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OCR for page 67
Chapter 5
EDUCATION FOR PRIMARY HEALTH CARE PRACTICE
In the past ten years, primary care has been increasingly emphasized
in education programs for health professionals. Family medicine depart-
ments have been established in most medical schools (Figure 1), and a
growing share of residency positions has been offered in primary care
programs . At the same t ime , nursing and other nonmedical disciplines
have extended their responsibilities by taking a team approach to primary
care problems, and federal and state governments have supported the
education of more professionals in various disciplines to provide primary
care. 1/
This increased attention to primary care education is important to
primary care manpower policy in two ways. First, professional manpower
goals can be attained only if education programs provide a sufficient
supply of professionals. Second, the nature, scope, and quality of edu-
cation help determine the extent to which manpower meets the public's
needs.
Issues discussed in this chapter are the total number of primary
care residencies nationwide, public support of graduate medical education
in primary care, the nature of medical education, and credentialing of
primary care practitioners. The chapter reviews the state of primary
care manpower education and offers recommendations to improve on the
record of recent years. These recommendations are offered after careful
consideration not only of alternatives but also of possible deleterious
results of policy changes. The committee has tried to be particularly
mindful of the fact that new policies can produce unintended conse-
quences, which require careful thought and attention.
The study committee supports training of nonphysicians - in
particular, nurse practitioners and physician assistants - to provide
primary care. 2/ However, today physicians have the central role in the
delivery of primary care in this country, as in other industrialized
countries, 3/ and the committee therefore concentrates on medical
education.
EVOLUTION OF MEDICAL E DUCATION
The present model for undergraduate medical education was developed
after publication of the Flexner Report, Medical Education in the United
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FIGURE 1: U.S. MEDICAL SCHOOLS WITH DEPARTMENTS OF FAMILY, COMMUNITY AND
PREVENTIVE MEDICINE, 1966-76*
Number of
Schools
80
70-
60-
50--
40-
30-
20-
10-
~ e
7-
-
-
-
_0,
'66- '68-
'67
* Departments are discrete admini
included in each category.
_~:
TAX_
-
_ _
-
—k,
I ~ I - I — - —— I a a
170
'69 '71
strative units.
-
~~~_
i_
'72- t74- ';6-
'73 '75 '77
Combined departments are
Source: Association of American Medical Colleges, D' rectory of
Education (1966-67 through 1976-77)
-68-
OCR for page 69
States and Canada, in 1910. That report criticized the unregulated
proprietary schools that were graduating many poorly trained physicians.
Reforms stimulated in part by the report included defined entrance
requirements for medical schools, generally including a college degree;
development of a full-time faculty trained in both basic science and
clinical medicine; firmer economic bases for qualified medical schools;
laboratories within the schools to help assure excellence among basic
science faculties and to provide resources for student learning; and
direct academic medical center influence over teaching hospitals as
bases of student learning in clinical medicine.
By the end of the 1940s, these reforms had been largely accom-
plished. After World War II, proposals for direct funding of medical
education and for national health insurance were rejected by the U.S.
Congress, but the movement for more public support for medicine resulted
in increased public funding for biomedical research. From 1965 to 1974,
federal obligations for biomedical research and development grew from
1.17 to 2.75 billion dollars (of which the National Institutes of Health
expended 61 and 63 percent, respectively). 4/ This funding indirectly
subsidized medical education by permitting employment of more full-time
researcher-instructors, but it also required diversion of medical school
resources since the federal funding was always lower than the cost of
the research. 5/ The results were an enhanced biomedical research
establishment and remarkable advancements in scientific knowledge, which
were reflected in education programs where students were encouraged to
specialize.
By the mid-1960s, primary care manpower shortages were perceived,
and medical schools altered some of their priorities to accord with new
federal and state legislation. First-year medical and osteopathic school
enrollments increased 41 percent between 1963, when the first federal
Health Professions Educational Assistance (HPEA) legislation was enacted,
and 1976. 6/ New health practitioners were trained to increase access
to primary care, and family medicine departments were established, partly
with HPEA support in the 1970s. The results of these policies are not
yet fully apparent. Medical school and post-graduate training require
approximately eight years to complete, and a new medical school requires
about five years of planning and development before it can open.
THE NUMBER OF PHYSICIANS TRAINED IN PRIMARY CARE
Interest in increasing the supply of primary care physicians
currently centers on the medical specialties usually associated with
comprehensive and coordinated services--family medicine, general internal
medicine, general pediatrics, and to some extent, obstetrics and gyne-
cology. (Federal health manpower legislation excludes obstetrics and
gynecology from the list of primary care specialties, although the
American Medical Association includes it. The present study has found
that many American women receive many health services from obstetricians
and gynecologists but did not determine the appropriateness of primary
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care delivered by these specialists.) 7/ Thus, to expand the supply of
primary care physicians, the Congress An the 1976 Act provided an
inducement for medical schools to place residents in family and general
internal medicine and general pediatrics. This inducement, a central
feature of the Health Professions Educational Assistance Act of that
year, 8/ required medical schools to place 35 percent of first-year
residents in 1977, 40 percent of the residents in 1978, and 50 percent
of the residents in 1979 in these specialties as a condition for receiv-
ing federal capitation support with statutory limits of $2,000 per
student per year.
