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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