7
Education and Training for Primary Care

If primary care is to move in the direction advocated by this committee, many aspects of education and training of primary care clinicians must be restructured. The committee has already drawn attention to the wide range of responsibilities that primary care clinicians might have, the equally broad array of settings in which they might practice, and the need for a team approach to the delivery of primary care. Various other issues, more widely examined in the arena of health professions education, also impinge on primary care and have implications for the recommendations this committee is making.

Considerable attention has been focused on these important issues. Christakis (1995) reviewed reform proposals for undergraduate medical education in 19 major reports issued from 1910. He found consistent themes in these reports, including the need to increase generalist training and exposure of students to ambulatory care. In recent years, many statements regarding the content and financing of graduate medical education and primary care education of other health professionals have been issued. Moreover, targeted grants from The Robert Wood Johnson Foundation, The Pew Charitable Trusts, and The W.K. Kellogg Foundation have addressed the changes in academic infrastructure, curricula, and financing that must be implemented to respond successfully to a mandate to increase the availability of well-trained primary care clinicians. Most recently, The Robert Wood Johnson Foundation has funded Generalist Initiative grants to medical schools with a goal of promoting primary care and interesting medical students in generalist training.

To this rich mix the present IOM committee adds its particular perspective, which relates more explicitly to primary care. Specifically, this chapter addresses essential changes that need to be made in undergraduate and graduate health



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--> 7 Education and Training for Primary Care If primary care is to move in the direction advocated by this committee, many aspects of education and training of primary care clinicians must be restructured. The committee has already drawn attention to the wide range of responsibilities that primary care clinicians might have, the equally broad array of settings in which they might practice, and the need for a team approach to the delivery of primary care. Various other issues, more widely examined in the arena of health professions education, also impinge on primary care and have implications for the recommendations this committee is making. Considerable attention has been focused on these important issues. Christakis (1995) reviewed reform proposals for undergraduate medical education in 19 major reports issued from 1910. He found consistent themes in these reports, including the need to increase generalist training and exposure of students to ambulatory care. In recent years, many statements regarding the content and financing of graduate medical education and primary care education of other health professionals have been issued. Moreover, targeted grants from The Robert Wood Johnson Foundation, The Pew Charitable Trusts, and The W.K. Kellogg Foundation have addressed the changes in academic infrastructure, curricula, and financing that must be implemented to respond successfully to a mandate to increase the availability of well-trained primary care clinicians. Most recently, The Robert Wood Johnson Foundation has funded Generalist Initiative grants to medical schools with a goal of promoting primary care and interesting medical students in generalist training. To this rich mix the present IOM committee adds its particular perspective, which relates more explicitly to primary care. Specifically, this chapter addresses essential changes that need to be made in undergraduate and graduate health

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--> professional training and the need for clinical training to include multidisciplinary team practice; attention is directed to the three types of primary care clinicians—physicians, nurse practitioners, and physician assistants—focused on in Chapter 6. The need to identify common core competencies across these professions is an important ramification of the discussion. The chapter also explores retraining of physicians for primary care. Finally, it offers nine recommendations by which the committee's vision of primary care might be brought closer to reality through appropriate changes in education and training of health care personnel. Appropriate Training In Primary Care The scope of primary health care services is broad and often complex. Both the content and the challenges of primary care demand a considerable period of education. The committee believes that all newly trained primary care clinicians must have adequate and discipline-appropriate training—that is, specific training in primary care appropriate to their expected roles. For physicians (many of whom will ultimately provide the gamut of primary care services), this means a residency with emphasis on primary care followed by certification by an appropriate specialty board. For the nurse practitioner, it means graduate education and national credentialing. For the physician assistant, it means graduation from an accredited physician assistant program and certification by the National Commission on Certification of Physician Assistants. The Education Of Physicians In considering the education of a physician, this committee concluded that attention ought to be directed at both undergraduate and graduate training, because it believes that new efforts to produce a primary care doctor will be far less productive if instituted only at the graduate level. Thus, this section examines issues for both medical students and residents, noting in particular that models of practice to which physicians-to-be and newly graduated physicians are exposed play a critical role in long-term career directions (Stimmel, 1992; GAO, 1994; Martini et al., 1994; Kassebaum and Haynes, 1992). Undergraduate Medical Education Experience in Primary Care Settings The challenges of revamping the undergraduate medical curriculum should not be underestimated, and this committee was not empaneled to explore such issues in depth. One aspect of primary care is especially important in this context, however, and the committee spent considerable time debating it. Specifically, a true appreciation of a patient's family and community context—a tenet of