Several considerations may be relevant to a determination of the
most desirable number of residencies in primary care specialties. For
example, the experience of other countries with different percentages of
practicing physicians providing primary care as opposed to secondary or
tertiary care may be instructive. Also, the potential effectiveness of
a percentage goal in attaining primary care needs is related to the
effects of primary care residency training on the sunolv of nr~;~in~
· . .
primary care p aystctans.
Proportion of Physicians in Primary Care
——r r—~ ~ ~ r ~ o'er
Recent experience does not clearly show what portion of physicians
should practice in primary care. A greater percentage of physicians are
general practitioners in other Western countries than in the United
States. For example, the proportion of physicians who are general
practitioners is twice as high in Australia, Canada, Belgium, and Norway
than in the United States. 9/ But international comparisons are diffi-
cult to make due to the lack of uniformity of data and delivery systems.
Similarly, in this country different physician specialty mixes exist in
different geographic areas or within different comprehensive health
plans, but research has not yet clearly revealed the effects of such
varying mixes on patient satisfaction, the health status of the popula-
tion, outcomes of care, or other indicators of quality.
In one sense especially, a percentage of physicians providing
primary care is an oversimplified representation of a complex scene. A
physician labelled as a primary care provider might devote part of his
or her practice to specialty procedures of particular personal interest.
And a physician labelled as a secondary or tertiary care provider might
also deliver primary care to many patients. 10/
In the mid-1970s, most practicing doctors of medicine were not in
primary care fields. In the 1975-76 academic year, 36 percent of all
filled residency positions were in the fields of general or family
practice, internal medicine, or pediatrics; another 7 percent were in
obstetrics and gynecology. 11/ At the end of 1974, 40 percent of
doctors of medicine whose mayor professional activity was patient care
considered themselves general practitioners, family physicians,
internists, or pediatricians; another 7 percent considered themselves
obstetricians and gynecologists. 12/
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Many factors besides current percentages are involved in setting a
percentage goal for the optimal number of primary care physicians. One
factor is the population's need for specialty procedures and the
frequency with which such procedures must be performed to maintain the
specialist's competency. Another factor is the national requirement
for primary care services related to the supply, productivity, and
geographic distribution of physicians rendering the services. Also
involved is the volume of primary care services provided by different
mixes of primary care physicians or interprofessional configurations.
Data collection pertinent to these factors now appears inadequate to
anchor any percentage goal in generalizable empirical findings.
Residency Training and the Supply of Primary Care Practitioners
Assignment of a medical school graduate to a residency in internal
medicine or pediatrics does not guarantee the making of a life-long
primary care practitioner. The resident may later decide to obtain
training in a subspecialty, to switch specialty fields in mid-career,
or to limit the primary care portion of his or her practice to selected
procedures or certain times. 13/ For example, in the years 1971-75,
15,241 doctors of medicine became certified in general internal medicine,
while 6,986 certificates were awarded in internal medicine subspecial-
ties. 14/ These figures suggest that in many cases graduate training in
genera I internal medicine is an early step in preparation of a subspe-
cialist rather than a primary care practitioner.
To a large extent, these kinds of practice decisions made by physi-
cians may reflect the kinds of patients or cases of interest to the
physician, demands for medical services, and reimbursement policies.
Mere establishment of residency quotas does not assure a steady supply
of primary care practitioners.
Options and Recommendations
The current goal, articulated in the 1976 Health Professions
Educational Assistance Act, is an allocation of 50 percent of all first-
year residency positions to the primary care specialties of family
medicine, general internal -medicine, and general pediatrics. This 50
percent goal might be maintained, increased, decreased, or abandoned in
concept.
Selection of any of these options relies on some estimates of primary
care demands on the total expected physician supply and on some specula-
tion about the effects of residency allotments on individual physicians'
decisions to provide primary care. Although the goal of 50 percent does
not appear to rest on Cal lected data or even on a formal expert group
process, it has not been widely criticized as unrealistic. In fact, the
Bureau of Health Manpower of DHEW determined that 52.8 percent of the
first year residents in 1977 were being trained in primary care
specialt ies . 15/
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Because of the paucity of relevant data, the committee believes that
it is unable to choose a precise percentage goal for primary care resi-
dencies with sufficient confidence that attainment of the goal would
improve health or consumer satisfaction.
In the committee's opinion, primary care is a unique service, best
provided by those trained to provide it. Primary medical care can be
provided by any practicing physician but most sensibly is provided by
physicians trained in primary care residencies, rather than in other
fie].ds. And, because the committee's definition specifies that primary
care could include the management of the great majority (more than 90
percent) of health prob].ems presented to physicians, as we].1 as the
coordination of the management of referred cases, ].6/ most physicians
probably should receive their specia].ty training in primary care. How-
ever, the committee is inclined to believe that a figure significantly
greater than 50 percent, perhaps in the range of 60 to 70 percent,
should be chosen, now during the transition when shortages exist in the
supp].y of primary care practitioners.
