Primary Care America's Health in a New Era (1996) / Chapter Skim
Currently Skimming:
Education and Training for Primary Care
Education and Training for Primary Care
Pages 179-215
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 179... ...
Moreover, targeted grants from The Robert Wood Johnson Foundation, The Pew Charitable Trusts, and The W.K. Kellogg Foundation have addressed the changes in academic infrastructure, curricula, and financing that must be implemented to respond successfully to a mandate to increase the availability of well-trained primary care clinicians.
|
From page 180... ...
Thus, this section examines issues for both medical students and residents, noting in particular that models of practice to which physicians-to-be and newly graduated physicians are exposed play a critical role in long-term career directions (Stimmel, 1992; GAO, 1994; Martini et al., 1994; Kassebaum and Haynes, 1992~. Undergraduate Medical Education Experience in Primary Care Settings The challenges of revamping the undergraduate medical curriculum should not be underestimated, and this committee was not empaneled to explore such issues in depth.
|
From page 181... ...
The committee did not find these arguments about the problems of conducting some undergraduate medical education in outpatient or primary care settings persuasive. Calls for greater emphasis on out-of-hospital primary care training in both undergraduate and graduate medical training are not new; they have been raised with increasing frequency in the last several decades (Alpert and Charney, 1973; IOM, 1983~.
|
From page 182... ...
years and are offering or requiring clerkships in one of the generalist disciplines during the third or fourth years, including clerkships that emphasize experience in primary care settings. At some medical schools, even first-year medical students can apply for primary care clerkships, where they can observe generalist physicians in hospital clinics and doctors' offices.
|
From page 183... ...
Medical schools and various health policy groups have also begun to consider the competencies that should be required of all graduating medical students. As a case in point, The Pew Health Professions Commission (1994)
|
From page 184... ...
Manage information and continue to learn. With increasing interest in the third-year clerkship in primary care, the latest addition to efforts to define appropriate curricula for medical students has been developed by Goroll and Morrison with support from BHP/HRSA (Bureau of the Health Professions of the Health Resources and Services Administration)
|
From page 185... ...
Different medical schools have quite different missions: Some focus more on research and the production of specialists, others focus more on education and the production of primary care clinicians. Moreover, the effect of the structure of universities within which medical schools function and of the history within each institution of its departmental affiliations can be substantial (a point noted in another recent IOM report [IOM, 19951 on dental education)
|
From page 186... ...
Residency Programs in Family Practice, Internal Medicine and Pediatrics Primary care has begun to attract more residents (rein, 1995~. Part of this trend is attributable to external forces, both the growth of managed care (and its greater demand for primary care clinicians)
|
From page 187... ...
In general these curricula are closer to what the committee is advocating, but they are still small in number and remain the exception rather than the rule. OTHER CONTENT ISSUES IN TRAINING FOR PRIMARY CARE Academic health centers educate and train all types of primary care clinicians (physicians, physician assistants, and nurses practitioners)
|
From page 188... ...
In short, academic health centers will have to change to reflect the practice environment in which its graduates will practice; but society, if it is to enjoy the health care system and practitioners it evidently wants, will need to provide the policy and financial support without which academic health centers will not be able to move forward.3 Common Core Competencies Defining core competencies is a requisite for every field in health care. Credentialing of health practitioners whether by hospitals or managed care organizations depends on defined competencies.
|
From page 189... ...
What specific competencies would enable primary care physicians to fulfill these roles? For half a century or more, the various primary care disciplines have been engaged in defining core competencies within their own fields.
|
From page 190... ...
is in the process of updating this curriculum (Roger Sherwood, STEM, personal communication, November 1995~. Various joint residencies and activities by specialty boards also reflect concerns about common core competencies, typically involving internal medicine with either pediatrics or family practice (JAMA, 1994~.
|
From page 191... ...
