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CHAPTER 1 CONCERNS ABOUT PRIMARY CARE RESIDENCY TRAINING This chapter outlines some of the concerns about the production of primary care physicians to meet the nation's future requirements. Included are discussions of primary care manpower and the interactions between the provision of indigent care and the financing of primary care residencies. Although the content of primary care residency training is not the focus of these last two topics, they discussed here because they are topics of national importance that can be influenced by the financing of primary care residencies. New Directions for Primary Care Residencies are The education of primary care physicians being prepared to work in the late twentieth and early twenty-first century must respond to changes that have occurred and are occurring in the organization and delivery of health care. The following sections outline some of those changes and the extent to which GME for primary care physicians has adapted. Why is There a Need to Increase Ambulatory GME? Changes in the content of inpatient and outpatient care, and in the roles that primary care physicians are called upon to play, have made the inpatient hospital setting less appropriate as the principal site for primary care education. These changes and why they are important can be summarized briefly: 0 For a number of reasons, including technological changes, economic incentives, and decreased length of stay, hospital patients are sicker than they used to be. Therefore the inpatient educational experience is becoming increasingly narrow, and the inpatients seen by primary care residents are less like those they will encounter in their practices. O The length of hospital stay has decreased. As a result inpatient residencies do not provide an ongoing interaction between resident and patient, nor are residents able to participate in the diagnosis or post-operative care of patients to any great extent. Residents on inpatient service also have little chance to view the full course of disease. 15

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o Key patient decisions and interactions between patients and physicians, such as those that involve consideration of life-style or behavioral aspects of care increasingly occur in the ambulatory care setting. O The range of disease seen in inpatient settings has decreased as the ability to manage disease without hospital admission has increased. The crux of the problem is described by Rueben et al. (1988) who state that the mismatch between education and clinical practice can result in suboptimal preparation of primary care physicians for patient care. Much of the residency experience involves patients with end-stage diseases complicated by co-morbid chronic conditions, with care taking place in a setting where speed and efficiency are at a premium. This compares with a practice setting in which the physician is generally alone with the patient, where the physician must establish trust lest the patient disregard advice or fail to return, and where the range of diseases and ailments encountered will be substantially different from those encountered in the inpatient setting. In addition, the primary care physician should be particularly well-versed in the behavioral sciences and epidemiology in order to understand the complex interactions of patients with their environments. A primary care physician should also be familiar with local agencies that can offer assistance to patients. The Match Between Training and Practice Sites The importance of ambulatory care and the role of primary care physicians can easily get lost in today's high technology, specialty oriented approach to care. It is also easy to forget that the primary care practitioner is likely to deal with a different range of problems than other specialists, and than physicians in specialties and subspecialties that are hospital based. In addition, the primary care practitioner most often practices outside the hospital, in a physician's office. The ambulatory care workload of primary care specialists is illustrated by data from the National Ambulatory Care Survey. This survey of 2,000 office-based non-governmental physicians, collects data about the ambulatory patients encountered during a randomly selected study week. Regarding the patient problems seen in ambulatory practice, 15 diagnostic clusters in 1978 accounted for 50 percent of the half billion annual ambulatory care visits. General and family physicians, general internists, and pediatricians together provided well over 50 percent of outpatient visits for these diagnostic clusters (Rosenblatt et al., 1983~. Figure 1.1 illustrates the nature of the primary care ambulatory practice and the emphasis on conditions that are usually not seen in the inpatient setting. Although the composition of primary care ambulatory visits may have shown some change in the past decade, it seems reasonable to conclude that primary care 16