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--> this committee's definition of primary care—requires that students gain experience in practices and sites that are primary care based. This does not now happen to nearly the extent the committee sees as desirable. The reasons are varied. Financing issues have been a major impediment to undergraduate education in ambulatory settings. Training costs are increased, and the logistics can be complex; finding ways to offset such costs has been difficult. Other objections to ambulatory training have been raised as well (Petersdorf and Turner, 1995). Some faculty, for example, believe that inpatient education with its intense exposure to acute disease provides better education and can be transferred to the ambulatory setting more readily than vice versa. Others are concerned that, during office visits, patients may not be willing to devote the extra time that might be required to accommodate undergraduate teaching and that, similarly, community-based physicians may be unwilling to have their patient schedules disrupted by student involvement. The committee did not find these arguments about the problems of conducting some undergraduate medical education in outpatient or primary care settings persuasive. Calls for greater emphasis on out-of-hospital primary care training in both undergraduate and graduate medical training are not new; they have been raised with increasing frequency in the last several decades (Alpert and Charney, 1973; IOM, 1983). As discussed below, therefore, the committee concluded that the benefits of such training can and do outweigh the drawbacks and that concrete steps therefore need to be taken to provide all future medical students with such exposure. For this reason, it recommends the following: Recommendation 7.1 Training in Primary Care Sites All medical schools should require their undergraduate medical students to experience training in settings that deliver primary care as defined by this committee. The committee concluded that useful, indeed crucial, educational experiences can take place in doctors' offices, community health centers, and other out-of-hospital community sites. It also judged that such exposure to primary care settings and practices should be relatively intense; that is, an occasional short rotation in several sites is unlikely to provide an adequate experience. References in this chapter to ambulatory in regard to student and resident training should be understood as ambulatory care in primary care settings. The committee strongly cautions against the view that a "rotation in an ambulatory setting" is equivalent to experience with primary care. Substituting ambulatory for inpatient service at either the undergraduate or graduate level will not necessarily yield primary care experience to trainees, because much of ambulatory care is not primary care. For example, many procedures that were once performed in an inpatient setting are now done in offices or ambulatory surgery

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--> facilities—including subspecialty procedures in ophthalmology, gastroenterology, neurology, and others. In the committee's view, undergraduate medical education in sites like those in which doctors are expected to practice in the future has several benefits. First, it will expand their knowledge of the goals and processes of primary care, improve the skills required in primary care, and raise students' sensitivity toward core elements of primary care, such as prevention. Second, it may affect the choices that students make about their careers, especially if they encounter, in those sites, role models who are competent and enthusiastic about their work (Osborn, 1993; Martini et al., 1994). Third, past resistance of residents in graduate medical training to off-campus or out-of-hospital clinical rotations is understandable, to some extent, given the absence of any earlier undergraduate experience in community-based, ambulatory settings. Providing such training at the undergraduate level might go far toward reducing such resistance. Curricular and Other Structural Reforms Curricula and clerkships. Medical schools of course have a certain degree of latitude to determine what their students must know and be able to do when they graduate, and the committee was heartened by information demonstrating that many schools are responding to the challenge of devising innovative undergraduate programs. In 1992, the Association of American Medical Colleges (AAMC) appointed a Generalist Physician Task Force to develop a policy statement for the association and to recommend actions to help reverse the trend away from generalism. The task force report recommended that, as an overall national goal, a majority of graduating medical students be committed to generalist careers and that appropriate efforts be made by all schools to reach this goal quickly (AAMC, 1992). The AAMC task force found that medical schools are adding courses with a primary care focus during the first two (preclinical) years and are offering or requiring clerkships in one of the generalist disciplines during the third or fourth years, including clerkships that emphasize experience in primary care settings. At some medical schools, even first-year medical students can apply for primary care clerkships, where they can observe generalist physicians in hospital clinics and doctors' offices. At other medical schools, first-year medical students take required longitudinal primary care clinical care experiences during which they observe generalist physicians in their own office practices. Several schools teach beginning physical diagnosis to their first-year students and supervise patient care interactions such as interviewing and simple clinical examinations. Many schools now include primary care or ambulatory experiences as part of their basic clerkships.1 Gradually more of the core clerkships in family practice, 1   A clerkship is a block of educational time that a medical student spends in a particular clinical setting or defined area of medicine.

