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INTRODUCTION
This report by an Institute of Medicine committee results from a widely held
belief that the current system of financing graduate medical education impedes
efforts by medical educators to prepare primary care physicians to be effective and
efficient in today's health care delivery system. The premise is that increasing the
quantity and quality of ambulatory training of primary care residents could have a
major impact on the quality and efficiency of care that a ~rimarv ears nhv~ininn
delivers during 40 or so years of professional life.
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Educators recently have come to appreciate that the present financing system
is a barrier to reshaping the education of residents to enable them to meet the
realities of modern primary care practice. These realities include the management
of patients in a health care system that is responding to new financial incentives
by increasing the practice of medicine outside the hospital; technological
developments that allow the movement of care to outpatient settings; changes in
demographics and disease patterns that make new demands on primary care
physicians; and efforts to contain health care cost increases that require primary
care physicians to play central roles in decisions about access to services.
The Institute of Medicine received support from The Josiah Macy, Jr.
Foundation and the Health Resources and Services Administration of the Public
Health Service. A committee of 13 members was appointed to conduct the study.
A major component of the study was an invitational workshop which provided the
foundation for the committee's deliberations and recommendations.
Scope of the Study
Because of the ways in which health care services and medical education are
financed, educators trying to provide primary care residents with training in
appropriate ambulatory care settings face financial barriers. These barriers are
more severe than those faced by other specialties or by training in inpatient
settings. The task for the committee was to develop ways of starting to overcome
the financial barriers by enhancing the support of graduate medical education in
ambulatory settings for primary care physicians. To accomplish this objective the
committee was to identify fiscal constraints on primary care graduate medical
education and identify potential resources and mechanisms for support, which
might include federal state and local governments, institutional resources, and the
private insurance industry.
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Those concerned with primary care specialties have approached the topic
from different viewpoints (see for example Millis, J.S. 1966; Institute of Medicine,
1978; U.S. Department of Health and Human Services, 1987; Wartman, 1988;
Gastel and Rogers, 1989). There has been interest in elucidating what the nation
wants of its primary care practitioners in terms of the sorts of services they
provide and the health care needs of the nation's population that they address.
There has been interest in ensuring that physicians are trained in the skills
needed to provide appropriate care and there has been interest in ensuring that a
sufficient number of primary care physicians are available and are geographically
distributed to meet the needs of the local populations.
A well-conceived manpower policy must be based on an understanding of all
of these aspects of primary care. This committee, however, had a narrower
charge. It was asked to develop recommendations for policy changes that would
improve the support of graduate medical education (GME) for primary care
physicians in appropriate ambulatory settings. On the premises that there is a
problem in the financing of primary care GME; that residency training in
ambulatory settings is particularly disadvantaged; and that because of these
factors a needed shift of training to ambulator settings is inhibited, the
committee was asked to identify fiscal resources and fiscal constraints on the
funding of the ambulatory parts of primary care residencies. The committee was
also asked to recommend strategies for overcoming the fiscal constraints that are
resulting in insufficient use of primary care outpatient training sites.
However, the committee recognized that it could not treat the question of
support of GME in isolation from other issues. In particular, the issue of the
supply of primary care manpower cannot be divorced from the issue of GME
financing because patient care revenues have an impact on both the number of
entrants into the primary care specialties, and the ability to support residents in
ambulatory settings. The committee examined evidence concerning the adequacy
of the future supply of primary care physicians and adopted the policy goal of
expanding the primacy care physician workforce. Therefore, while support of
primary care GME in ambulatory settings remained the focus of the study, the
committee approached solutions to the problems bearing in mind that a double
benefit would accrue if strategies that enhance GME funding would at the same
time help attract additional physicians into primary care practice.