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Figure 1.1 Diagnosic Clusters Accounting for the Majonty of Ambulatory Visits to U.S. Physician In Selected Specialties In 1977 and 1978. 50+ o o 3 o - ~ 30 E - o 40 bC - 20 10 DJD (16) diabetes Mell (15) . Dep/Anx (5) _ Isch HI Dis (8) Pre & Postntl (3) acute LR! (10) - acute Sp & St (9) soft tissue . . nJurles (6) hour tension (4) general medical exam (1) acute URI (2) acute Sp , & St (9) peptic Dis (29) Malig neoplasm l (20) Acute LRI (10) Dep/ Anx (5) DJD (16) diabetes mell~tus (15) acute URI (2) general medical exam (1) . schemlc heart disease (8) hyper tension (4) acute URI (2) general medical exam (1) general medical exam (1) Pre and Post natal care (3) 1 ~ general practice and family practice internal general obstetrics medicine pediatrics and gynecology breast Dis (58) hvper tension (4) Acute Sp & St (9) peri rectal (39) hernia (57) acute URI (2) Malig neoplasm (20) benign neoplasm (23) general medical exam (1) soft tissue . . . Injuries (6) medical and surgical after care (7) medical and surgical after care (7) acute sprains and strains (9) frac tures and dislo cations (13) general ortho surgery pedics arrhyth mias (54) hyper tension (4) . schemlc heart disease (8) derma titis and eczema (12) acne and related condi tions (18) depres sion and anxiety (5) cardi- derma- psychi atry ology tology Source: Rosenblatt, Roger A., and Daniel C. Cherkin, Ronald Schneeweiss and L. Gary Hart. 1983. The Content of Ambulatory Medical Care in the United States. The New England Journal of Medicine. 309~15~:892-897. Reprinted by permission of The New England Journal of Medicine. 17

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physicians still pronde the majority of care for these 15 diagnostic clusters, and that these clusters still represent a substantial portion of primary care practice. Certainly the primary care experience differs radically from the inpatient experience, where admissions increasingly are for specific, invasive procedures. To the extent that it is desirable that the settings and experiences of residency training replicate those that will be found in practice, it is clear that not all ambulatory settings are of equal quality. The primary care practitioner most often practices in a physiciants office--a site that is underemphasized in todays training. By one estimate, family practice residents spend roughly 40 percent of their time on inpatient services, 30 percent in ambulatory clinics including those of other specialties such as dermatology and ophthalmology, and 30 percent of their residency time in continuity practice where the residents provide primary care for families over an extended period of time and follow patients who are admitted to the hospital (Colwill, 1989). Many sites that are used for ambulatory care training of primary care residents do not meet the description of the recently approved Special Requirements for Residency Training Programs in Internal Medicine, which state that "the conditions under which ambulatory patients are managed should be similar to those of office practicet' (Accreditation Council for Graduate Medical Education, 1988~. The Association of Program Directors in Internal Medicine (1987) investigated both the duration and sites of ambulatory care experiences of internal medicine residents in 1985. Ninety-five percent of the programs surveyed stated that residents had at least two years with continuity experience. For more than 95 percent of these programs the experience consisted of a half day per week. For most residents this experience was in hospital service clinics which differ in many ways from office based experience. The indigent case load is high and advanced disease and multiple conditions are more frequently observed; patients are likely to show evidence of a poor socio-economic environment. Few internal medicine residents spent much time in office-style settings. Only 11 percent of programs offered experience in HMOs and 40 percent offered experience in private offices. Moreover, of those programs that offered these sites only 4.! percent and 14.9 percent of residents respectively trained there. In addition, only 22.6 percent of programs indicated that they also offered ambulatory care block time--an experience that is not interrupted by inpatient duty. Furthermore, despite suggestions that more time be devoted to ambulatory care, change appears to be slow. Data from the National Study of Internal Medicine Manpower (which surveys all accredited internal medicine programs), indicate that between 1976 and 1987 no significant change took place in the proportion of residency time devoted to ambulatory care. However, over that period the site of ambulatory training shifted, with an increase in training away from the hospital campus (Anderson et al., 1989). One indication that the slow rate of change is due in part to the 18