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--> internal medicine, and pediatrics are being conducted in physicians' offices, community health centers, and group practices. Specialty societies such as the American Academy of Family Practice and the American Society of Internal Medicine (ASIM) actively support such activities with advice, curricula, and evaluation tools. Efforts to encourage states to fund placement of students with practicing preceptors are also under way, with Texas already having passed legislation to fund such programs. According to a later AAMC report (1994), responses to the 1993 Medical School Graduation Questionnaire found that 36 percent of third-year students and 49 percent of fourth-year students had a primary care clerkship, and 57 percent of these third- and fourth-year respondents had taken the clerkship as a required course. The AAMC task force also found that curricula are being modified to emphasize the evaluative sciences that are associated with primary care, such as epidemiology and evidence-based medicine. This point is especially relevant with respect to the research agenda issues discussed more fully in Chapter 8. Furthermore, schools are developing programs to provide experience in a number of other fields thought important for a fully rounded primary care education. For example, Dartmouth Medical School requires its students to teach preventive medicine in nearby public schools. Medical students are also matched with needy families whom they advise on health care and social services (New York Times, 1992). These are illustrative examples only, and a broader set of examples of office-based clerkships is provided in a ''mentorship kit" developed by the ASIM (ASIM, 1995). This kit encourages local efforts (in part because ASIM is dubious about whether federal funding for such programs will be forthcoming), and it offers practical advice for implementing and evaluating community-based internal medicine teaching for students. Collectively, these examples demonstrate that medical schools across the country can act on, and indeed already are acting on, the above recommendation (Recommendation 7.1) in creative and productive ways. In so doing, schools can also lay the groundwork for acceptance of greater out-of-hospital training during residency years, as discussed more fully below. Competencies and clerkships. Medical schools and various health policy groups have also begun to consider the competencies that should be required of all graduating medical students. As a case in point, The Pew Health Professions Commission (1994) identified seven capabilities that it believes will be essential for all future practitioners, clearly including primary care: Care for the community's health. Provide contemporary clinical care. Participate in the emerging system (including new health care settings and interdisciplinary team arrangements) and accommodate expanded accountability.

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--> Ensure cost-effective and appropriate care. Practice prevention and promote healthy lifestyles. Involve patients and families in the decisionmaking process. Manage information and continue to learn. With increasing interest in the third-year clerkship in primary care, the latest addition to efforts to define appropriate curricula for medical students has been developed by Goroll and Morrison with support from BHP/HRSA (Bureau of the Health Professions of the Health Resources and Services Administration) and approved by the Society of General Internal Medicine (SGIM) and the Clerkship Directors in Internal Medicine (CDIM) (SGIM/CDIM, 1995). This model curriculum for the third-year medicine clerkship is based on a national survey of internal medicine faculty. It emphasizes the importance of training students in basic generalist competencies and shifting a greater portion of their educational experiences from the inpatient to the primary care setting. As described in their materials, the model curriculum divides the competencies into three categories2 that should be taught to third-year students: Category one competencies (taught in all cases when appropriate): diagnostic decisionmaking; case presentation; history and physical examination; communication and relationships with patients and colleagues; test interpretation; therapeutic decisionmaking; bioethics of care; self-directed learning; and prevention. Category two competencies (taught in some but not all cases): coordination of care and teamwork; basic procedures; geriatric care; community health care; and nutrition. Category three competencies (taught occasionally): advanced procedures; occupational and environmental health care. For each competency, a set of corresponding learning objectives, divided into knowledge, skills, and attitudes, has been devised to help guide the learning agenda. Faculty. Other changes proposed by the AAMC have included raising the prominence of generalist physicians in teaching and medical school administrative positions. Some medical schools have responded by appointing faculty from the generalist disciplines to serve on important administrative committees. For example, 2   Categories are derived from a survey of faculty to identify and prioritize basic generalist competencies. Respondents used a five-point scale (1 = low, 5 = high) to rank competencies. Category one corresponds to a mean ranking above 3.38; Category two to 2.72—3.38; Category three to 2.09–2.71. Mean rankings below 2.09 were ranked Category four.

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--> in 1990, one medical school had an associate dean for primary care; five years later, eight schools had created such a position, and many more had added special advisers to the dean on primary care (Fein, 1995). Examinations. The National Board of Medical Examiners (NBME) administers the United States Medical Licensing Examination (USMLE), which was first administered in 1992. Taken by medical students at the end of their undergraduate years, it has also begun to move in a direction that supports greater emphasis on education and training for primary care. In testimony submitted to the committee, the NBME acknowledged that several areas of primary care practice had been underemphasized in its licensure examination—namely, ambulatory care, chronic care, care of the elderly, and preventive care. Acting on its belief that these areas are critically important, it has revamped the examination and placed a priority on generalist knowledge and skills (NBME testimony to the IOM Committee on the Future of Primary Care, 1994). Remaining issues. Despite these encouraging examples, the dominant model continues to be education in the inpatient services of teaching hospitals, and such training can be expected to have a lasting influence. When medical students begin their third- and fourth-year clinical rotations in the hospital, the role models tend overwhelmingly to be those in the increasingly acute, inpatient setting with high-technology interventions (GAO, 1994). Thus, the committee believes that Recommendation 7.1, above, must be acted on more forcefully at the medical school level as a counter to these long-standing traditional dynamics. The committee has discussed the system of undergraduate medical education as a whole, perhaps leaving the impression that medical schools are essentially the same institutions across the nation. This is clearly not the case, however. Different medical schools have quite different missions: Some focus more on research and the production of specialists, others focus more on education and the production of primary care clinicians. Moreover, the effect of the structure of universities within which medical schools function and of the history within each institution of its departmental affiliations can be substantial (a point noted in another recent IOM report [IOM, 1995] on dental education). The committee was not ignorant of these factors, but it judged that exploring them would exceed both its charge and its resources. The basic conclusion is that efforts to overcome some of the problems of changing the mission and the curriculum of medical schools will need to take issues of the larger university organization and aim thoroughly into account. Graduate Medical Education Graduate medical education (GME) provides the opportunity to train physicians for a field of practice and to prepare them for independent practice and

