Education, Workforce Reform on the Horizon in 2010

The health care conversation was in full swing during 2010 as Congress, patients and physicians discussed the ramifications of health care reform. One area that received much attention both in the Patient Protection and Affordable Care Act and in the national conversation was the ongoing dearth of primary care health professionals and the need to entice more medical students to practice in primary care.

It seemed that the rest of the country was finally hearing the message that the AAFP has been trying to deliver for a long time: More family physicians are needed in the workforce pipeline if the United States is going to care for its citizens effectively.

Although turning the educational ship for medical students to focus more on primary care is expected to be a long, slow process, the AAFP was encouraged in March when it learned that the fill rate for family medicine residencies reached 91.4 percent -- the highest fill rate ever for family medicine -- according to the results of the 2010 National Resident Matching Program. In addition, 75 more family medicine positions were offered in 2010 than in 2009.

Efforts to increase the primary care workforce continued as HHS announced that it had awarded $103 million in grants for primary care training and workforce development programs for physicians and others. HHS officials said more than $42.1 million would support family medicine and other primary care training programs.

Workforce issues also were addressed in the Affordable Care Act. Part of the focus of the act is training more physicians for a revamped, primary care-focused health care system. In particular, one provision of the law specifies that hospitals' unused graduate medical education slots must be redistributed to hospitals in regions with health professional shortages that want to expand or establish primary care or general surgery residency programs.

In November, the AAFP's Robert Graham Center unveiled a medical school mapping program that allows users to gauge the role of medical schools in promoting and sustaining primary care access within states, regions and localities.

"We designed this program to help people understand the role of medical schools in their state in making sure they have access to the doctors they need, in the places they need them the most," said Andrew Bazemore, M.D., M.P.H., assistant director of the Graham Center. "One of the ideas behind the Med School Mapper is to identify medical schools that are particularly prone to producing graduates in areas of high societal needs," said Bazemore. "Primary care is one of those areas of high need."

In response to the increasing shortage of family physicians at a time of high demand for primary care services, the Texas Tech University Health Sciences Center School of Medicine rolled out a Family Medicine Accelerated Track program that will allow students who are committed to primary care to complete their education in three years at half the cost of a standard four-year program.

The shorter program, which will maintain the same educational requirements and rigor of a four-year program, is a step toward recruiting more students into family medicine, said Texas AFP EVP Tom Banning. "I think any innovative pilot that does not decrease the learning experience is a good thing to examine," said Banning. "The benefits are obvious. By taking a year off of time spent in medical school, you can reduce medical school debt load while still maintaining the education requirements."

Also in November, Harvard Medical School, which had only recently defunded its primary care division, launched a new $30 million Center for Primary Care. The center, which Harvard described as "a center of excellence geared toward transforming primary care education, research and delivery systems," was funded through an anonymous donation.

"It is significant that one of the nation's leading medical schools has taken steps to revitalize and expand its focus on primary care education and training," AAFP President Roland Goertz, M.D., M.B.A. of Waco, Texas, said of the announcement. "To have Harvard appreciate and value primary care is very important."

Indeed, in 2010, it seemed that changes in the way students are educated were being called for in multiple venues. In June, the Carnegie Foundation for the Advancement of Teaching released a study on medical school and residency education. According to the study, present-day medical education is "inflexible, excessively long and not learner-centered." Formalized knowledge and experiential learning are poorly integrated, and inadequate attention is paid to patient populations, systems of health care delivery and effectiveness, said the study.

Many family medicine educators noted that the recommendations called for in the study would make physician training more patient-centered and safety-oriented and would promote quality improvement. "We have ample evidence that professionalism training is badly needed," said Perry Pugno, M.D., M.P.H., director of the AAFP Division of Medical Education.

The report called on educators to standardize learning outcomes and general competencies and then individualize the learning process for students and residents; unite formal knowledge and clinical skills; support the engagement of all physicians-in-training in inquiry, discovery and systems innovations; and make the development of professional values, actions and aspirations the backbone of medical education.

But it wasn't just medical student education that was being questioned. Late in 2009, the Institute of Medicine released a report detailing a number of deficiencies with the current continuing education, or CE, system for health professionals in the United States. The report said that there are major flaws in the way health CE currently is conducted, financed, regulated and evaluated; the science behind CE for health professionals is fragmented and underdeveloped; and efforts need to be made to bring health professionals from various disciplines together in a tailored learning environment.

The AAFP, however, noted that it is ahead of the curve in terms of its CE activities. "The AAFP has a long history of providing excellent quality CE to its members," said (then) AAFP President Lori Heim, M.D., of Vass, N.C. "There are a number of ways in which the Academy already is looking to the future, and many programs that have been initiated to improve the overall quality of our CE product to meet the ongoing needs of our members. The AAFP has been a leader in looking at models of learning and incorporating learning at the point of care."

As proof of the AAFP's educational innovation, in April, the AAFP piloted a new category of CME Prescribed credit called Translation to Practice. The program allows physicians who take an AAFP Prescribed CME credit activity to earn as many as two additional AAFP Prescribed CME credits for each activity by completing a Translation to Practice activity.

The new credit category gives physicians an opportunity to demonstrate how they translate knowledge into practice by identifying a change, applying what they learned to incorporate the change and reflecting on the outcome, said AAFP Director Laura Knobel, M.D., of Walpole, Mass., who is the Board liaison to the Academy's Commission on Continuing Professional Development. "The Translation to Practice credit is a way for (physicians) to go back home and look at their practices to see if they are actually doing what they said they would."

Also in 2010, patient safety was the focus of renewed calls to limit resident duty hours. In July, the Accreditation Council for Graduate Medical Education, or ACGME, task force on resident physician training standards released a draft of a proposal that would provide more supervision of first-year residents, reduce first-year residents' duty periods to no more than 16 hours a day and set stricter requirements for duty hour exceptions.

The AAFP, in concert with the Association of Departments of Family Medicine, the Association of Family Medicine Administration, the Association of Family Medicine Residency Directors, the North American Primary Care Research Group and the Society of Teachers of Family Medicine, sent a letter to ACGME CEO Thomas Nasca, M.D., outlining their objections to the proposal.

The groups noted that they had concerns that the new limitations would decrease the overall educational time and clinical experiences for family medicine residents. In addition, they said, the limitations could

"The ACGME is trying to find the right balance between patient safety, avoiding excessive resident fatigue, excellent education and high-quality care," said (then) AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho. "However, the restrictions at the PGY-1 (postgraduate year 1) level are excessive and will create a total reworking of many residency programs' infrastructure to accommodate these new proposed changes."

The groups recommended that the ACGME conduct pilot studies to examine different duty hour requirements and their effect on medical errors and patient safety guidelines. They also want the ACGME to publicly acknowledge increases in program costs if duty hour restrictions and other proposals are implemented.