One important reason for increasing the percentage of physicians
trained in primary care specialties is some physicians may later deliver
non-primary care. A recent study of physicians with graduate training
in internal medicine, pediatrics, and obstetrics and gynecology in
Massachusetts revea].ed that, less than ten years after enro].lment in the
programs, most physicians believed that less than half their practice
comprised primary care. 17/ A national study showed that one-sixth of
physicians trained in primary care specialties switched to non-primary
care specialties within five years. 18/ Because of the physician migra-
tion from primary care, the need for primary care is even greater; more
than two-thirds of a].]. visits to office-based physicians are to genera].
Or family practitioners, internists, pediatricians, and obstetricians
and gynecologists. _/
Several disadvantages could result from a shortage of residency
training positions in primary care. Demands for primary care might be
unmet, or physicians not trained in primary care might not use their
costly training, and instead, turn to meet primary care demands.
Further, physicians providing primary care after being trained in other
fields might feel tempted to perform unnecessarily the specialty
procedures for which they were trained, or they might perform those
procedures so seldom that they would not maintain clinical competency
in them.
(Recommendation #].2) The committee recommends a substantial increase
in the national goal for the percent of first-year residents in primary
Residency distribution affects not on].y the mix of medical. services
offered and the training experience of physicians providing those services,
but also the distribution of services in training facilities and the
economics of health care. Facilities are constructed, support personnel
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are trained and employed, and procedures are performed and paid for
largely because of expectations about physician specialization. Resi-
dency goals or quotas should be chosen carefully and adjusted when
necessary. Elsewhere this report endorses health services research _
physician activity across specialties and into patient activity acros
categories of accessibility to health care. 20/
Separate from the question of what the percentage goal should be
is the question of how that goal should be used. Primary care residency
goals can be used in evaluating our system of medical education or in
measuring medical schools or medical centers (including hospitals) for
purposes of accreditation or public or private financial support.
Medical students and applicants to medical school or residency programs
also night wish to compare an institution's percentage of affiliated
primary care residency positions to the national goal. It is important
to recognize that service institutions as well as educational institu-
t ions play a role in graduate medical education.
The committee accepts the use of residency goals as a federal
funding criterion, as is now being tried in capitation support under the
1976 law. llowever, it notes that residency goals are not themselves
sufficient to ensure that the needed number of physicians will enter
pr wary c are.
PUBLIC SUPPORT FOR PRIMARY CARE RESIDENCY PROGRAMS
In addition to criteria for capitation grants to medical schools,
public efforts to provide primary care include government financial
assistance for residency training in family practice, general pediatrics,
and general internal medicine. The wisdom of this support depends on
judgments about the federal and state roles, financial incentives as an
alternative to regulation, and the distribution of limited public funds.
Federal and state governments have shown a commitment to foster
medical training in primary care. The 1976 Health Professions Educa-
tional Assistance (HPEA) Act authorized 20 million dollars for each of
the succeeding three fiscal years for the construction of primary care
teaching facilities. 21/ The same act authorized support for establis-
ing and maintaining departments of family practice in medical and
osteopathic schools and for providing graduate training in family practice,
general pediatrics, and general internal medicine. 22/ Area Health
Education Ce it ers (AHECs) are given lIPEA support for, among other pur-
poses, residency training in family practice and general internal medicine.
Additional funding is allowed for team training for third and fourth
year medical students in health -manpower shortages areas.
State governments nave been supportive in funding and establishing
rainily practice departments, especially in state universities. States
also have played key roles in the development of .AHECs (most notably in
the case of North Carolina 23/ ~ and in the construction of ambulatory
care training facilities.
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Options and Recommendations
l
The 1976 HPEA Act places new requirements on the receipt of federal
funds by medical schools and training programs. Conditions on capitation
support - such as the requirement that a certain percentage of residency
positions be in primary care disciplines - sometimes are considered a
prelude to federal control over academic policies and curricula. In
contrast, the targeting of federal support to specific projects, including
the development of family practice residency programs, provides incentives
which educational institutions or other facilities are free to reject
without jeopardizing federal support for other purposes.
Because public financial resources are limited, health policy
leaders addressing the issue of government support for primary care
residency programs must realize that a recommendation for public support
of primary care residency programs presupposes that other contenders for
public funds will be disappointed. Therefore, such a recommendation
presumes not only the appropriateness but also the relative need for
government assistance and the potential social benefits from the support-
ed programs.
A recommendation for support of primary care residency programs
also might be grounded in the belief that primary care training can pro-
duce a long-run saving to society. Primary care practitioners may be
especially skilled at preventing costly illnesses and managing health
problems inexpensively, whereas a large supply of secondary and tertiary
care practitioners may result in the more frequent use of relatively
high-cost procedures. Such cost effects, however, remain to be
demonstrated.
Relative training costs are another economic consideration. A
recent local study determined that graduate training in primary care
costs about $7,000, above patient care costs, annually per resident. 24/
If primary care services were more generously reimbursed, then patient
care costs might offset a larger share of the training costs. An
Institute of Medicine study determined that among twelve types of
graduate medical training programs, family practice residency programs
were the least costly, while general pediatrics and internal medicine
residency programs cost the fourth and fifth least per trainee, respec-
tively. _/
In the context of government support, primary care residency
programs are considered in this report, as in the 1976 HPEA Act,
approved programs for the graduate training of medical and osteopathic
physicians in family practice, general pediatrics, and general internal
medicine, regardless of whether the program is directed by a school, a
hospital, or another institution. In the committee's opinion, of
course, the programs most wisely supported by any funding source provide
training and experience in primary care as defined in Chapter 2.