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--> certification. The medical school graduate is an undifferentiated physician who is not capable of independent practice and who must take at least one year of residency training to be eligible for licensure. For practical purposes a physician will require residency training leading to certification to establish his or her place as an appropriately and completely trained physician. Thus, GME becomes as essential for the production of a physician as medical school and is the time when differentiation occurs. Unlike medical schools, which have relatively broad discretion about teaching curricula, graduate programs in primary care (i.e., residencies) are much more closely defined by the residency review committees (RRCs) of each primary care discipline and by the Accreditation Committee on Graduate Medical Education (ACGME). RRCs approve residency programs, which must comply with their requirements. The specialty boards that examine graduates of residency programs for board certification also influence the curricula by determining what is included—and emphasized—on examinations. In short, regardless of the impact of the above-mentioned changes in medical school curricula, how residency programs are structured will remain a dominant factor in creating a cadre of primary care physicians with the characteristics thought to be significant by this committee. Residency Programs in Family Practice, Internal Medicine and Pediatrics Primary care has begun to attract more residents (Fein, 1995). Part of this trend is attributable to external forces, both the growth of managed care (and its greater demand for primary care clinicians) and trends in public policy. For example, several state legislatures have mandated or attempted to mandate that a given proportion, such as 50 percent, of medical school graduates go into primary care residency programs (M. Garg, University of Illinois, Chicago, personal communication, October, 1995). Nevertheless, the main physician specialty areas of primary care—family practice, internal medicine, and pediatrics—have some distance to go in creating training experiences that match the committee's vision of the capabilities that will be needed by primary care clinicians of the future, especially a future dominated by managed care organizations. Managed care organizations made clear to the committee that the current products of family practice, internal medicine, and pediatric residencies lack key competencies required to function maximally in their systems. Based on its public hearing and site visits, the committee shares with many medical educators and the medical directors of integrated health care delivery systems concerns about traditional GME, especially about the extent to which such training is preparing tomorrow's doctors for the new ways and settings in which they will be expected to function. Graduates of residency programs often lack knowledge of population-based health promotion and disease prevention, evidence-based clinical decisionmaking, and patient interviewing skills (particularly communication

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--> and consultation skills). Many are not taught how to function as a member of a team and have little knowledge of information systems or time and resource management. Internal medicine and pediatrics merit special attention, in the committee's view, because tertiary care and specialty care still constitute too much of the training in their programs; internal medicine residents may lack experience in ambulatory clinical specialty areas such as dermatology, ophthalmology, office gynecology, behavioral health care, behavioral medicine, and preventive medicine (Kantor and Griner, 1981; Kern et al., 1985; Linn et al., 1986; McPhee et al., 1987). Other commonly cited deficiencies are training in clinical nutrition, occupational medicine, working with other primary care clinicians (e.g., nurse practitioners, physician assistants), use of community services, resource management, and setting up an office practice (Barker, 1990). Primary Care Tracks Family practice residency programs are unambiguously committed to preparation for primary care practice, whereas internal medicine and pediatric residencies have competing interests in training for referral practice. In the late 1970s, however, residency programs in primary care internal medicine and general pediatrics were established to train more general internists and pediatricians. Primary care tracks provide more office-based training in gynecology, dermatology, orthopedics, otolaryngology, ophthalmology, psychiatry, and preventive and occupational medicine than traditional programs, and they offer much greater continuity experience. Residents in internal medicine primary care tracks spend considerable time in ambulatory settings, serving as the principal physician for their patients. Less emphasis is placed on hospital-based and subspecialty training; more attention is directed to ambulatory specialties, medical interviewing, and clinical epidemiology (Lipkin et al., 1990). In general these curricula are closer to what the committee is advocating, but they are still small in number and remain the exception rather than the rule. Other Content Issues In Training For Primary Care Academic health centers educate and train all types of primary care clinicians (physicians, physician assistants, and nurses practitioners) as well as many other health professionals. Their role is evolving, however, as health care restructuring moves rapidly ahead, and their responsibilities with respect to creating innovative education and training programs will likely be more complex in the future than today. One particular challenge will be to identify, in concert with professional and other groups, common core competencies for primary care, so that tomorrow's training efforts will reflect the committee's vision of primary care and primary care teams.

