In a July 24 research report(link.springer.com) published online in the Journal of General Internal Medicine, New York-based researchers have concluded -- for the second time since 2006 -- that the New York University/Bellevue Primary Care Internal Medicine Residency Program(med.nyu.edu) in New York City has a winning strategy when it comes to turning out residents who want to practice primary care in underserved communities.
In fact, according to the latest survey responses from 37 physicians who graduated from the residency program between 2007 and 2014,
- 89% currently practice in a primary care setting,
- 70% care for underserved patients in their practices,
- 74% felt prepared for the challenges of primary care and
- 85% endorsed primary care as a career choice.
Furthermore, 92% agreed or strongly agreed they were living balanced lives, and just 6% reported persistent symptoms of burnout. That last figure, study co-author Mack Lipkin, M.D., told AAFP News, was well below the expected rate of 45%.
These stats are impressive, especially when taking a look back to 2006, when some of the same researchers surveyed program graduates dating back 20 years and found that more than 90% of those residents were engaged in primary care.
- A recent research report details survey findings that show most graduates from a New York University residency practice primary care and serve underserved communities.
- The program focuses on providing psychosocial training, caring for the whole person and using the best clinical evidence available.
- A total of 89% of survey respondents who graduated from the program between 2007 and 2014 currently practice in a primary care setting, and 70% care for underserved patients in their practices.
"We believe but cannot prove that our focus on longitudinally reinforced psychosocial training, a rigorous skills- and clinical reasoning-focused curriculum, role models, care of the underserved, and strong social support from faculty and peers provides our trainees with the resilience required in under-resourced systems with underserved communities," wrote the authors of the current report, titled "Training Primary Care Physicians to Serve Underserved Communities: Follow-up Survey of Primary Care Graduates."
Lipkin, an internal medicine physician, is the founding director of the New York residency program. In an interview with AAFP News, he pointed to the turmoil that has rocked primary care in recent years.
"There's an ever-increasing pressure for productivity, and yet there's more regulation, more box-clicking," in the EHR, said Lipkin.
Still, he noted, the recent survey confirmed the program is still getting it right.
"We were a little worried because over the past 10 years or so, the subspecialty paradigm has become more dominant, and administrative control and corporatization of practice has increased," said Lipkin.
"We didn't know whether our graduates had been effectively immunized against those things or not -- and they were," he added.
When considering components of their residency training that proved essential to their professional development, the top items that earned physician ratings of 4 on a 4-point Likert scale were
- provided care in a primary care setting (90%),
- practiced psychosocial medicine (83%),
- received inpatient training at a safety-net hospital (83%),
- engaged in resident-led conferences (73%),
- had opportunities to teach (65%) and
- studied clinical epidemiology (48%).
Physicians also provided open-ended responses to questions about the impact of their New York University residency training on their current practice.
"Psychosocial rounds dramatically changed my ability to sympathize/empathize/connect to patients and situations," said one.
"The time that we spent during our PC blocks doing research, learning to lobby and thinking about psychosocial contributors to health were very unique. My preparation as a well-rounded physician meant for vastly different interactions with my patients, their families and my interns throughout my years," said another.
The authors acknowledge that even though graduates reported they were well prepared to care for underserved patients in their primary care careers, respondents did report challenges to providing patient-centered care.
"They still suffer the slings and arrows of primary care today," but the graduates recognized the challenges and felt equipped to deal with them, wrote the authors.
The survey, though focused on general internal medicine residents, applies to family medicine residents, as well, according to Lipkin.
"Family physicians are very much in the same tribe of primary care physicians," he said. "We all serve the mission of caring for people based on a longitudinal relationship, including psychosocial and disease-oriented care, prevention and lifestyle modification."
Lipkin's message to leaders in graduate medical education was strong.
"If you care about treating the underserved, the vulnerable, the stigmatized and the undocumented, then you have to invest in a program that addresses all the necessary elements -- psychosocial medicine, care for the whole person and use of best evidence -- and you must have a vision for the future that will allow you to resist the dumbing down of medicine that we see going on now," said Lipkin.
And although the program he founded in 1984 already has a proven record of success, change waits in the wings.
"In our program we're focusing on transformation. In the future, we want a population-based residency where our residents are told when they arrive, 'This is the population you're caring for with your team, and that's your job for the next three years. You might want to live where they live, know what languages they use, become familiar with their pharmacies and their street-corner bodegas,'" said Lipkin.
"We want to get away from the hospital-dominated approach" in which the residency serves the needs of the hospital and residents mostly visit hospital wards rather than seeing people in the community, he added.
That brand of residency training is "totally out of whack" with the kind of primary care patients want and need, said Lipkin.
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