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To the extent that federal and state authorities respond to
contrasting pressures and imperatives, conflicts could arise in the
making of primary care manpower policy. For example, a state might
decide not to provide any funds to maintain primary care residencies,
leaving the full burden to the federal government's discretion.
(Matching fund programs, a moratorium on all federal aid other than
start-up assistance, and massive capitation support with strict
conditions are among federal vehicles available for preventing such
state government action, although each of these vehicles encounters
philosophical and administrative objections.) Ultimately, states appear
to have different policy levers than the federal government in develop-
ing a uniform primary care manpower policy. The federal government has
made primary care initiatives an outstanding feature of HPEA. One factor
impeding the development of a uniform state policy is that policy co-
ordination is difficult to achieve among the states. State efforts to
develop a uniform policy also would be hampered by state concentration
on public, as opposed to private, schools.
The committee considered whether to recommend continuing or termi-
nating federal or extraordinary state financial support for primary care
_ _
reset ency programs.
Long-term federal support was seen to have the possible detrimental
effect of tending toward federal regulation, with adverse consequences
for the flexibility of medical schools and graduate training programs.
But the committee believes that residency programs must be built up in
order to produce sufficient numbers of practitioners adequately trained
to deliver primary care. Federal support appears to be a necessary
adjunct to state activity, given current constraints on state revenues,
the judgment that primary care residency programs are a national need,
and the difficulties of coordinating medical manpower policy on the
state level. An additional reason for maintaining federal support is
that the funding mechanisms are already in place as part of HPEA.
The committee therefore concluded (Recommendation #13) that federal
~ nts-should continue to promote primary care partly by
using financial incentives for the creation and support of primary care
residency programs. This is by no means the only desirable method for
reinforcing primary care in medical education, but it is a useful and
attractive one. Public expenditures should be earmarked for graduate
medical and osteopathic education in primary care disciplines until
there are graduate programs training enough physicians to deliver primary
care. 26/
PRIMARY CARE MEDICAL EDUCATION
Medical schools and legislatures have taken action in recent years
with important effects for primary care. As suggested by the historical
summary at the beginning of this chapter, these changes have followed
years of enhancement of specialization and scientific knowledge in
. . .
medicine.
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Changes in the Undergraduate and Graduate Medical Curriculum
. . ~
A new medical school emphasis on primary care might be reflected in
changes in the curriculum. Although no studies Nave comprehensively
examined recent trends in the array of courses available to medical
students throughout the country, comprehensive care programs and depart-
~nents of community and social medicine were developed in many medical
schools during the 1960s. In the present decade, most schools have
established departments of family medicine as well as primary care
programs in other clinical departments.
A greater diversity in the academic and cultural backgrounds of
medical school entrants was projected by a committee of the National
Board o f Medical Examiners in 1973. 27/ In 1975-76, 15 percent of
medical school entrants had undergraduate majors in psychology, social
sciences, humanities, general studies, or business. 28/
Approved residency programs in family medicine, initiated in 1969,
have grown to 325 in 1977. 29/ Approved family pract ice residencies are
of three years' duration and rely on a family practice center as a basic
t raining ground . The resident spends a minimum of one-hal f day a week in
the center and maintains continuing responsibility for a selected group
of patients that represent a spectrum of problems from chronic disease
to health maintenance. Behavioral science and epidemiology also are
stressed. Several other types of departments, especially internal i~edi-
cine, now offer primary care tracks for interested residents.
Leg i s l at ive Approac he s
Lack of access to medical care beca'.ne a paramount public concern in
the 1960s . Direct federal aid for medical educat ion was inn' fated with
passage of the first HPEA Act in 1963, which encouraged medical schools
to produce more physicians. Two years later medical schools began to
receive inst itut tonal grants, with the proviso that the schools increase
enrollments. Support was increased under 1968 and 1971 health manpower
legis let ion.
Federal aid for medical education initially has survived a decline
in concern over a possible physician shortage. The 1976 HPEA Act marked
both the end of congressional efforts to expand physician supply and the
start of congressional efforts to support only those medical schools
act ive in primary care . Besides establishing primary care residency
quotas as a condition of capitation support and offering a series of
incentives to create or expand primary care programs, the act also pro-
vided for generous support for student s pledged to pract ice in tile
Nat tonal Health Service Corps after gradual ion . Corps ~ne.mbers serve
popular ions designated by DREW as underserved .
Since the late 1 960s, states have developed a variety of approaches
to increase the supply of primary care pract it loners or improve access to
primary care services. In 1969, the New York legislature passed an act
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that required a family practice department in all state medical schools.
Subsequently, other states have mandated such departments in their state
medical schools. By 1977, almost every state with a medical school had
taken some legislative action to affect its medical schools or residency
programs. 30/ Most of these have provided specific financial support for
family practice programs in both undergraduate and graduate medical edu-
cation.