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--> Future Steps for Academic Health Centers The above-mentioned trends toward reform of undergraduate curricula, changes in graduate training, and more physicians opting for primary care training are encouraging, but they do not tell the entire story. Traditional curricula, training sites, and distinguished role models can all have a powerful reinforcing influence once residents begin their training. Unless primary care faculties are in prestigious administrative and departmental positions (e.g., deans and department chairs), and unless medical students and residents encounter enthusiastic role models, mentors, and teaching methods that support prerequisite skills described in this report, market-driven changes are likely to be short-lived and may eventually give rise to dissatisfied and demoralized physicians who resent not being able to practice medicine as they choose or were trained. The required changes are complex. Academic health centers must undertake fundamental alterations in their missions, administrative structures, practice environments, and curricula. The logistical difficulties are formidable; for example, emphasizing nonhospital settings is costly under current reimbursement policies. Moreover, they come at a time when academic health centers are struggling to change quickly enough to survive in competitive markets, and these pressures do not foster long-term planning strategies. The committee believes that the survival of academic health centers depends on their adoption of primary care teaching and service as a central mission, while continuing and maintaining their roles in providing extraordinarily complex patient care and pursuing biomedical research that has justly earned an international reputation. Further, society needs to support these changes by providing funds for primary care just as it has supported the traditional teaching and research missions of the academic health center. In short, academic health centers will have to change to reflect the practice environment in which its graduates will practice; but society, if it is to enjoy the health care system and practitioners it evidently wants, will need to provide the policy and financial support without which academic health centers will not be able to move forward.3 Common Core Competencies Defining core competencies is a requisite for every field in health care. Credentialing of health practitioners—whether by hospitals or managed care organizations—depends on defined competencies. For primary care to prosper, these competencies must be sufficiently well defined for patients, residents, faculty, 3   A recent IOM report on aggregate physician supply also drew attention to the potentially precarious state of academic health centers (IOM, 1996), especially if changes in Medicare GME reimbursement bring fewer revenues at the same that their health care service obligations remain steady or increase.

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--> managed care organizations, other health practitioners, and physicians seeking retraining to understand clearly what is expected of the professional who provides primary care. Confusion arises over what it means to be a primary care clinician when members of diverse disciplines and specialties (within medicine as well as outside it) declare that they are practicing primary care. Not everyone who declares that he or she is practicing primary care is, in fact, doing so. Despite efforts to define competencies within each discipline and specialty (as illustrated above), no common, cross-discipline competencies have yet been defined and agreed on, either within medicine or across all primary care clinical fields. The remainder of this section reviews efforts by medicine or other health care professions to articulate sets of capabilities or proficiencies for generalist practice. Defining Core Competencies in Medicine Medical training programs have remained separate for historical and understandable reasons. Those reasons and the values they represent—clear and justifiable as they may be to those within the medical establishment—are murky to those outside it. The idea of core competencies, however, is reminiscent of the first-year rotating internship that, at one time and in some states, was required for licensure. The committee does not think that GME ought to return to those days. It holds, rather, that in the long term GME programs in primary care would do better to be based on a core set of competencies for all primary care residents and that such core training ought to be augmented by a series of specialty modules (e.g., in the care of the elderly, of children, or of persons in rural areas). At its most general, training in primary care should equip the clinician to practice competently in a number of areas; for example, for physicians the following competencies would be important: periodic assessment of the asymptomatic person, screening for early disease detection, evaluation and management of acute illness, assessment and either management or referral of patients with more complex problems needing the diagnostic and therapeutic tools of the medical specialist and other professionals, ongoing management of patients with established chronic diseases, coordination of care among specialists, and provision of acute hospital care and long-term care. What specific competencies would enable primary care physicians to fulfill these roles? For half a century or more, the various primary care disciplines have been engaged in defining core competencies within their own fields. For example, in internal medicine, the Federated Council of Internal Medicine Curriculum

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--> in its university-affiliated HMO and its geriatric practice. Similarly, in 1994, with support from The Josiah Macy, Jr. Foundation, the Harvard Medical School and then Harvard Community Health Plan began to implement an educational model of this sort that incorporates practicing and learning in a managed care setting (Moore et al., 1994). The committee is acutely aware of the logistic difficulties of accomplishing this goal in institutions that are organized and funded by program (e.g., physician assistant, nursing, medicine) and by department (e.g., family practice, medicine, pediatrics). Further, these programs and departments may have differing, but deeply held, values that make merging curricula and faculty problematic. It also believes, however, that the commonalities of primary care curriculum content and the realities of the practicing environment make multidisciplinary training both desirable and necessary. Health professionals must develop a common understanding of each other's roles and feel comfortable working with other health professions; they must have confidence about which clinical areas can be appropriately delegated or referred and to whom, and about whose skills augment their own, especially for the complicated medical and social problems that some patients present. Thus, a considerable amount of innovation, experimentation, study, and evaluation of new approaches is called for, and attention should be directed at the best ways to accomplish such teaching. Recommendation 7.8 Experimentation and Evaluation The committee recommends that private foundations, health plans, and government agencies support ongoing experimentation and evaluation of interdisciplinary teaching of collaborative primary care to determine how such teaching might best be done. Although there is no one way that teams should be configured, active exploration of different models can improve our understanding of what works best for patient care and, by extension, what works best for teaching primary care. Three questions about teams have been of particular interest: (1) Who should be on the team? (2) How should work be distributed? (3) Who should provide leadership to the primary care team? Preparing clinicians to practice in a team is a considerable challenge to health professions educators. Long-held distrust between professions, as well as issues of the autonomy of different disciplines, such as nursing and medicine, underlie systems of education. Furthermore, given the differences in length of training and the costs of that training, facilitating the experience of learning together is understandably difficult. Despite such financial and political realities, it is nevertheless essential that interdisciplinary education be pursued if there are to be effective primary care