Though little collective progress has been made regarding formal approval of a common core set of competencies for a generalist curriculum, one thorough analysis of the educational content of curricula developed for pediatrics, family medicine, and general internal medicine residencies identified 15 educational components shared by the three disciplines (Noble et al., 1994~: · Biomedical content: a well-integrated knowledge of biomedical sciences encompassing all the major organ systems and health problems encountered in primary care practice and principles of therapeutics fitted to the requirements of the generalist; · Special skills: clinical and procedural skills including history taking, physical examination, and office and emergency procedures needed in practice; . Life cycle: an age-based curriculum taught longitudinally from family planning to care at the end of life; · Psychosocial and medical interviewing curriculum: specific skill sets that foster the ability to identify and respond appropriately to psychosocial elements within patients and clinicians; · Multicultural dimensions of health care: understanding international epidemiology, divergent health belief systems, alternative healers, and a range of human behaviors pertinent to health; · End-of-life care: knowledge of palliation and maintenance of function and quality of life, including, for example, nutrition, pain control, and advance directives; Family-oriented care: proficiency in interviewing family members and conducting a family conference; understanding the family life cycle and its influence on health and utilization of medical care, family dynamics in illness, and collaborative care with family therapists; · Community and population-based practice: training experience in the .
|
From page 192... ...
Defining Core Competencies in Nursing The nursing profession has also recognized the need for core competencies and the desirability of instilling these during training. Nurse training programs for advanced practice, for example, include a primary care track that has separate branches for older adults and for young people.
|
From page 193... ...
Defining Core Competencies Across Primary Care Clinical Fields Reaching a mutually agreed-upon set of core Competencies across all primary care clinical fields that is, physicians, nurse practitioners, and physician assistants poses formidable obstacles. The committee supports and encourages the efforts of health professional societies, residency review committees, academic medical centers, and specialty boards to define a set of common core competency requirements for primary care.
|
From page 194... ...
Special Areas of Curricular Emphasis Two areas of competency are of particular interest to this committee: communication skills and cultural sensitivity. Recommendation 7.4 Special Areas of Emphasis in Primary Care Training The committee recommends that the curricula of all primary care education and training programs emphasize communication skills and cultural sensitivity.
|
From page 195... ...
Emerging links between health professional schools and approximately 600 federally funded health centers are beneficial to both students and health centers because in culturally diverse areas primary care clinicians are expected to be familiar with the cultural context and environmental conditions that affect their patients' health. In many areas of the country, primary care settings are uniquely positioned to fulfill the dual purposes of education providing students with a very broad set of clinical conditions and offering cultural diversity that helps them gain appropriate cultural competence.
|
From page 196... ...
The W.K. Kellogg Foundation has funded the CommunityBased Public Health Initiative to improve the practice and teaching of primary care through collaborative efforts between academic health centers, health professions institutions, and communities.
|
From page 197... ...
Some readers might wonder why if ambulatory training is so essential for primary care training it has not supplanted hospital-based training. The answer lies to a large extent in how GME is financed.
|
From page 198... ...
In the face of many calls for decreases in the training of specialists and increases in the production of primary care physicians, this aspect of Medicare GME funding in effect encourages the training of more specialists. Title VII Funds for Primary Care Training Federal targeted support for residencies in primary care including general medicine, general pediatrics, and family medicine was authorized in the 1976 health professions legislation, specifically Title VII, Section 784, of the Public Health Services Act.
|
From page 199... ...
Instead, an increasing proportion of the new graduate students pursued subspecialty training. In 1974, the Bureau of Health Professions in the Health Resources and Services Administration (BHP/HRSA)
|
From page 200... ...
Specifically, Title VIII programs fund the development of innovative programs to reach underserved areas, the development of educational programs for advanced practice nurses, and the special programs for nursing education for individuals from disadvantaged backgrounds. Professional Nurse Traineeships for nurse practitioner and other advanced nurse education at the master's and doctoral level are also provided under this authority (Janet Heinrich, American Academy of Nursing, personal communication, January 1996; Bureau of Health Professions, Division of Nursing, 1994~.
|
From page 201... ...
