Changing the Health Care System Models from Here and Abroad (1994) / Chapter Skim
Currently Skimming:
Response to Jo Ivey Boufford
Response to Jo Ivey Boufford
Pages 52-67
The Chapter Skim interface presents what we've algorithmically identified as the most significant single chunk of text within every page in the chapter.
Select key terms on the right to highlight them within pages of the chapter.
From page 52... ...
in a 1978 reports concluded that "primary care is distinguished from other levels of personal health services by the scope, character, and integration of the services provided." The IOM study described five attributes that are essential to the practice of primary care: accessibility, comprehensiveness, coordination, continuity of services, and accountability. I will use for the purposes of my discussion the definition developed by the Council on Graduate Medical Education (COGME)
|
From page 53... ...
When the elements and competencies of primary care are defined clearly, the physician specialties that constitute the primary care specialties become evident those trained, certified, and practicing in the specialties of family practice, general internal medicine, and general pediatrics.3 As Dr. Boufford stated, the United States has a comparatively small proportion of physicians practicing in primary care specialties.
|
From page 54... ...
Data from studies of medical school seniors' specialty preferences conducted by the Association of American Medical Colleges (AAMC) show that the proportion favoring primary care dropped from 36 percent to 14 percent in the last 10 years, and the decline was spread across the board, from 50 to 77 percent.4 If that was not bad enough, the number of slots in internal medicine programs that are for transients, the preliminary positions, increased by 133 percent.5 These positions were filled by graduates who intended to stop off in internal medicine for a year or two while they waited to be accepted into anesthesiology, emergency medicine, or another program that better suited their expectations as a career choice.
|
From page 55... ...
medical graduates in 1992, the number of international medical graduates in those programs increased dramatically, to 1,400 from 1,007. And, not necessarily related, the number of Alpha Omega Alpha Honor Fraternity members selecting primary care has declined, supporting arguments that the quality of students selecting primary care may also be declining.
|
From page 56... ...
They have not adequately provided opportunities for students and residents to experience the real world of primary care practice by including mentorships in which trainees can see firsthand the rewards of longitudinal relationships with patients who also become friends. Neither have they uniformly provided residency training that teaches the necessary skills for confident and fulfilling primary care practice.
|
From page 57... ...
The most important feature is the fact, desirable in my view, that medical subspecialists provide a lot of primary care much of it highquality and cost-efficient care. I know of no data on the percentage of primary care provided by medical subspecialists, but a few years ago, an ASIM survey showed that 75 percent of internist subspecialists also did some primary care.
|
From page 58... ...
The future availability of primary care services is also influenced by an increasing supply of women physicians and employed physicians. Data from the American Medical Association show that women work fewer hours per week and fewer weeks per year than their male counterparts.
|
From page 59... ...
We should provide undergraduate financial incentives, including loans and scholarship programs, to train more generalists and fewer nonprimary-care specialists and subspecialists. We should provide higher stipends for primary care residencies compared with those for other residencies to lessen the education debt burden and provide loan forgiveness for those who practice in areas with a shortage of primary care physicians, even though the record of retention is spotty.
|
From page 60... ...
We are entering what George Lundberg has called the Golden Age of Medicine, and it is a message that we must continue to send as we go through the fundamental reorganization of the way in which health care is financed and delivered in this country. George quotes Dizzy Dean, who, when the bases were loaded and nobody was out, used to say, "The ducks is on the pond." He believes the bases are loaded with resources and opportunities.
|
From page 61... ...
While the traditional GP has the ability to buy laboratory and radiology diagnostic services from the hospitals and limited specialty outpatient consultants, fundholders now buy all elective services, including day surgery and elective medical and surgical work, both outpatient and inpatient. In some areas, they hold a very large segment of the district's money.
|
From page 62... ...
BOUFFORD: There is an historical network of nurses community health nurses, home visitors, and nurses for chronic care and some specialties like cancer that are now increasingly managed through community health service trusts. The trusts are run as organizations that sell their services to GPs and to acute care hospitals that provide home care.
|
From page 63... ...
QUESTION: Something Dr. Boufford did not touch on that I would like to put on the table because I think it is part of the future of health professional reform is the matter of Medicare's very substantial investment in health specialist training, which is, I think, the sleeping giant of the health professions' or medical education's dilemma.
|
From page 64... ...
NELSON: I will take it even one step further. If there are set goals, such as those of the Council on Graduate Medical Education, and if those goals become fairly firmly accepted, whatever contribution government makes to medical education, including the research budget, can be utilized for leverage if that is what it takes.
|
From page 65... ...
One of the conflicts, it seems to me, about the National Health Service Corps maybe it is less true now was people using it as a loan forgiveness mechanism rather than because they were really interested in primary care; as a result, their willingness to stay in practice after their commitment was over was often quite limited. There needs to be balance in terms of having enough other loan forgiveness programs, payback service programs, or other mechanisms so that the National Health Service Corps does not become the only route to paying medical school debts.
|
From page 66... ...
That is very powerful in terms of mutual respect and colleagueship. Personnel planning that limits the number of consulting posts means that a number of medical students go toward general practice because they know the waiting time to get a consultant post in another specialty is quite long.
|
From page 67... ...
DISCUSSION 67 again, the doctors and the students will figure out a way to get around that if they believe that the ultimate outcome should be something different, unless the rewards are there for the long term. We must not lose sight of the question of what is the ultimate standing of the primary care provider in the society.
|
Key Terms
This material may be derived from roughly machine-read images, and so is provided only to facilitate research.
More
information on Chapter Skim is available.