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--> teams. Otherwise, it is unrealistic, despite a common commitment to patient care, to expect different health professions magically to come together after the completion of their programs and work effectively and efficiently to provide primary care services. Students need to be placed on teams that provide good models of primary care in order to appreciate each clinician's role. Cross-professional preceptorships—such as nurse practitioners working with medical or physician assistant students—convey to all concerned the message that all health disciplines have valuable knowledge and skills. Trainees will also learn to manage the conflicts that are bound to arise as the result of different disciplinary approaches, overlapping roles, and competing demands for team resources and time (Doyle et al., 1993). Integrated Delivery Systems And Primary Care Training Cooperation between academic health centers and integrated delivery systems is currently not occurring to any meaningful degree. Barriers include competition for patients, inflexibility and resistance to change on both sides, and failure of leadership to grasp the long-term potential for community benefit. In the committee's view, however, this should change. Integrated delivery systems (IDSs) can derive benefits from academic centers, and the converse is also true. Shortages of primary care clinicians can be alleviated by creating or participating in primary care residency programs with IDSs providing training sites. To address an oversupply of specialists, academic health centers and IDSs may cooperate in implementing retraining programs in primary care (discussed below under Physician Retraining). Other health professional students—in particular physician assistants and nurse practitioners—can and should be included in IDS sites as well. For example, IDSs may develop training programs for physician assistants and nurse practitioners and then employ these clinicians to increase the efficiency of care in their system. They may also develop programs to expand the skill of nurses who are no longer needed in hospitals to enable these nurses to take on roles in homes, skilled nursing facilities, and with medical groups that need personnel for telephone triage and care management. Such teaching practices can thus be models of multidisciplinary training. If the health plan or system has a primary care residency program, the teaching faculty may be given clinical appointments, and these practices can be the center of physician graduate education. Patients will accept that some clinicians are faculty and that residents and other health professional trainees will participate in their care in these sites. Such partnerships or affiliations between academic health centers and IDSs can include clinical rounds and other linkages with the academic health center as a way to ensure that patients have the benefit of up-to-date

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--> clinical knowledge. Teaching practices can also serve as test sites for new models of care and new technologies such as computer-based patient records. Academic health centers would gain primary care facilities to expand teaching resources in the community. Costs of education and related research could be spread over a broader base. IDSs could provide support for medical, PA education, or advanced practice nursing education in exchange for services and graduates that meet their particular personnel needs. For example, IDS practices that include residents might be able to provide preventive services and continuity of care to a population that otherwise uses an emergency department for its care. Funding will be a critical issue in considering the role for IDSs in primary care education and training. If funding for teaching in these systems is absent or inadequate, IDSs will refuse to participate or will invest only enough to meet their immediate needs. This may result in short-lived programs and programs of questionable educational quality. If, however, IDSs are supported by general revenues or other monies for their medical education activities, as recommended above, they are more likely to be longer-term participants. Because IDSs can bring a defined population—even a community—to medical education, they should be understood as indispensable resources for education and training in primary care. Thus, funding to support cooperation between academic medical centers and integrated systems in primary care education is in the public interest and should be encouraged. Continuing Medical Education The knowledge base of medicine continues to grow, and clinicians change their practices over time. Attention needs to be paid to how primary care clinicians maintain and improve their skills. Traditional forms of continuing medical education (CME) such as conferences and journals may be augmented increasingly by computer-based methods such as CD-ROM learning materials, telemedicine conferences (both presentations and case conferences), and simulated clinical situations that provide learning experiences tailored to an individual clinician's need and interests. Increasingly powerful search methods are available for locating reference materials, experts, and clinical guidelines through the Internet, and these could be especially useful to those in rural and underserved areas where participation in CME is more difficult. Other promising methods give clinicians feedback about test ordering, prescribing, reminders about needed preventive care, and the like (Davis et al., 1995). The development of large IDSs may provide especially appropriate settings for relevant CME that can take place in the practice setting itself and bring within reach rural practitioners and those whose care settings are more isolated. This should include training of primary care nurse practitioners, certified nurse midwives, and physician assistants in addition to the training of primary care physicians.

