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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 67
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-
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 -69-
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/ -70-
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/ -71-
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 -72-
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. -73-
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. -74-
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. -75-
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 76
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 ~ -77-
In an educational atmosphere permeated by these factors, primary care prospects are dimmed, for the future of the primary care concept (like any medical ideal depends heavily on its being regarded favorably in academic medical centers. This educational atmosphere leads the committee to advocate an across-the-board effort, aimed at all levels and aspects of medical education, because important changes in medical education are necessary to create an environment where primary care edu- cation can flourish. Some signs of change already are evident. The rise of family practice departments in most medical schools demonstrates 'medical schools' receptivity to primary care. The committee believes that the creation of family practice departments is only one of the many steps that need to be taken. Because of the need for effective and widespread reform, the com- mittee in its deliberations rejected the course of advocating only minor adjustments in medical education, to be accomplished in piecemeal fashion. On the other hand, the committee proposes no detailed agenda for reform of medical education. Rather, general recommendations are presented in several education areas important to the enhancement of primary care - namely, medical school admission standards, curriculum, clinical experience, residencies, continuing education, and team training. These recommendations should be implemented as a unit in order to achieve reform in the atmosphere of medical education. The committee recognizes that these areas in which it of fers recommendations are among several areas of medical education where action could be taken to improve or expand primary care training. One option facing the committee was to present recommendations affecting all such areas of identifiable relationship to primary care. To illustrate, a recommendation could have been made to encourage primary care practitioners to take continuing education courses in primary care. Or a recommendation could have been made to require al 1 medical students to participate in a clinical preceptorship in primary care in a communi- ty-based setting outside of a hospital. The committee chose not to make such recommendations, either because the perceived benefits were con- sidered not to be worth the costs, or because such proposals were considered less important to primary care education than the proposals which the committee adopted. Residencies. Graduate medical education issues center on the . . ~ . . _ training base, which can be a hospital, a physician solo or group practice, or a primary care clinic. Hospital-based residencies do not usually offer much experience in the continuity of care, and those hospital residencies which consist of a series of rotations among - different hospital services may not be oriented toward primary care at all. In some settings, the ratio of residents to faculty members may be too high for effective personal instruction, whereas in other settings the ratios may be too low to facilitate residents' management of the care of a suf ficient number of patients. -78-
The committee weighed options to recommend or not to recommend that all medical schools be affiliated with primary care residency programs. The committee also considered whether to specify the type of institution where primary care residencies should be located and whether to specify ot'ner broad standards for residency training. It dec ided to recommend that (Recommendation #14) it is desirable that all medical schools ,_ .. .. - _ . . . .. ___ . - - direct or have a major affiliation with at least one primary care residency program In which residents have responsibility under faculty . . , _ . . , . . . . ,, . ~ . . .. . . , .., , . . .. , ,. _ . supervision for the provision of accountable, accessible, comprehensive, c ant inua 1 ? and coord inat ed c are. A ma jority of the committee believes that a student graduating from a medical school should be able, if qualified, to obtain primary care training in a graduate program connected with his or her school. The committee would accept within the terms of this recommendation any residency program in which supervised residents deliver primary care as defined in Chapter 2. Graduate medical education in primary care should, in the committeets view, provide participants with experience in managing accessible, comprehensive, coordinated, and continual care in an accountable way, preferably as members of a multiprofessional team. Admission standards. Student attitudes toward primary care reflect _ not only their experience in medical education but also previous experi- ence and personality baits e Medical school applicants who have performed well in physical and natural sciences but poorly in the humanities and social sciences might be unlikely to choose or succeed in primary care careers, where social skills and interests are especially important. Researchers are beginning to examine the factors apparent in primary care career selection to determine whether medical school admissions examiners can test for them. Another admissions issue, of great social and legal sensitivity, concerns policies to increase the share of students from minority and disadvantaged backgrounds. These policies are opposed by those advo- cating maximum test score and grade-point average admission standards and the rights of majority applicants. But the policies are supported on grounds of equal economic opportunities and on the assumptions that students from disadvantaged backgrounds will practice after graduation in primary care disciplines among underserved populations and will sensitize fellow students to the problems and way of life of minority groups. Black physicians are believed to cluster more heavily than white physicians in metropolitan areas containing underserved popula- lations and may be especially likely to be family or general practi- tioners. _/ (Recommendation #15) In selecting among applicants for admission, medical schools should give wei~ght~t-o ~~l~lk~ely Indicators Of primary care ~ ,, , , ~ , Hi. . . ... ... .. . . . selection. Indicators now being investigated include an affinity for personai service, interpersonal skills, ability to function as part of a team, and training in behavioral and social sciences and related 79