One legislative approach to meeting primary care needs is the
establishment of Area Health Education Centers (AHECs). First proposed
In 1970 by the Carnegie Commission of Higher Education, 31/ AHECs are
intended to improve both the geographic distribution of health care
providers and the clinical experience of practitioners-in-training by
combining education and service functions in health manpower shortage
areas. Both primary care residencies and undergraduate medical precep-
torships, often set in team contexts, are based in AHECs, which currently
are supported by the DREW Bureau of Health Manpower and by several
states. _ / While evaluation efforts are being made, it is now too
early to determine the success of AHECs in improving the distribution of
services in a cost-effective manner, in leading students into primary
care careers, in providing satisfactory educational settings, or in
coordinating care across professions.
Options and Recommendations
Medical schools' influence over primary care manpower education
involves the selection and assignment of residents, undergraduate
curriculum, faculty composition, research, admission standards, physician
assistant training programs, even in some cases continuing medical
education. In all these areas, issues exist concerning the proper ways
to improve the quantity and quality of primary care training.
These are issues directly confronting medical schools, but they are
are also of interest to policymakers. Public expenditures might be
supplied only to those schools meeting defined primary care objectives,
assuming that promotion of primary care is a major purpose of public
financing of medical education. However, medical educators are sensitive
to the idea that federal pressure on faculty decision-making could
restrict academic freedom, and several medical schools have begun to
reevaluate or even reject federal capitation support.
In the co~mittee's view, education for primary care in the United
States has had several developmental problems. There is a lack of
faculty role models in primary care, and generalists sometimes are
subtlety portrayed as inadequately trained physicians. The committee
also believes that insufficient attention has been devoted to teaching
and research in behavioral and social sciences, to the coordination
and continuity of health care, and to clinical experience in outpatient
sett ings ~
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capably and sometimes at lower cost than physicians. The public's need
for all members of the team, as practitioners and in the training of
primary care physicians, should be recognized, in the committee's
opinion, in distributing support for health professions education.
These recommendations for promoting primary care medical education
are meant to be implemented in concert. The emergence of primary care
as a major area of medical school activity requires change across all
levels of medical education. Moreover, advances in primary care
education are important not only in 'medical education but also in the
education and training of other health professionals - although this
chapter concentrates on the education of physicians as the most common
practitioners of primary care.
CREDENTIALING POLICIES
Education of primary care practice proceeds under the assumption
that graduates of the education programs will be allowed to perform the
primary care services for which they were trained. Credentialing - the
processes of approving individuals to practice health professions and
accrediting education programs - therefore is an important aspect of
education policy.
Credentialing of Primary Care Practitioners
Credentialing of health professionals is done under the authority
of governments or professional associations. The federal government
has a credentialing interest because federal reimbursement progra~ns--
such as l~led~care, Medicaid, and any system of national health insurance--
~nust contain criteria for determining who is elig, ble for payment. State
governments are direct ly involved in credential~ng, because states have
inherent constitutional authority to protect the health of their inhabi-
tants through regulation and therefore to license healths care
pract it loners .
The credentialing activity of professional associations includes
the spec Ha 1 ty cert i f icat ion o f phys ic tans by med ic al specialty organi-
zations, the specialty certification of nurse practitioners by organized
nursing, and the certification of physician assistants who have passed
a national examination developed jointly by the National Board of
Medical Examiners and the American Medical Association. Certification
is largely an honor that in some cases helps an individual obtain
employment, public reimbursement, higher pay, or institutional privileges ;
licensure is actual governmental authority to pract ice a particular
profession.
Physician practice acts, or licensing laws, provide for the licensure
of doctors of medicine and osteopathy. Licensing boards in all states
confer upon every legally qualified physician, and only physicians, the
right to perform the full range of medical and surgical procedures, both
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diagnostic and therapeutic. This situation does not reflect recent
trends in specialized training that prepares some physicians to deliver
primary care while others are trained mainly to perform surgical or
other specialized procedures.
In recent years, most states have amended physician and nurse
practice acts to allow new health practitioners to perform some medical
procedures under various condit ions ~ These reco`mmendat ions have been
of two kinds. Simple authorization amendments (also called delegatory
a'.nendments) permit nurse practitioners and physician assistants to
perform procedures delegated or assigned to them by supervising physi-
cians or employers. Regulatory amendments, in contrast, mandate state
medical licensing boards or other official bodies to authorize practice
by nurse practitioners and physician assistants under conditions set by
law and regulation. Another approach is to license members of the new
profession just as physicians and nurses are licensed. Licensure of new
health pract itioners has been enacted only in the case of child health
associates in Colorado. 37/
~ _
Credentialing Issues and the Use of Nurse Practitioners and Physician
Assistants
Many issues center on credentialing.
In fact, development of the
state nurse practitioner and physician assistant amendments has helped
reopen the questions of how, by whom, and when health professionals
should be credentialed.
The debate encompasses a wide range of opinions, stretching from
the view that the federal government should be the ult innate credent ia-
ling authority to the view that no public agency should undertake to
decide who can perform any specific health service. The debate further
addresses mandatory cant inning education and inc. ludes an interprofes-
sional colloquy over which professions are qualified to perform specific
service s .
