one where, yes, we have to hold programs accountable to what our training standards are, but we can do it in a way where we’re open in our communication and we set clear expectations. We listen and hear what people need help with. I tell people, ‘The review committee is you. We do the same jobs that you do. We’re program directors, faculty members or department chairs. We’re family physicians who practice in the trenches, just like everybody else.’”

Hoekzema once would have seemed an unlikely leader in shaping the future of family medicine. During his studies as a biology and chemistry student at Calvin College in Michigan, he worked in a National Cancer Institute research lab and envisioned a career in research. A trip to Nigeria changed his path, motivating him to combine his interests in research and caring for vulnerable populations.

He enrolled in the Washington University School of Medicine (located near his future wife’s family) and has been in St. Louis ever since. Washington University doesn’t have a family medicine department, but Hoekzema found his way to the specialty through the school’s family medicine interest group and a community-based mentor.

“You really were on your own,” he said, “and that helped me because I went out and found family medicine experiences as a student that let me see people outside of an academic medical center practicing medicine. I spent time with real doctors in their offices as a first-year student.”

Hoekzema’s first rotation was with Peter Danis, M.D., who was then the Mercy program director.

“It was a great place to experience family medicine,” Hoekzema said. “It really solidified that this is what I was meant to do.”

Danis agreed, and after Hoekzema completed his residency training at Mercy he stayed on as chief resident and then as core faculty. It was Danis who put Hoekzema on the program director path, encouraging him to pursue the new National Institute for Program Director Development Fellowship.

“When I was a new faculty member, he thought I would be a good person to eventually take over from him, but he thought it would be really good if I had some additional training first,” Hoekzema said. “It was a godsend. I went into it with trepidation, but it turned out to be the best career move I could have made. I met program directors from all around the country and learned from them. I was fortunate to get pushed out of my local St. Louis bubble and into a national scene because it changed my view of what we needed to look like as a program and what I would want to do in my career. I realized that if I benefited from getting outside our four walls, so would our faculty. We make it a priority to send people to national meetings to learn, come back and share.”

Like Danis, Hoekzema made way for a Mercy grad in 2016 when he moved from program director to associate program director and elevated Sarah Cole, D.O., to director. Chair of Mercy’s Family Medicine Department since 2015, Hoekzema relinquished the associate program director role in 2020, but he remains core faculty.

“I think if you’re honest with yourself, you know when it’s time to step aside and let somebody else take the reins,” he said. “Once I started to take on more responsibilities, it became clear that it was probably better for me not to try to juggle the role of the program director along with some of those other roles. Sarah is just a gem, and I would have been foolish to let her go seek a leadership position elsewhere. She was definitely the right person for our program.”

Hoekzema has teaching roles at four different Missouri medical schools and continues to see patients three or four half-days each week.

“I would not want to give that up,” he said. “Helping people is why I went into this field. It’s also important for people in leadership roles to see patients in active practice because it’s the best way to understand how leadership is making an impact. If we’re just making decisions outside of the experience of the exam room, you lose a lot of what is really important when it comes to training residents, teaching faculty, physicians in practice. You have to walk the walk.”