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difficulties in financing and in coping with logistical problems is found in the reaction to a proposal by the Residency Renew Committee in Internal Medicine. In 1988 the committee proposed special requirements for internal medicine training that mandated a minimum of 25 percent of the three-year training program be spent in ambulatory settings. Despite support from such groups as the Association of Program Directors in Internal Medicine, and a general acknowledgement that the change is necessary, the difficulties in implementing the change are enormous. Cost and logistical problems are causing programs to request, at least, a delay in implementation (Cohen, 19891. The pediatric residency experience resembles internal medicine in its lack of similarity to subsequent practice (Schroeder et al., 19861. Charney (1989) notes that a considerable amount of the pediatric resident's ambulatory experience is in acute illness clinics or emergency departments. The climate in an emergency room is in many respects unlike a primary care setting: patients are not likely to be known to the physician, there is little ability to observe over time, and there is pressure to make swift diagnoses. The sites for continuity experience are also criticized. Charney surmises that one of the problems with the continuity clinic is that it is an artificial construct, designed for teaching purposes, where residents do not observe role models for future practice. Better experiences can sometimes be found in neighborhood health centers and private offices. However, only about 30 percent of pediatric residents spend time in those settings. Thus, despite mounting concern about the amount of ambulatory care training, and the quality of training in the most frequently used ambulatory care sites, change has been slow to occur. The ways in which current financing mechanisms make the transition difficult is the subject of Chapter 2. Primary Care Physicians and Cost Containment The concept of the physician as gatekeeper--a designated health professional who serves as the patient's primary physician and refers patients to specialist services, as needed--is not new (Somers, 1983~. Today the emphasis is on the role of the primary care physician as a gatekeeper or case manager, often in managed care systems, with responsibility for balancing cost and quality considerations and ensuring that patients receive good, cost effective, care. The question of whether primary care physicians are the most appropriate gatekeepers was answered in the affirmative by Somers (1983), with limitations. In some circumstances a subspecialist might be appropriate--for instance for a patient with end-stage-renal disease the nephrologist might function as gatekeeper. In practice it appears that, at least in HMOs, primary care physicians do perform 19

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the gatekeeper role. Of 91 HMOs that responded to a survey and used patient care managers/gatekeepers, 79 percent always used physicians for that function. Family practice, internal medicine, and pediatrics were the three most frequently used specialties (American Medical Care and Review Association, 19881. In addition to these formal roles, primary care physicians can play major roles in containing health care costs in less formal ways. Even in traditional solo practice or group fee-for-service practices, the primary care physician makes decisions concerning testing and referral that have major cost implications. In addition, some of the attributes emphasized in primary care, such as preventive care, health education and counseling are thought to be useful in forestalling more costly episodes of illness. Eisenberg (1986) reviewed the literature on differences in behavior among specialties. He notes that, in general, the literature suggests that the more specialized physicians provide more intensive care than do generalists even when controlling for case mix and severity. Eisenberg also notes that residents learn decision-making styles during their residency training. Thus, the nature of the residency experience can be a powerful influence on the ability of the physician to provide cost effective care--an ability that is increasingly valuable in today's environment. As one examination of the need for teaching in the ambulatory setting noted, organized forms of medical care find that the more tightly they control care to emphasize primary care, the more likely they are to be financially viable. Therefore primary care physicians, even more than other physicians, need clinical training in ambulatory-care settings (Perkoff, 1986). Other Policy Issues Relating to Financing Primary Care GME The following sections discuss two areas that may be affected by changes in the support of GME for primary care physicians--the supply of primary care physicians and access to care for indigent people. PrimarY Care Manpower Two issues in primary care manpower are pertinent to the committee's deliberations. The first is whether the educational system is producing enough primary care physicians to meet the nation's needs, or to put it another way, whether the proportion of primary care physicians and specialists being produced matches future needs. The second issue is linked to the answer to the first. If there is a desire to sustain the rate of production of primary care physicians, or perhaps increase the rate of production, will a sufficient number of physicians choose primary care specialties and fill available residency slots? The question of the balance between the demand for and supply of physicians has been debated for a long time. Major uncertainties result from difficulties in 20

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estimating demand, which is affected by many variables such as health care financing, the organization of services, technological change, disease patterns, demographics, and economics. The supply of physicians is theoretically easier to project, yet it too is fraught with difficulties, as evidenced by the recent debate about the supply, as well as the demand, forecasts of the Graduate Medical Education Advisory Council. Also debatable is the appropriate supply of primary care physicians. Such groups as a 1978 Institute of Medicine committee have affirmed the key role of primary care physicians in the nation's health care system (Institute of Medicine, 1978). The limited data that are available contain elements that are causing concern about the adequacy of the future supply of primary care physicians. A major study for the Federated Council for Internal Medicine (1987) found that although there will be a slight excess of internal medicine physicians through 2020, there will be shortages of general internists. Taking into account such variables as the ratio of physicians to population, the Council on Graduate Medical Education (COGME) concluded that there is a current or impending undersupply of family practice and general internal medicine physicians, but there is likely to be an oversupply of pediatricians. However, COGME points out that its conclusion is based on an assumption of no change in the demand for pediatric services, which may be invalid; adolescent morbidities are increasing and between 12 and 16 million children are uninsured. Expansion of insurance coverage would cause a major increase in demand for pediatric services (Council on Graduate Medical Education, 1988). Table 1.1 indicates that between 1981 and 1987 the three specialties with which this report is concerned -- general internal medicine, general pediatrics, and family medicine -- experienced growth rates close to, or substantially in excess of, the growth rate of all physicians. However, in 1987, these three groups together represented less than 26 percent of all active physicians. Table 1.2 shows the projections to the year 2020 of the Bureau of Health Professions, indicating that in future years the three primary care specialties together are expected to grow at a slower rate than the supply of all physicians. The Bureau attributes the slow rate of growth in part to loss of older physicians who will not be replaced in sufficient numbers (Department of Health and Human Services, 1988). Growth in the supply of primary care physicians in the near future must come from the pool of physicians doing their residency training. Table 1.3 indicates the relatively meager growth between 1985 and 1988 in the number of residents in the three primary care specialties compared with the total growth in 21

