Areas of Concentration


Areas of Concentration (AOCs) are an identified educational method of customizing and enhancing resident education and encouraging the natural development of resident interest and expertise in a focused area, while maintaining a strong commitment to comprehensive generalism in family medicine. Building off the 2007 AFMRD Guidelines for Individual Areas of Concentration, our model emphasizes an institutionally coordinated approach to the step-by-step process of choosing, developing curricula for, and ensuring the maintenance of AOCs which are uniformly high educational value. “Intentional diversification” through a specific enhanced curriculum has been attractive to medical students and residency programs (Nash 2008). This has been implemented in a variety of ways with various terminologies – tracks, areas of concentration, areas of focus, majors, etc. in 2007, the Association of Family Medicine Residency Directors (AFMRD) developed a guideline for what largely based on work done by P4 Project, where many programs included areas of concentration in their innovations. The challenge for many programs is how to take these guidelines and implement locally appropriate areas of concentration that have equivalency of educational value across what can be very diverse topic areas. From our experience, we have defined important steps when developing areas of concentration including:

  • Institutional criteria for choosing which AOC’s to develop.
  • Defining the degree of flexibility to be offered with regards to individualization of AOC’s
  • Developing uniformity of curricula across AOC’s to ensure equivalency of educational value.
  • Developing curricula aligned with ACGME competencies and with measurable outcomes.
  • The incorporation of research, QI, community medicine, and scholarly activity into Area of Concentration curricula
  • The logistics of scheduling block time and longitudinal time for the AOC curricula.
  • The establishment of timelines and deadlines for the various AOC curricular components.
  • The inclusion of opportunities for “resident-as-teacher”, information mastery, and HER enhancement as an expectation of AOC curricula.
  • A coordinated institutional approach to tracking resident progress and portfolio maintenance.

Areas of Concentration (AOC’s) allow family medicine residents to diversify their educational experience beyond traditional elective time. The transition of four-year residency training offers residents an even more in-depth exposure to, and a more expanded breadth of training in, their chosen AOC.

Some Background Reading on Areas of Concentration: Pungo PA “One Giant Leap for Family Medicine: Preparing the 21st-Century Physician to Practice Patient-Centered, High-Performance Family Medicine” JABFM March-April 2010 Vol. 23 Supplement. S23-27.

Crownover B, Crawford PF. “Areas of Concentration Increase Scholarly Activity” Family Medicine 2008; 40(2):87-90. Nash LR and Robinson MD. “Areas of Concentration in Family Medicine Residencies”. Family Medicine 008. 40(9):614-615.

AFMRD Guidelines for Individualized Areas of Concentration (2007).

AOC Descriptions

Addiction Medicine

The addiction AOC trains residents to provide comprehensive team-based care for patients with the full spectrum of addiction issues. Objectives of the AOC includes a goal of competency in biopsychosocial screening, diagnosis and evaluation of patients with all types of addiction, non-pharmacological modalities, counselling, psychosocial/spiritual approaches and medication-assisted treatment with buprenorphine for patients with opiate=use disorder. AOC residents will develop expertise in proper use and interpretation of office-based toxicity screens, appropriate use of opiates in clinical practice and use of naloxone in public health. The AOC will offer experience in methadone treatment, vivitrol, hepatitis and HIV treatment, with an option of training to competency in hepatitis C treatment, as well as methadone and vivitrol treatment.

Resident limit: This AOC is not limited

Faculty member: Stephen Buttenwieser, MD

Advanced Surgical Maternity Care

The Advanced Surgical Maternity Care AOC is integrated OB fellowship that will train residents in high risk and operative obstetrics, promoting continuity of care and family-centered model of care. Objective of the AOC include a goal of 120 vaginal deliveries as well as surgical competency in cesarean sections, tubal ligations, and D&Cs. Residents will also be comfortable with antepartum and intrapartum management of common high risk patients such as twins, hypertensives, and diabetics. Other skill that will learned include basic OB ultrasound, group prenatal visit facilitation, operative vaginal deliveries, and complicated laceration repair.

Resident limit: This AOC can accommodate up to two residents per class.