experience - although evidence linking these attributes to primary care achievement is not yet well developed. Besides emphasizing indicators of primary care career selection, medical school admission committees are encouraged to accept and seek out candidates who are likely to practice among medically underserved populations. Shortages of primary care practitioners may be especially severe or detrimental in inner cities and rural areas. The committee also believes that continued special attention should be given to ad- mission of minority students. Curriculum. Medical school curricula in the first two years of school are weighted heavily toward the traditional basic sciences. In a sample of 14 medical schools in 1972-73, these sciences accounted for 94 percent of faculty members' classroom instructional hours. 34/ Didactic instruction in the basic sciences is applied and somewhat recapitulated in student rotations among clinical services in teaching hospitals where cases are disproportionately complex and critical. The committee is aware of recent reforms that have introduced epi- demiology, medical ethics, and some social science into the curriculum. The committee believes that such topics, when taught with sufficient resources and skill, can help assure the breadth and quality of medical education. (Recommendation #16) Undergraduate medical education should provide students with a knowledge of epidemiology and aspects of behavioral and , social sciences relevant to patient care. Prospective physicians should be presented with an array of course material, suitably taught, that might be helpful in understanding and communicating with patients. A combination of public funding and imaginative policies on the part of educators could make choices of study opportunities available in such fields as epidemiology, sociology, psychology, communications, economics, political science, history, anthropology, ecology, ethology and other new or continuing disciplines which can offer primary care physicians insight into patients' problems and behavior. Of course, students with prior training in these subjects should not be required to repeat course material in medical school. Nor do these subjects need to be taught in separate courses rather than integrated into existing courses and clinical training. Related to matters of curriculum is the composition of medical school faculties. The presence of faculty role models may be important in encouraging students to plan for careers in primary care. Since faculty prestige usually rests on accomplishments in research, greater efforts in primary care research by medical school faculty members might help persuade medical students of the scientific and direct social worth of primary care. Such research could lead to improved diagnostic and triage techniques, superior or simpler treatments for common health prob- lems, illness prevention, and innovative health care delivery methods. 35/ -80-
Primary care clinical experience. Because primary care providers manage most problems presented to the health care system, 36/ clinical exposure to primary care practice is an important feature of the contem- porary education of all medical practitioners. In the committee's judgment, clinical primary care experience is as important in medical education as a clinical rotation among the services of a teaching hospital. For that reason, and because the public expects any physician to be able to respond to medical emergencies and simple health problems, the committee decided to recommend a mandatory primary care component in clinical undergraduate medical education. (Recommendation #17) Medical schools should provide all students with some clinical experie primary care experience can be obtained in academic medical centers, under faculty supervision in nearby clinics or offices, or under preceptorships. Brief service with a provider of primary care as defined in Chapter 2 provides students with experience in the rendering of accessible, comprehensive, and coordinated care by an accountable provider and can demonstrate the nature of continual care. Such experience also can provide students with primary care role models. Team training. Effective learning situations involving health care teams are not easily structured. But even difficulties in creating an efficient team offer opportunities to practitioners and students who must experiment in communication, act sensitively, and keep patient needs uppermost in mind while functioning as part of an interdiscipli- nary team. The committee favors a team approach in primary care training because multiprofessional teams are best able to provide comprehensive and coordinated care and because the committee expects team training to promote beneficial interprofessional relationships. While recommending a team approach to primary care training, the committee recognizes that team training may cause some unintended effects. For example, it could create friction between professions, result in inefficient patterns of group rather than individual decision- making, or confuse patients in clinical settings about responsibility for different aspects of their care. On balance, however, the committee is confident that the advantages of team training far outweigh the disadvantages. One advantage is the preparation of professionals to serve in a health care system that is increasingly relying on collabo- rative relationships. Other advantages are cooperative rather than fractionated multiprofessional care and more beneficial use of the expertise of each profession or discipline. (Recommendation #18) Medical schools and primary care training programs should teach a team approach to the delivery of primary care. The primary care team might include only one primary care physician and a new health practitioner. Or it might include other types of physicians, such as psychiatrists, who offer perspectives on particular problems. The team also might include other professionals - such as social workers, dietitians, and allied health workers - who can perform specific services 81
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 -82-
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. 83
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. 84
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
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. -86-
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 . -87-
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. -88-
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 -89-
(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~. 90
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