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Table 1.1 Supply of Active Physicians in Family Practice, General Pediatrics and General Internal Medicine, 1981 - 1987 1981 1987 1981-87 Percent Change 20.7 Specialty No. % of All MDs 485,123 100.0 585,597 No. % of All MDs 100.0 Total Physicians Family 31,195 6.4 44,944 7.7 44.1 Practice General 28,027 5.8 34,669 5.9 23.6 Pediatrics General 60,118 12.4 72,038 12.3 19.8 Internal Medicine Total 119,340 24.6 151,165 25.8 26.7 Source: American Medical Association, Physician Characteristics and Distribution, 1982 Edition and Forthcoming 1988 Edition. 22

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Table 1.2 Projected Change in Number of Professionally Active Physicians, General and Family Practice, General Internal Medicine and General Pediatrics 1986, 2000 and 2020 Percent Percent Change Change Specialty 1986 2000 2020 1986-2000 1986-2020 All 521,780 667,370 757,130 27.9 45.1 Physicians General 71,320 81,660 95,100 14.5 33.3 and Family Practice General Internal Medicine 76,260 91,440 105,930 19.9 38.9 General 34,530 46,040 51,520 33.3 49.2 Pediatrics Primary Care 182,110 Physicians 219,140 252,550 20.3 38.7 U.S. Department of Health and Human Services, Sixth Report to the President and Congress on the Status of Health Personnel in the United States. DHHS Publication No. HRS-P-OD-88-1. June 1988. 23

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cD ~14 a a a no ec ~ hi ~ - ~ ~ ME ~x'o on-. i,, US .O o o. o 0 ec o ~ ~C ~Z ~0- ^ =^ C;5 ~ ED ~ == ~o C) ~ o ~ ~ ~= ~=~ P~ Ct O O . ~ Z ~i ~m~ Z ~,^ ~- - C~ =~ ~ ~ 's o .= 24 e Cd ~ _ U] _ ~ U: _ ~ _ _ ~ o _ C~ ~ _ _ O Ct e e ~ O cd C Ct a~ a O ~q ~ ~S: ~ . 1 _ ~ ~ e e_ ~ e _ e_ ~ O O ~e e e_ 00 C~ C~ _ (V 3 ~ ~ ~ o ~ V ~ ~ e_ ,= C) e_ o - o ~n Ct V: e_ _ C) o ~Q ~n e e o ~Q

