A Manpower Policy for Primary Health Care Report of a Study (1978) / Chapter Skim
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Chapter 5: Education for Primary Health Care Practice
Chapter 5: Education for Primary Health Care Practice
Pages 67-92
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From page 67... ...
Second, the nature, scope, and quality of education 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.
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From page 68... ...
Departments are discrete admini included in each category. _~: TAX_ _ _ —k, I ~ I - I — - —— I a a 170 '69 '71 strative units.
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From page 69... ...
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 gynecology.
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From page 70... ...
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 receiving 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.
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From page 71... ...
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 firstyear residency positions to the primary care specialties of family medicine, general internal -medicine, and general pediatrics.
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From page 72... ...
.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.
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From page 73... ...
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 institut ions play a role in graduate medical education.
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From page 74... ...
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, respectively.
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From page 75... ...
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.
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From page 76... ...
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 provided for generous support for student s pledged to pract ice in tile Nat tonal Health Service Corps after gradual ion .
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From page 77... ...
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 education.
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From page 78... ...
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.
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From page 79... ...
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.
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From page 80... ...
(Recommendation #16) Undergraduate medical education should provide students with a knowledge of epidemiology and aspects of behavioral and , social sciences relevant to patient care.
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From page 81... ...
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.
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From page 82... ...
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 organizations, 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.
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From page 83... ...
permit nurse practitioners and physician assistants to perform procedures delegated or assigned to them by supervising physicians 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.
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From page 84... ...
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 .
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From page 85... ...
. 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.
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From page 86... ...
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.
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From page 87... ...
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.
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From page 88... ...
See John S Millis, A Rational Public Policy for Medical Education and Its Financing, (New York: National Fund for Medical Education, 1971 , P
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From page 89... ...
for family practice residency programs, and 60 million dollars for general pediatrics and general internal medicine.
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From page 90... ...
26. For a more comprehensive discussion of graduate medical education in primary care, see Robert J
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From page 91... ...
39. See staff paper, "Education of Primary Care Practitioners." 40.
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