Faculty member: Elise LaFlamme, MD

Health Systems Leadership

The mission of LFMR is to provide all residents with the skills to provide medical care and medical leadership in the emerging new healthcare system, particularly in underserved communities. The Health Systems Leadership AOC is designed to provide additional knowledge, practical skills, and leadership competencies for those residents who wish to extend the reach of what they can do to affect more people through leading Community Health Centers or other healthcare organizations. The current transformation of the US healthcare system provides an unparalleled opportunity for family medicine to assume a leadership role; the goal of the HSL AOC is to prepare residents to lead in this effort. Residents completing the HSL AOC curriculum will be especially well prepared to play an important role designing and implementing future healthcare delivery models in underserved communities, and advocating for system change and healthcare reform to achieve the “quadruple aim” for all. Specific curricular areas include performance measurement and improvement, quality and safety, CHC operations and governance, payment systems and finance, regulatory and medical-legal aspects, organizational culture and behavior, management skills and communication, leadership, care redesign and population health management, project management, health systems and policy, advocacy, data driven decision making, and personal and career management.

Resident limit: This AOC is not limited

Faculty Members: Jonathan Lichkus, MD and Tuhin Roy, MD

HIV and Viral Hepatitis Care

The goal of the AOC in HIV and viral hepatitis is to train family physicians with the knowledge base and clinical experience needed to provide compassionate, high-quality longitudinal care and treatment for patients with HIV and/or viral hepatitis. It is expected that all residents completing this AOC will demonstrate competence in the longitudinal and primary care of persons with HIV, and will meet the requirements needed to sit for the American Academy of HIV medicine’s (AAHIVM’s) HIV Specialist examination and will additionally achieve competence in care and treatment of individual with viral hepatitis. Specific competencies will cover a broad scope of HIV and viral hepatitis care, treatment, and practice – including, but not limited to, prevention; counseling and testing; primary care management of persons with HIV, viral hepatitis, and/or liver disease, ART and antiviral management; and viral hepatitis- and HIV-related complications and co-morbidities. It is also expected that residents completing this AOC will be able to apply the concepts of PCMH to the care of persons with HIV, and serve as team leaders for an HIV focused PCMH. Activities used to achieve these objectives will include: supervised longitudinal care of individuals with HIV assigned to the resident’s patient panel; participation in the team-based HIV Comprehensive Care Clinic and Viral Hepatitis Clinic; Participation in HIV case conferences and Continuous Quality Improvement (CQI) activities, engagement in community-based outreach and advocacy activities; participation in both independent and group didactic activities (e.g. web-based case studies, journal clubs, and formal lectures); and established electives at outside institutions.

Resident limit: This AOC can accommodate up to two residents per class. Case-by-case evaluation needed if more than 2 residents express interest to ensure adequate training opportunities.

Faculty member: Katrina Baumgartner, MD

Hospital Medicine

The goal of the hospital medicine AOC is to provide additional training for residents interested in pursuing a deeper appreciation of caring for inpatients, critically ill patients, and inpatient teaching. Residents will obtain additional training in inpatient procedural skills and management of inpatient adult patients.

Resident Limit: Two residents per class

Faculty Member: Jennifer Somers, MD; Josh St. Louis, MD, MPH; and Ricardo Camacho, MD

Innovation AOC

The goal of the Innovation AOC is to allow residents to design an AOC that specifically meets their additional training needs, particularly when those needs do not fit within one of our traditional AOCs. Examples of prior innovation topics include geriatrics, behavioral health, and weight management/bariatrics. 

Residents interested in this AOC will need to be able to demonstrate an exceptional level of commitment to designing their own AOC as they -and not the AOC Advisor- will be the main driver in the development and implementation of a successful AOC. Residents who choose this AOC will need to recognize that departing from the traditional AOC tracks imparts a significant risk of a variance in educational experiences.  Residents committed to this AOC will develop educational goals, a curriculum, and educational rotations that meet these specific training needs. They will use the attached ‘AOC Template’ to help structure their AOC, which will need to comply with the attached ‘Common AOC Expectations’ document. Submission process will need to comply with the attached ‘AOC Resident Timeline.’  

Residents interested in this AOC will identify a willing core faculty mentor who will pair with them throughout the AOC design/implementation process. The faculty mentor will review and approve the proposed AOC prior to submission to the residency leadership team for consideration. The Innovation AOC will then be subject to approval by the residency leadership team prior to implementation. When considering whether to approve the AOC, the leadership team will consider 1) whether the AOC accomplishes educational goals not attainable in our traditional curriculum 2) whether the educational goals can be accomplished in an existing AOC 3) financial implications of the AOC 4) ability of the AOC to function without compromising either core learning or AOC specific learning of other AOCs 5) logistics and feasibility of the AOC.  Faculty members who agree to mentor in the ‘Innovation AOC” will be given administrative time to assist with the development, implementation, and maintenance of this AOC as well as to provide protected time for the furthering of this curriculum (eg an AOC coordinator in Behavioral Health would also be expected to help to advance this area of the curriculum for all residents).  