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residents.) It must be remembered that close to two thirds of internal medicine residents enter subspecialty training (Department of Health and Human Services, 1988). Some analysts interpret data from the National Resident Matching Program as cause for alarm (see for example Colwill, 1988). Table 1.4 illustrates the four-year trend in United States seniors entering primary care residency programs. Each of the three specialties experienced a downward trend of some magnitude. These data, together with indications from an annual survey of graduating medical students, underlie the concerns about the supply of primary care physicians. Data from this survey (Table 1.5) show declines in the proportion of medical students, who each year represent the most recent entrants into the residency pipeline, choosing primary care specialties. Data from the National Resident Matching Program also highlight the fact that the number of available primacy care residencies is not necessarily the determinant of the number of primary care physicians that enter the workforce. Between 1983 and 1989, the number of residency positions in primary care offered to physicians in their first year after medical school increased faster than the positions were filled. Thus, family practice positions offered increased by 4.4 percent and the proportion filled by U.S. graduates fell from 71.4 percent to 59.8 percent. Including foreign graduates the proportion filled fell from 80.6 percent to 71.1 percent. Internal medicine first year positions offered grew by 19 percent between 1983 and 1989, while the fill rate dropped from 71.9 percent to 63.5 percent and 86.3 percent to 80.4 percent respectively for U.S. graduates and in total. The pediatric experience was similar. Positions increased 15.2 percent and the fill rate dropped from 65.8 percent to 60.7 percent and 84.6 percent to 80.0 percent respectively for U.S. graduates and in total (National Resident Matching Program, 1989). However, there are indications that the number of U.S. graduates filling residencies is higher than indicated by data from the National Resident Matching Program. ~ Data from the American Board of Pediatrics indicate that the number and growth rate of pediatric residents may be somewhat higher than indicated by the data in Table 1.3 According to data derived from the number of residents taking the Board's annual in-training exam and a follow-up survey of programs, the number of general pediatric residents grew from 6,695 in 1985 to 6,942 in 1988. (Personal Communication, Thomas K. Oliver, Senior Vice President, American Board of Pediatrics, October 2, 1989). This growth of 3.6 percent exceeds the 2.9 percent shown by data from the American Medical Association, but is nevertheless substantially below the 9.2 percent growth for all residents between 1985 and 1988 shown by the same data set of the American Medical Association. 25

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Table 1.4 National Resident Matching Program Positions Matched by U.S. Seniors Percent Change Specialty 1986 1987 1988 1989 1986-89 Internal 4,067 3,750 3,668 3,432 - 15.7 Medicine* Family 1,680 1,729 1,493 1,468 - 12.6 Practice Pediatrics 1,367 1,366 1,313 1,256 - 8.1 * Excludes preliminary programs because a high proportion of that group enters other specialties. Sources: Jack M. Colwill. 1988. Primary Care Education: A Shortage of Positions and Applicants. Family Medicine 20~41:250-254; National Resident Matching Program, Evanston, Illinois. 26

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Table 1.5 Specialty Choice of Medical School Graduates 1981 - 1988 Percent of All Graduates with Definite Choice General Internal General Family Medicine Pediatrics Practice 198112.7% 7.3% 17.3~o 198213.9 6.8 18.2 198312.7 6.5 17.7 198410.4 6.6 17.0 198510.3 5.6 15.9 19868.3 5.4 17.0 19876.8 5.2 18.3 19887.3 4.9 13.6 Source: Association of American Medical Colleges. Graduation Questionnaire 1981 - 1988. Washington, D.C.: Association of American Medical Colleges. 27

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Such indications are found in data collected by the American Medical Association and frequent anecdotes of positions unfilled by the match being filled by U.S. graduates after the match has been completed. Behind these numbers lie the factors that cause physicians to select specialties. The extent to which financial factors determine choice is not completely clear. Only 0.7 percent of graduating medical students in 1988 stated that income relative to other specialties was the most important factor in the choice of specialty (Association of American Medical Colleges, 1988). However, survey data on such a topic may contain distortions because of reluctance to admit to being influenced by financial factors. Nevertheless, rational economic decision- making would steer physicians away from primary care specialties; the return on the educational investment is lower for the primary care specialties than for all other specialties except psychiatry (Marder, 1988); the incomes of primary care specialties are low compared with other specialties, and the income differential between the highest-paid specialties and the lowest-paid specialties (pediatricians, general and family practitioners, and psychiatrists) is growing. Between 1977 and 1987, the real mean net income (after expenses and before taxes) of general and family practice physicians fell by 0.3 percent; for pediatricians the drop was 0.6 percent and for internal medicine physicians there was an increase of 0.7 percent. Other specialists did better. The real net income of the average physician increased by 1.5 percent over the same period; 3.3 percent for surgeons and 2.8 percent for anesthesiologists. The actual net income differentials were also considerable in 1987. Pediatricians, general and family practitioners and internal medicine physicians had net incomes of $85,300, $91,5000 and $121,800 respectively, compared with net earnings of over $163~000 for obstetrician/gynecologists and anesthesiologists, and over $180,000 for surgeons and radiologists (Gonzalez, 1988). Some economic analyses indicate that future earnings do have a small impact on specialty choice (Sloan, 1980 and Hadley, 1977 cited in Yoder, 1983). One empirical analysis using sophisticated econometric techniques indicates that expected lifetime earnings have a statistically significant but small effect overall on the specialty choice of United States medical school graduates. It is, however, interesting to note that this finding does not hold for women physicians (Marder, 1988). Primary Care and the Problems of indigent Care The committee felt strongly that any policies that increase the support of primary care ambulatory residencies should be analyzed in terms of their impact on access to care for medically indigent patients--both to ensure that access is not imperiled and if possible to increase the availability of services for disadvantaged populations. 28