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--> Physician Retraining One area of concern to the committee is physicians who are currently practicing in non-primary-care fields and who have not had primary care training. Some of these physicians are now interested in practicing primary care, and some assert that they are already doing so. The basic question is to what extent such physicians, never having had any grounding in primary care, ought now to be regarded as primary care clinicians. The American Board of Family Practice (ABFP) has taken the position that a full residency is required to qualify one for primary care practice. Nevertheless, the ABFP position may be unrealistic for most subspecialists, because few physicians are able to return to a training program that reduces their incomes by substantial margins for a year or two, and public or private funding is not likely to be available for substantial retraining, especially not for physicians who may already be earning considerable incomes. In any case, it will be necessary (and more practical) to evaluate the results of current shorter programs before concluding that full primary care residencies are needed for retraining purposes. On the one hand, the committee takes issue with the notion that one can ''self-declare" as a primary care physician if one has never received the relevant training or that a weekend or so of continuing medical education will suffice. The committee strongly affirms that primary care requires special training, but it also believes that requiring currently practicing physicians to undertake a full residency equivalent to those of a newly graduated medical student in order to practice primary care is neither desirable nor feasible. "Retraining" is a middle-ground solution. Experience with retraining of acute-care-based clinical nurse specialists as nurse practitioners has shown that assumptions about the skills that trainees bring to a program based on their educational background are often unwarranted and that more is required than might have been expected. Given discipline-specific demands, nursing should similarly consider that retraining may require significant education. Although commonly used, the term "retraining" in this context is something of a misnomer. Many physicians in medical practice have never been trained in primary care, so retraining in reality refers more to the need to augment the training of clinicians who have been engaged solely or predominantly in subspecialty practice (e.g., a subspecialty of medicine or pediatrics, dermatology, ophthalmology, or anesthesiology) or in specialties that generally involve little or no patient contact (e.g., radiology or pathology). The term does not include training for management positions. A host of issues might be raised about training experienced clinicians to provide primary care.

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--> Reasons for Retraining Several reasons can be given for retraining. First, from a practical standpoint, some managed care plans now require that physicians be classified as primary care physicians either on the basis of specialty training or by self-declaration; in the latter case, the plans may require evidence of some primary care training. Thus, the most recent impetus for retraining is to enable physicians who are already in practice to participate in managed care plans and to continue to see their patients. Second, retraining would avoid a waste of human resources and clinical experience in situations where specialists, because of an excess supply in some areas, are unable to practice. Although some might argue that it would be more efficient for specialists to reduce their practice or retire early, 50 percent of all physicians in practice today are 40 years of age or younger with many productive years ahead of them, so early retirement is not an option for many. Third, there are issues of quality of patient care. On the one hand, if physicians self-identify as primary care clinicians without appropriate training, they may provide poor quality care to their patients. Appropriate training can provide the requisite knowledge and skills. By contrast, newly retrained subspecialists in internal medicine, psychiatry, dermatology, OB-GYN, or other fields could bring needed expertise to a primary care team and thus expand its internal resources. Fourth, the nation needs some additional primary care clinicians now. Retraining could be an efficient way to produce a well-qualified primary care workforce. By implication, training specialists to practice primary care could help to reduce the specialist-generalist imbalance described in Chapter 6. Because subspecialists may not be needed in many rural areas that would welcome a primary care clinician, it might also assist in recruiting and retaining primary care physicians in rural and urban underserved areas. Kinds of Retraining In November 1994 the Pew Health Professions Commission identified 25 different retraining efforts in 13 states (Pew Health Professions Commission, 1994). Of these 25 programs, 10 were in existence, another 6 were under development, 6 task forces or committees were examining research initiatives, and 3 groups were addressing retraining issues. Some of these programs are designed specifically for OB-GYNs; others are directed to internal medicine subspecialists or physicians who have been out of the workforce for a time. One program at the Medical College of Pennsylvania has been in existence for about 20 years, but most are very recent. Length and intensity range widely—from a fully accredited residency program at the University of Tennessee to much briefer programs that might last half a day per week for 6 weeks or more and that are usually described as dependent on the needs of the individual.

