Because the nation's shortage of primary care physicians is not a new problem, one medical educator suggests that primary care residency programs could benefit from a look to the past.
Allan Goroll, M.D., writing in the February issue of Academic Medicine,(journals.lww.com) analyzed two programs that were created to attract more medical students into primary care: one that opened in 1973 at Massachusetts General Hospital and another that began recently at the University of New Mexico.
The Massachusetts program opened as an older generation of physicians began to retire and lucrative subspecialties were drawing medical students away from primary care. Now the generation of physicians that began residency in the 1970s is entering retirement age. The residency changes that helped attract them to primary care -- including a greater emphasis on outpatient experience and team-based care -- should be considered for current programs, Goroll said.
- A medical educator argues in the February issue of Academic Medicine that changes to residency programs in the 1970s could help guide new efforts to attract more students into primary care.
- Residents should be given input into program design, the author wrote.
- Devoting more time to outpatient care also could help.
Goroll, a professor of medicine at Harvard Medical School, said that for primary care training to be effective with this new generation of students, programs should take into account residents' input and incorporate settings that are relevant for future practice, such as a medical home or a clinic. Goroll also advocates for "protected time" when residents can focus on continuity of care and are not saddled with inpatient responsibilities as, essentially, a "reserve workforce" for the hospital. The quality of the training experience plays a major role in who chooses to enter primary care practice, he said.
Goroll is a primary care internist, but his vision aligns well with calls to bolster family medicine residencies because primary care overall faces competition from subspecialties. However, Jay Fetter, M.S.H.A., medical education operations manager for the AAFP, said it is important to remember a key distinction between family medicine and internal medicine.
"Many students go into general internal medicine with little intention to stay in primary care," Fetter said. "When students go into family medicine they almost always practice primary care with the rare exception of urgent care or emergency medicine."
Goroll suggested that training for primary care residents should be a 50-50 split between inpatient and outpatient visits. Fetter said that while most hospital-based internal medicine residency programs residents devote 80 percent of their time to inpatient care, family medicine residents typically spend just two-thirds of their first year in the hospital and devote most of their third year to outpatient care. Even so, Fetter said, family medicine residents should have a greater proportion of outpatient experience to prepare them for the team-based continuity of care that family medicine stresses.
Several family residency training programs are already adopting a "clinic-first" model that allows residents to spend much of their time on outpatient care.
At the Group Health Cooperative in Seattle,(www.primarycareprogress.org) family medicine residents spend more time in outpatient settings during their first year. Working in a medical home setting, they learn about population health, chronic care management and working in a team environment, all key principles for family medicine practice. In Salt Lake City, residents at the St. Mark's Family Medicine Residency(secure.utahhealthcare.org) spend time every day caring for patients in an outpatient center.
Goroll also called for more innovation that helps residents keep pace with upcoming payment reforms. Without change, he said, residency programs will fall into a pattern of 15-minute patient visits with no training on working in teams or managing population health needs. New Medicare payment models that emphasize quality could open the door to reform of graduate medical education in ways that can enhance primary care, Goroll said.
Beyond adapting the residency curriculum to new demands, Goroll said even the vocabulary used to describe the profession of primary care should change to attract more qualified candidates.
"Denigrating, unprofessional terms like 'provider' and 'gatekeeper' have no place in the lexicon of primary care," he wrote, "'Personal physician' seems more appropriate, and 'quarterback' might be helpful if an analogy is required to help underscore the intensity of training, level of responsibility and degree of compensation required."
Goroll acknowledged that the term 'quarterback' might not please everyone, but it places the primary care physician as the focal point of the care team. Fetter prefers the term 'coach' because physicians delegate tasks to the most qualified team member instead of initiating every play themselves.