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The interaction between care for indigent patients and primary care resident financing is complex. On the one hand, primary care training in ambulatory settings is hard to finance, in part because these settings customarily provide care for substantial numbers of medically indigent patients. On the other hand, as can be seen from numerous examples (Walkington, 1989), primary care ambulatory residency programs can be used by state and local governments to provide needed care for indigent residents. When state or local governments pay for such care, the financial difficulties of the programs can be eased. Such a proposal is spelled out by Reiselbach (19861: " a linkage between the funding of graduate medical education and care of the indigent may be an effective means of accomplishing the changes in clinical education and indigent care necessitated by major problems in these areas". The natural affinity that has developed between GME and hospital care can be extended to primary care settings resulting in benefits to education as well as patients. Another aspect of the relationship between primary care physicians and care for indigent people is the role of primary care in the prevention of hospitalization and serious illness. This role is made clear by the following data: a survey of uninsured patients admitted to Washington, D.C. hospitals indicated that nearly 40 percent had no usual source of primary or outpatient care. When evaluated by hospital quality assurance staff it was discovered that more than one-third of uninsured, non-obstetric, non-trauma patients could have avoided the admission of they had received timely primary care. In addition, analysis revealed that admission rates for diagnoses that are well suited to management in an outpatient setting were much higher in poorer areas of the city, where the proportion of uninsured residents is highest (Barch, 1989). These data again indicate that access to primary care can be a cost effective and humane health system response to the problem of medical indigency. Finally, residents are important in enabling teaching hospitals to provide significant amounts of uncompensated care. The fear is that if primary care residents substantially reduce their inpatient service time, the costs of replacing residents with other personnel will reduce the financial ability of the hospitals to sustain their uncompensated care load. This could, in some localities, have a serious impact on access to hospital care for medically indigent people. The role of teaching hospitals in the provision of uncompensated care is quite substantial. In 1986, 369 teaching hospitals (members of the Council of Teaching Hospitals) provided a disproportionate amount of the uncompensated care (deductions for charity care and bad debt) provided by short term non-federal hospitals. These 29

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369 hospitals provided 40 percent of uncompensated care and received only 29 percent of net patient revenues (Association of American Medical Colleges, 1988b). 30

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REFERENCES Accreditation Council for Graduate Medical Education. 1988. Special Requirements for Residency Training Programs in Internal Medicine. Chicago: Accreditation Council for Graduate Medical Education. American Medical Care and Review Association, Council of Medical Specialty Societies. 1988. Patient Care Managers and Gatekeepers: A Status Report. Bethesda, Maryland: American Medical Care Review Association. Anderson, Ronald M., Christopher Lyttle, Claire Kohrman, Gerald Levey, and Catherine Glen. 1989. National Study of Internal Medicine Manpower: XV. A Decade of Change in Residency Training in Internal Medicine. Annals of Internal Medicine. Il0~111:922-929. Association of American Medical Colleges. l98Sa. 1988 Graduation Questionnaire Results. Washington D.C.: Association of American Medical Colleges. Association of American Medical Colleges. 1988b. Bad debt and charity deductions for short-term non-federal hospitals by membership in the Council of Teaching Hospitals. Based on data from the American Hospital Association Annual Survey of Members, 1986. Washington D.C.: Association of American Medical Colleges. Association of Programs Directors in Internal Medicine. 1987. Ambulatory Settings in Internal Medicine Residency Programs. Final Report. Order No. HRSA 86- 468(P). Division of Medicine, Bureau of Health Professions. Health Resources and Services Administration. U.S. Department of Health and Human Services. Barch, Michael. 1989. Director of Administrative Affairs, George Washington Medical Center, Washington D.C. Testimony before the Subcommittee on Health, House Committee on Ways and Means, Washington D.C. April 6. Charney, Evan. 1989. Primary Care Residency Training in Pediatrics: Current Status, Current Issues, Selected Solutions. Presented at the workshop of the Institute of Medicine Committee to Study Strategies for Supporting Graduate Medical Education in Primary Care. April 17-18. Washington, D.C. See Appendix A. 31