Some aspects of the credentialing debate may be considered
especially relevant to primary care. In particular, there are several
nationally unresolved questions about the credentialing of nurse prac-
titioners and physician assistants. prong the most pressing questions
are the following:
First, should states authorize nurse practitioner and physician
assistant practice throug'n regulatory or simple authorization amendments
or through strict licensure? Regulatory aTnend.qlents are the most common
method and allow for some control by regulatory boards over the use of
new health pract it loners . Simple authorizat ion amendments leave
professional responsibilities rather vague and permit decisions about
use of nurse practitioners and physician assistants to be made in the
private sector by health care providers and patients. Licensure
suggests rather strict control on the part of licensing boards with
minimal opportunity for innovative practices.
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Second, should nurse practitioners and physician assistants have
the same scope of practice? Thus far, there is no clear state legi-
slative trend for distinguishing between medical services which nurse
pract it loners can provide and those which can be performed adequately
by physician assistants. Yet these two personnel categories may have
quite different qualifications, epitomized by the previous nursing
education of nurse practitioner trainees. For example, psychosocial
services are emphasized in the education and training of most nurses.
These services are different from medical acts, although the distinction
between medical and nursing services is blurred and marked by different
points of view and changes over t ime ~
The third credentialing question is how broad the scope of practice
should be. Medical diagnosis, treatment judgment and modification, and
the prescription and dispensing of drugs are all types of medical
services that nurse practitioners and physician assistants can perform
under some state laws. Drug prescription is an especially sensitive
area, involving doubts over the sufficiency of scientific knowledge of
new health practitioners as well as doubts that they can perform
effectively, especially in areas with few physicians, unless they are
able to prescribe medication.
Fourth, how much supervision should be required of new health
practitioners? In some states, physicians trust be on the premises
where nurse practitioners or physician assistants perform medical
services. Another type of state restriction prohibits any physician
from supervising more than one or two new health pract it loners .
Studies so far have not shown the quality of care to be superior where
these restrictions are present. 38/ Related to this question is the
propriety of independent practice by new hearten practitioners. The
relationship of physicians to these practitioners might be one of
supervision or of collaboration and referral - hallmarks of independent
pract ice .
Finally, should qualifications include graduating from approved
educat ion programs or passing an approved examinat ion? Some nurses or
other health personnel may '~e qualified to provide some medical services
without participating in nurse practitioner or physician assistant
programs, but the costs of unnecessary formal education of these indi-
viduals nay be worth the risk that experienced but unqualified personnel
could be credentialed if formal education were not required. An
additional qualification question is whether practitioners should be
required to partic mate in cant inning educat ion programs .
These questions, and others like them, are complicated by the fact
that they ordinarily cannot be answered empirical ly unless state laws
are amended to permit the existence of both experimental and control
groups. State laws regularly require adherence to the state controls,
so that experimental credentialing practices usually are illegal.
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The Issue of Accreditation Authorirv over Ntlr.~ Pr=rti tinner P'^~mc
There appears to be no serious question that the medical profession
should be largely responsible for accrediting programs to train physician
assistants. The essential contribution of physician assistants to
primary care is to help medicine and other professions provide needed
medical services capably and economically, and therefore the education
programs offer training in those services that physicians are likely to
delegate to physician assistants. The medical profession thus has a
major interest in the quality and scope of physician assistant programs.
But in the case of nurse practitioner programs, accreditation
authority is a less precise issue. These are nursing programs for
registered nurses, so that the nursing profession has an obvious
interest in continuing to accredit and supervise them. Nurse practi-
tioner certificate training programs now are accredited by the American
Nurses' Association as continuing education programs, while master's
degree programs are accredited by the National League for Nursing. Yet
the medical profession also is vitally interested in programs that train
nurses to provide medical services. In any event, standards of nurse
practitioner programs nay now be too flexible, for the programs range
from brief graduate courses to two-year master' s degree programs. 39/
Such diversity in the length and rigor of educat ion programs nay create
confusion over the role and capabilities of nurse practitioners
general ly.
Although the professions have important responsibilities in program
accreditation, there is some opinion that professional power over educa-
tion programs protects professional monopolies and that accreditation
should be a responsibility of the entire public. Against that opinion
is the view that professionalism requires professional standards of
educat ion and academic freedom from regular ion .
Opt ions and Reco~nmendat ions
. . . .
The co^~,nittee considered four alternatives for a national policy of
public credentialing of nurse practitioners and physician assistants:
o enactment of regulatory amendments for the authorization
of nurse practitioner and physician assistant practice
in all states
simple authorization amendments in all states
o state licensure
0 snaking no change in policy.
The committee favors the first alternative. Licensure of new health
practitioners was rejected by the committee because of the belief that
licensure wou id restrict innovation without necessarily protect ing the
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quality of care. A course of leaving the matter in its present situation
was rejected because the absence of state authorization of nurse practi-
tioner and physician assistant practice is perceived as a barrier to the
utilization and geographic mobility of these groups. The present
situation includes great variation among the states and confusion over
the rights of nurse practitioners and physician assistants in states
where laws have not been amended to authorize practice by new health
practitioners.
A minority in the committee prefers simple authorization amendments
which maximize flexibility; but most members believe that regulatory
amendments offer the best protection against abuse and restrictive
practices by placing regulatory control in a state agency.