Integrative Medicine

Residents in the AOC will meet the requirements to be eligible to make the Integrative Medicine Board Exam (ABOIM) for certification by the American Board of Physician Specialties. The Area of Concentration in Integrative Medicine has 4 aims: social justice, self-care, skills and science that will be met through a 2-year curriculum with weekly didactics and Integrative Health Consult Clinic. The first year will focus on foundational concepts of integrative medicine followed by an in-depth review of each item on the Whole Health wheel. The second year focuses on learning in an organ system-based curriculum. A longitudinal curriculum is woven throughout to address diversity and decolonization of integrative health by centering Indigenous voices and knowledge, social determinants of health and the impact of loneliness, trauma, poverty and low ACE scores on health and tools to mitigate their impact, nutrition and supplements, environmental health, traditional healing systems and modalities, self-care and space for self-reflection. The first aim is social justice. Whole person care requires embracing cultural humility through honoring, listening to and learning from cultural and individual traditions, stories and narratives. AOC residents will learn how to address social determinants of health as a part of integrative primary care and integrative consult clinic. They will use innovative, compassionate approaches in caring for patients with a history of trauma, addiction, and chronic pain. The second aim is self-care. We recognize that physician burnout is a public health crisis with multiple causes and that self-care may help mitigate its’ effects. Primary care physicians working in underserved communities have higher burnout rates and we hope to provide a learning environment where residents learn to not only care for their patients but also themselves. The third aim is science. AOC residents will learn evidence based integrative medicine through a 2-year curriculum. Lastly, they will have an opportunity to choose a skill that they may apply in their integrative consult or primary care clinics. Former fellows have chosen osteopathic manipulation, herbal medicine and functional medicine.

Resident limit: This AOC can accommodate up to two residents per class.

Faculty member: Suhani Bora, MD

Musculoskeletal Medicine

The primary goal of the Sports Medicine AOC is to foster the advancement of the resident’s knowledge base and clinical skill set in the area of musculoskeletal medicine. It is available to interested residents who wish to further their training in Sports Medicine, supplementing their abilities as a primary care physician. It also aids in the preparation of those who are interested in pursuing a Sports Medicine Fellowship. Residents in the AOC will join primary care sports medicine physicians and orthopedic surgeons in the office to learn diagnostic and therapeutic techniques. They will develop a feeling of confidence in handling common orthopedic problems and encountered in the family physician’s office. Under supervision by our Sports Medicine Certified Family Medicine faculty, residents work with faculty and athletic trainers at Lawrence high School, Greater Lawrence Technical School and Merrimack College. They will also participate in sideline medical coverage, mass participation coverage, injury clinics, rehabilitation, counseling, sport related concussion evaluation/management, pre-athletic screening services for schools and corporations. Residents in this AOC will apply this knowledge to their patients and can elect to work as a team physician for local high school sport teams. 

Resident limit: This AOC can accommodate up to two residents per class

Faculty Member: Christie Langenberg

Reproductive Health

The Women’s Health AOC provides both a broadening of the essential women’s health clinical and didactic experience as well as gives opportunities for additional procedural training in areas such as early pregnancy ultrasound, STD testing, colposcopy, and manual vacuum aspiration for miscarriage management. Additional training opportunities are available in Pediatric and Adolescent Gynecology, STD diagnosis and treatment, options counseling, contraception, and uro-gynecology. It has a framework of increasing responsibilities, moving from learners to supervisors, participating in didactic training of other residents in topics of women’s health, and having opportunities to teach women’s health courses in the community. We anticipate residents in this track will apply the concepts of PCMH to the care female patients, serve as team leaders for a Women’s Health PCMH session, be a resource for staff and clinicians for issues related to women’s health, and co-teach longits on a Gyn topic with faculty instructor. We expect residents to complete a trainer course and serve as an instructor for Sexuality education or ALSO, participate in women’s health advocacy on the local, state, or national level, and complete a WH specific QI and/or research project. Residents will maintain active membership in the Association for Reproductive Health Professionals (AHRP). 

Resident limit: This AOC can accommodate up to two residents per class.

Faculty Member: Julie Johnston, MD