The committee also had to define the scope of the study in terms of the
specialties that constitute primary care. The question of what constitutes primary
care has been the subject of considerable discussion. An IOM committee
attempting to define primary care in 1978 reviewed 38 definitions used by various
groups or individuals (Institute of Medicine, 1978). Undoubtedly the last decade
has added to the number. However, for the purposes of this study, which focuses
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on the training of primary care physicians in ambulatory settings, the important
attributes of primary care are: that it is a major entry point into the health
system; that it is to a great extent provided in outpatient settings; that the
primary care practitioner determines the need for, and facilitates referral to, other
health care providers and community services while providing continuity in the
patient's care. Committee members recognized the significant contribution of
osteopathic physicians to primary care, and recognized the problems confronted by
this branch of medicine in supporting primary care residencies. Some solutions
proposed in this study have potential for easing the problems of osteopathic
graduate medical education. The committee gave serious consideration to the
inclusion of obstetrics and gynecology in the definition of primary care specialties.
While acknowledging the major role played by obstetricians and gynecologists in
the delivery of primary care services to women, the committee believed that it
should concentrate on the three specialties of general internal medicine, general
pediatrics, and family practice for which a commonality of problems in the
financing of GME are found, and which are federally defined as primary care
specialties and receive support from federal grants programs intended to enhance
primary care.
Conduct of the Study
During the course of the study the committee held two meetings. The
principal activity of the first meeting was to develop the program for a workshop.
At the second meeting the workshop took place and the committee developed its
recommendations.
The workshop performed a dual function. First, the information derived
from the workshop provided the basis for the deliberations and recommendations
of the committee. Second, the workshop provided a meeting ground for an
exchange among leaders in the three primary care specialties, program directors,
department chairmen, hospital executives, financing experts, and government
officials (See Appendix A for the workshop program). Approximately 50 people
participated in the workshop.
In addition, the committee commissioned background papers to provide in-
depth analyses of topics of particular interest. These papers are Appendix B.
Given the focus of its charge and severe time constraints the committee did
not conduct independent evaluations of some important financial and nonfinancial
issues that play a major role in shaping the training of primary care physicians.
These include the role of the Residency Review Committees in shaping the
residency training experience, the extent to which the process of accreditation of
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education programs assures that "essentials" (the educational requirements for
accredited residency training programs that are approved by a Residency Review
Committee of the specialty) are fulfilled, the problems residency programs confront
as they seek to implement changes in essentials, what needs to be done to
enhance the quality of the training experience in different ambulatory settings,
and to what extent, if any, residency programs may be closing because of financial
problems. In addition, the committee did not address in depth ways of reducing
teaching costs and increasing practice revenues.
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A number of questions have been
ralsea Hour one quality and content of ambulatory training and the funding of
specific elements of education such as the teaching of behavioral sciences and
epidemiology. These important questions, which bear on the development of
quality education programs in primary care, are subjects worthy of investigation
but could not be undertaken by the committee. Moreover, the committee did not
undertake an investigation of the organizational structure of medical schools and
hospitals. An attempt to initiate long term, radical change in the way in which
GME is conducted and financed would require some fundamental reorganization of
these institutions. However, the concern of the committee was to initiate
immediate movement in constructive directions.
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REFERENCES
Gastel, Barbara and David E. Rogers, Eds. 1989. Clinical Education and the
Doctor of Tomorrow. Proceedings of the Josiah Macy, dr. Foundation.
National Seminar on Medical Education. flung, 1988. New York: New York
Academy of Medicine.
Institute of Medicine, 1978. A Manpower Policy for Primary Health Care.
Washington D.C.:National Academy of Sciences.
Millis, J.S. 1966. The Graduate Education of Physicians. Report of the Citizens
Commission on Graduate Medical Education. Chicago:American Medical
Association.
U.S. Department of Health and Human Services, 1987. Community Oriented
Primary Care: From Principle to Practice. Ed. Paul A. Nutting. HRSA
Publication Number HRS-A-PE 86-~. Washington D.C.: U.S. Government
Printing Office.
Wartman, Steven A. 1988. Moving Toward the Ambulato~y-Based Residency. In
Proceedings of the HRSA Conference held March 29-31. Hunt Valley,
Maryland. U.S. Department of Health and Human Services. Public Health
Service. Health Resources and Services Administration. Available though the
U.S. Department of Commerce, National Technical Information Service.
Springfield, Virginia.
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Representative terms from entire chapter:
medical education