The committee recognizes the sharp contrast in current opinions on
licensure'of nurse practitioners and physician assistants. In particular,
strong views are held on the questions of whether new health practitioners
should be allowed to make medical diagnoses and prescribe drugs and
whether laws should require them to be under physician supervision when
delivering medical services.
For example, nursing leaders often advocate an expanded scope of
practice for nurses, reject language classifying diagnoses and treat-
ment as "medical'' services, and prefer interprofessional collaboration
and referral to physician supervision.* The committee agrees that new
health practitioners must be afforded a fairly broad scope of practice,
but a majority of the committee believes that new health practitioners
should be supervised by physicians. Ultimately, physician supervision
of nurse practitioners may give way to equal joint referral and joint
practice arrangements; now, however, even though joint practice
relationships are beginning to occur and succeed in many sites, physician
supervision seems to most members of the committee to be necessary for
universal acceptance of nurse practitioners and physician assistants in
general. '
(Recommendation #19) Amendments to state licensing laws should
authorize, through regulations, nurse practitioners and physician
assistants to provide medical services, including making medical
. . .
diagnoses and prescribing drugs when appropriate. Nurse practitioners
and physician assistants in general should be required to perform the
range of services they provide as sk~Ifully as physicians, but they
should not provide medical services without physician supervision.
This recommendation is intended to foster the development of broadly
worded scopes of practice commensurate with the skills, knowledge, and
potential capabilities of nurse practitioners and physician assistants.
*See comment by Loretta C. Ford, R.N., Ed.D.
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The recommendation rules out independent practice (in the sense of per-
formance of medical acts by new health practitioners), because most
committee members believe that some physician supervision is necessary,
although the requisite degree of supervision may vary with circumstances.
The recommendation leaves to regulatory agencies - which, in the
committee's view, ideally would be consolidated on the state level - the
task of establishing education qualifications, including qualifications
for cant inning educat ion .
The committee expects that nurse pract it loners and phys ic fan
assistants will be liable for malpractice if they injure patients by
not performing medical services as well as most physicians . A review of
liability problems revealed that actual legal complaints of malpractice
do not hinder physician assistant or nurse practitioner utilization. 40/
Legal duties and immunities appropriate to all pri~.nary care practitioners,
including new health practitioners as well as physicians, include the
reporting of both communicable diseases and child abuse and protection
under good Samaritan laws for emergency aid.
In approaching the issue of accrediting nurse practitioner training
programs, the committee considered options to recommend either nursing
or joint medical-nursing control of accreditation. The committee also
considered encouraging greater uniformity through the development of
standards for the length and rigor of the education programs. The
alternative to greater uniformity is continued diversity through the
absence of stricter standards.
Recognizing that nurse practitioners are primarily nurses and that
the development of nurse practitioner fields is a responsibility of
nursing, the committee favors continued nursing control including
authority to set more uniform program standards. The committee believes
that this authority should be exercised, with the collaboration of other
professions, to clarify nurse practitioners' status. In the committee' s
view, collaboration among professions is useful in accrediting all
health professions education programs.
(recommendation #20) The nursing profession should continue to have
accreditation responsibility for nurse practitioner education programs
and should establish requirements for nurse practitioner education and
training, in collaboration with physicians and other health profession-
als. Speed is desirable in creating qualifications for education that
assure recognition of nurse practitioners as highly educated and capable
primary care practit loners .
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REFERENCES
Chapter 5
For further information, see staff paper, "Education of Primary Care
Practitioners."
2. See Chapters 2-3.
3. See Milton I. Roemer, ''Primary Care and Physician Extenders in
Affluent Countries," International Journal of Health Services 7
(1977~: 545-55.
4. James A. Shannon, "Federal Support of Biomedical Sciences: Develop-
ment and Academic Impact," Journal of Medical Education 51 (Supple-
ment, July 1976~: p. 85.
See John S. Millis, A Rational Public Policy for Medical Education
and Its Financing, (New York: National Fund for Medical Education,
-
1971 , P. 9.
6. Uwe E. Reinhardt, "Health Manpower Policy in the United States:
Issues for Inquiry in the Next Decade," paper presented to the
Bicentennial Conference on Health Policy, University of Pennsylvania,
November 11-12, 1976 (mimeographed), pp. 13-4.
For further information, see staff paper, "A Compilation of Data on
the Content of Primary Care Practice."
8. P.L. 94-484, Secs. 501(a), 502.
9. Milton I. Roemer, "Physician Extenders and Primary Care - An Inter-
national Perspective," Urban Health (October 1976~: 40-2.
10. See Chapter 3.
11. Sylvia I. Etzel and John F. Fauser, eds, "Medical Education in the
United States, 1975-76," Journal of the American Medical Association
236 (1976~: 2949-3040, p. 2977.
12. James R. Cantwell, ea., Profile of Medical Practice, 1975-76 edition
(Chicago: American Medical Association, 197-6), pp. 80-1.
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See staff paper, "Data on the Supply and Distribution of Primary
Care Physicians."
14. Calculated from figures of the American Board of Medical
Specialties, Annual Report, 1975-~b, pp. 17-8.
l
15. 42 Fed. Reg. 223 (November 18, 1977~.