A1though the committee endorses the support of all primary care clinicians, it emphasizes medical training because that training is long and expensive in comparison to the shorter and less expensive training of nurse practitioners and physician assistants. Recommendation 7.5 All-Payer Support for Primary Care Training The committee recommends the development of an all-payer system to support health professions education and training.
|
From page 202... ...
Support for Advanced Training in Primary Care Sites Rather than relying overwhelmingly on public payers such as Medicare, the committee has recommended just above that all payers support graduate medical education (indeed, support the education and training of all health professions)
|
From page 203... ...
education, many observers have advocated shifting in Medicare monies now spent on diploma education to advanced practice nursing education (Aiken and Gwyther, 1995; Pew Health Professions Commission, 1995~. INTERDISCIPLINARY EDUCATION OF PRIMARY CARE CLINICIANS Some physicians continue to organize their practices in traditional forms such as single or small, physician-only practices, but multidisciplinary team practice will be an increasingly common mode of practice in the future.
|
From page 204... ...
In this model, students from more than one discipline are assigned to a team that itself reflects an array of health professionals. The committee strongly urges academic health centers to move toward team delivery in their own clinics and inpatient settings and that they structure their primary care clinical practices into teams that can be models for teaching students.
|
From page 205... ...
It also believes, however, that the commonalities of primary care curriculum content and the realities of the practicing environment make multidisciplinary training both desirable and necessary. Health professionals must develop a common understanding of each other's roles and feel comfortable working with other health professions; they must have confidence about which clinical areas can be appropriately delegated or referred and to whom, and about whose skills augment their own, especially for the complicated medical and social problems that some patients present.
|
From page 206... ...
Shortages of primary care clinicians can be alleviated by creating or participating in primary care residency programs with IDSs providing training sites. To address an oversupply of specialists, academic health centers and IDSs may cooperate in implementing retraining programs in primary care (discussed below under Physician Retraining)
|
From page 207... ...
Academic health centers would gain primary care facilities to expand teaching resources in the community. Costs of education and related research could be spread over a broader base.
|
From page 208... ...
The basic question is to what extent such physicians, never having had any grounding in primary care, ought now to be regarded as primary care clinicians. The American Board of Family Practice (ABFP)
|
From page 209... ...
Because subspecialists may not be needed in many rural areas that would welcome a primary care clinician, it might also assist in recruiting and retaining primary care physicians in rural and urban underserved areas. Kinds of Retraining In November 1994 the Pew Health Professions Commission identified 25 different retraining efforts in 13 states (Pew Health Professions Commission, 1994~.
|
From page 210... ...
A different curriculum is required to retrain an internist subspecialist who has had exposure to primary care as a resident and has provided some primary care to his or her patients than to retrain an anesthesiologist who has had no primary care training since medical school and has delivered no primary care as a practitioner. The core set of competencies, when developed (see Recommendations 7.2 and 7.3)
|
From page 211... ...
SUMMARY If primary care is to move in the directions advocated by this committee, then many aspects of health professions education and training will need to be restruc
|
From page 212... ...
Consistent with earlier recommendations about universal coverage for health care, the committee called for an all-payer system to support health professions education and training, with some of this support reserved for primary care and directed to training in nonhospital sites such as offices, clinics, and extended care facilities. Adopting the recommendations in this chapter will require a realignment of funding and power to create incentives for different institutional behaviors (for example, in academic health centers and in integrated delivery systems)
|
From page 213... ...
Curriculum for Ambulatory Care Training in Medical Residency: Rationale, Attitudes, and Generic Proficiencies. Journal of General Internal Medicine 5 (Jan./Fete.
|
From page 214... ...
National Governors' Association, Curley, T., Orloff, T., et al. Health Professions Education Linkages: Community-Based Primary Care Training.
|
From page 215... ...
:S41-47, 1995. Pew Health Professions Commission.
|
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.