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Cohen, Jordan J. 1989. The Case for Increasing the Education of General Internists in Ambulatory Settings. Presented at the workshop of the Institute of Medicine Committee to Study Strategies for Supporting Graduate Medical Education in Primary Care. April 17-18. Washington, D.C. See Appendix A. Colwill, Jack M. 1989. Graduate Medical Education in Family Medicine - Its Ambulatory Emphasis. Presented at the Institute of Medicine Workshop on Strategies for Supporting Graduate Medical Education in Primary Care. April 17-18, 1989, Washington D.C. See Appendix A. Colwill, Jack M. 1988. Primary Care Education: A Shortage of Positions and Applicants. Family Medicine. 20~41:250-254. Council on Graduate Medical Education, 1988. First Report of the Council. Volume II. United States Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, Bureau of Health Professions, Division of Medicine. Rockville, Md. Department of Health and Human Services, 1988. Sixth Report to the President and Congress in the Status of Health Personnel in the United States. DHHS Publication No. HRS-P-OD-88-1. Public Health Service, Health Resources and Services Administration, Bureau of Health Professions. Eisenberg, John M. 1986. Doctor's Decisions and the Cost of Medical Care. Ann Arbor, Michigan: Health Administration Press. Federated Council of Internal Medicine. 1987. Projected Requirements for and Supply of Physicians in Internal Medicine 1990-1010. Prepared by Lewin Associates, Inc. Submitted to the Council on Graduate Medical Education. November 20. 1987. Gonzales, M.L. 1988. Trends, Variations and the Distribution of Physician Earnings, in Socioeconomic Characteristics of Medical Practice, 1988. M.L. Gonzales and D.W. Emmons, Eds. AMA Center for Health Policy Research. Chicago: American Medical Association. Hadley, J. 1977. An Empirical Model of Medical Specialty Choice. Inquiry. 14:384- 401. Institute of Medicine, 1978. A Manpower Policy for Primary Health Care. Washington D.C.: National Academy of Sciences. 32

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Marder, William D., Philip R. Kletke, Anne, B. Silberger, and Richard J. Willke. 1988. Physician Supply and Utilization by Specialty: Trends and Projections. Chicago, Illinois: AMA Center for Health Policy Research. National Resident Matching Program. 1989. NRMP Data. April. Evanston, Illinois: National Resident Matching Program. Perkoff, Gerald T. 1986. Teaching Clinical Medicine in the Ambulatory Setting. An Idea Whose Time May Have Finally Come. New England Journal of Medicine. 314~11:27-31. Reuben, David B., J.D. McCue and B. Gerbert. 1988. The Residency-Practice Training Mismatch: A Primary Care Education Dilemma. Archives of Internal Medicine. 148:914-919. Rieselbach, Richard E. 1986. In Support of a Linkage Between the Funding of Graduate Medical Education and Care of the Indigent. New England Journal of Medicine 314~11:32-35. Rosenblatt, Roger A., Daniel C. Cherkin, Ronald Schneeweiss and L. Gary Hart. 1983. The Content of Ambulatory Care in The United States. An Interspecialty Comparison. Special Article. New England Journal of Medicine. 309~15):892-897. Schroeder, Steven A., Johnathan A. Showstack and Barbara Gerbert. 1986. Residency Training in Internal Medicine: Time for a Change? Annals of Internal Medicine 104~4~:554-561. Sloan, Frank A. 1980. Patient Care Reimbursement: Implications for Medical Education and Physician Distribution in Medical Education Finances. Ed. Jack Hadley. New York: Prodist. Somers, Anne R. 1983. And Who Shall Be the Gatekeeper? The Role of the Primary Physician in the Health Care Deliver System. Inquiry. Vol.XX (4~:301-313. Walkington, Robert A. 1989. Financing Primary Care Residency Training; Examples and Lessons from Successful Training Programs. Prepared for the Institute of Medicine, Committee to Study Strategies for Supporting Graduate Medical Education in Primary Care. See Appendix B. 33

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Yoder, Sunny G. 1983. The Influence of Economic Factors on Medical Students' Career Decisions. In Medical Education and Societal Needs: A Planning Report for the Health Professions. Institute of Medicine. Washington, D.C.: National Academy Press. 34