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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. ,< , ~,, 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. 10

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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 11

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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 12

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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. __: _ ~ ~1 1 ~1 e 1 ~ 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. 13

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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. 14