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--> A single curriculum is not likely to be either adequate or necessary for all clinicians. Different needs by specialty and type of practice expected (e.g., elderly, large group, urban, rural) are likely to be substantial. Lundberg and Lamm (1993) have made the reasonable suggestion that methods be developed to assess the extent to which practicing specialists possess primary care competencies as a means of determining their retraining needs. The process of adding competencies will almost surely be different for those who, for example, have had three years of training in internal medicine than for those who were trained in a surgical subspecialty. A different curriculum is required to retrain an internist subspecialist who has had exposure to primary care as a resident and has provided some primary care to his or her patients than to retrain an anesthesiologist who has had no primary care training since medical school and has delivered no primary care as a practitioner. The core set of competencies, when developed (see Recommendations 7.2 and 7.3), could form the basis for a retraining curriculum. The length and intensity of the program needed by an individual would be individually determined, and additional modules could be added as necessary and appropriate. In addition, programs might augment ongoing specialty practice with gradually increasing responsibilities in primary care until "retrainees" can demonstrate adequate capabilities in primary care. Certification After Retraining The appropriate certification that should be awarded after retraining is an unresolved question. Many trainees would want a certification that would be more widely transferable than one given by the organization in which they practice or even by a specific state. Without an accreditation policy for retraining or certification examination for individuals based on defined competencies, however, it will not be possible to compare or judge the competence of graduates of widely varying programs. In internal medicine, one section of the recertifying boards is on general internal medicine, and this might be one avenue considered for certification. Recommendation 7.9 Retraining The committee recommends that (a) curricula of retraining programs in primary care include instruction in the core competencies proposed for development in Recommendations 7.2 and 7.3 and (b) certifying bodies in the primary care disciplines develop mechanisms for testing and certifying clinicians who have undergone retraining for primary care. A major oversupply of specialists is perhaps a time-limited problem. In the

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--> short term, retraining of specialists may represent an important opportunity to expand the primary physician workforce, but retraining is basically a coping mechanism, not a preferred route to becoming a primary care physician. The committee believes that the specialist oversupply problem may be largely self-correcting in the longer term, as the proportion of newly trained primary care clinicians increases and the supply of specialists decreases. As a start, a study using focus groups to explore issues of specialist retraining has been funded by The Josiah Macy, Jr. Foundation. The committee suggests that foundations and federal agencies such as HRSA and HCFA conduct or support studies on retraining. These studies should include examination of needed competencies and the feasibility and outcomes of various approaches to retraining for various kinds of clinicians. Questions that might be studied include the following: What is the level of interest in retraining and who are the interested clinicians? Which critical primary care competencies are already known and which need to be taught? Can this be viewed as expanding an impressive set of skills rather than starting over? What types of physicians are successfully retrained and enter primary care practice? What sort of retraining is most appropriate and for what kinds of programs? What elements of GME and CME work best for retraining of the sort contemplated here? Are short CME courses, part-time study, tailored mini-residencies, full residencies, or on-the-job training adequate? What are the characteristics of appropriate mentors or preceptors for experienced colleagues, and are these characteristics different for new residents? What are the most appropriate learning methods for mid-career physicians? Who should do the training? Medical schools? Professional associations? HMOs? Who should pay for retraining—the trainee, the organizations that will or have hired them, or state or federal government? Does the incorporation of retrained specialist and subspecialty physicians into a primary care team augment that team's resources, add a new dimension to the team's capabilities, and allow it to function more effectively? What sorts of standards are needed for retraining? Currently the specialty boards such as those for family practice, internal medicine, and pediatrics have taken different positions. What types of standards could be used, or imposed, by the managed care industry? Summary If primary care is to move in the directions advocated by this committee, then many aspects of health professions education and training will need to be restructured.

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--> This chapter explored the changes likely to be required in undergraduate and graduate training, argued that clinical training ought to involve exposure to multidisciplinary team practice, and examined issues of retraining physicians for primary care. To reach these goals, the committee put forward several recommendations. With respect to undergraduate medical education, the committee was concerned that students gain experience in primary care settings; with respect to graduate training, the committee explored issues of residency programs in family practice, internal medicine, and pediatrics and the value of primary care tracks. Education in ambulatory sites, community health clinics, and managed care organizations is essential to create a primary care workforce that will serve the needs of men and women, children and adults, rich and poor, individuals in rural and urban locations, and persons of all ethnic backgrounds. More broadly, the committee examined questions of advanced training for all primary care clinicians and called attention to the need for the development of a set of common core competencies for all primary care clinicians. In addition, the committee highlighted its concerns about two special areas of emphasis—communication skills and cultural sensitivity. A major consideration for the committee was financial support for primary care training. Consistent with earlier recommendations about universal coverage for health care, the committee called for an all-payer system to support health professions education and training, with some of this support reserved for primary care and directed to training in nonhospital sites such as offices, clinics, and extended care facilities. Adopting the recommendations in this chapter will require a realignment of funding and power to create incentives for different institutional behaviors (for example, in academic health centers and in integrated delivery systems) to focus on primary care and on training in ambulatory as well as hospital-based settings. Similarly, funding mechanisms for graduate medical education will need to be revamped to support training sites other than the traditional hospital base. Because the graduates of these programs will increasingly be needed by integrated delivery systems and the managed care industry generally, the committee believed that all payers should share the burden of establishing and maintaining the required educational infrastructure. Finally, the committee examined other elements of education and training and called for the development of more innovative and interdisciplinary training programs. It also advocated that better mechanisms be created by which nonprimary-care physicians can be formally and adequately retrained for primary care practice. References AAMC (Association of American Medical Colleges). Task Force on the Generalist Physician, October 8, 1992.

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