16. See Chapter 2 checklist.
17. Henry Wechsler, Joseph L. Dorsey, and Joanne D. Bovey, "A Follow-up
of Residents in Internal Medicine, Pediatrics and Obstetrics-
Gynecology Training Programs in Massachusetts: Implications for
the Supply of Primary Care Physicians," New England Journal of
Medicine 298 (1978~: 15-21.
18. William D. Holden and Edithe J. Levit, "Migration of Physicians from
One Specialty to Another: A Longitudinal Study of U.S. Medical
School Graduates," Journal of the American Medical Association 239
. .
(1978): 205-9.
19. See Chapter 3.
20. Chapter 4; see especially Recommendation #10.
21. This authorization extends to primary dental as well as primary
medical care programs. The figure is obtained by dividing in half
the total authorization for the construction of teaching facilities,
half of which is mandated for "ambulatory, primary care" facilities,
contained in Sec. 302 of the Act, P.L. 94-484.
22. Authorization limits total 45 million dollars for fiscal years
1978-80 for family practice departments, 140 million dollars (less
at least 14 million for general dentistry) for family practice
residency programs, and 60 million dollars for general pediatrics
and general internal medicine. P.L. 94-484, Sec. 801 (a).
23. The North Carolina AHEC program received initial funding under a
1969 authorization of the state legislature. Following execution
of a DREW contract for the development of three AHECs, the
legislature in 1974 appropriated 23.5 million dollars to expand
those three facilities and develop six new centers. See North
Carolina Area Health Education Centers Program, Progress Report,
1975-76, pp. 5, 22.
24. Robert S. Stern et. al., "Graduate Education in Primary Care: An
Economic Analysis," New England Journal of Medicine 297 (1977~:
638-43.
25. Institute of Medicine, "Graduate Medical Education Costs and
Sources of Supply," by Sunny G. Yoder and Joseph T. Brady
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(Washington, D.C.: National Academy of Sciences, 1977, mimeograph-
ed), pp. 47, 49-50.
26. For a more comprehensive discussion of graduate medical education
in primary care, see Robert J. Haggerty, "Graduate Physician
Training in Primary Care," Journal of Medical Education 49 (1974~:
839-44.
27. National Board of Medical Examiners, Report of the Committee on
Goals and Priorities, Evaluation in the Continuum of Medical Educa-
t _ (Philadelphia: 1973), pp. 43-4.
28. These majors (in order of frequency) were psychology, mathematics,
English, history, foreign language, psychobiology, philosophy,
sociology; also political science, anthropology, economics, general
studies, music, religion, and business. 2.4 percent of the entrants
had engineering majors. 70.3 percent had majors in biology,
chemistry, zoology, pre-med, biochemistry, microbiology, chemistry
and biology, physics, other biological sciences, or physiology.
Association of American Medical Colleges, Descriptive Study of
Medical School Applicants, by Travis L. Gordon, DREW Publication No.
. . _
(HRA 77-52 (1977), pp. 36~8e
29. American Academy of Family Physicians, Biannual Survey of Family
Practice Residency Programs - Preliminary Results.' (Kansas City:
1977).
30e ~ ~ ~ '[Collection of Available Data on State Legislation and
Funding for Family Practice Programs (Kansas City: 1977, mimeo-
graphed).
31.
32.
Carnegie Commission on Higher Education, Higher Education and the
Nation's Health: Policies for Medical and Dental Education (New
York: McGraw-Hill, 970), ~
Bureau of Health Manpower support for AHECs totaled 14 million
dollars in fiscal 1977. In 1977 the federal AHEC program served
13 states and was expanded to establish new centers in Colorado,
Pennsylvania, Maryland, and the District of Columbia. DREW Health
Resources Administration, News Release, October 27, 1977.
33. Most members of the predominantly black National Medical Association
apparently practice in the cities of Baltimore, Washington, New
York, Los Angeles, Chicago, Houston, Detroit, St. Louis, Atlanta,
and San Francisco-Oakland. (National Medical Association, personal
communication-) In 1972, 30 percent of black doctors of medicine in
active practice were family or general practitioners, compared to
only 18 percent of all active doctors of medicine. U.S. Department
of Health, Education, and Welfare, "Characteristics of Black
Physicians in the United States: Findings from a Survey," Health
Resources Administration Report No. 75-147 (mimeographed, 1975~.
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34. "Basic sciences" in this context include anatomy, pathology, bio-
chemistry, genetics, microbiology, immunology, pharmacology, and
physiology. Instructional hours not spent teaching those basic
sciences were instead devoted to behavioral sciences (four percent)
or statistics, biometrics, or epidemiology (two percent total).
Institute of Medicine, "Costs of Education in the Health
Professions - Part II" (Washington, D.C.: National Academy of
Sciences, 1974), p. 179.
Primary care research is discussed more fully in Chapter 4. See
Recommendation #11.
36. See Chapter 2.
For a full discussion of credentialing of primary care practi-
tioners, see staff paper, "Licensure of Primary Care Practitioners."
38. See Chapter 4.
39. See staff paper, "Education of Primary Care Practitioners."
40. For a discussion of this issue, see staff paper,
of Primary Care Practitioners."
—'91—
"Legal Liability
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Representative terms from entire chapter:
medical education
