Correspondence
Attracting Students to Primary Care
N Engl J Med 2005; 352:93-95January 6, 2005
- Article
To the Editor:
Whitcomb and Cohen1 and Fincher2 (Aug. 12 issue) call for changing the training settings for students and residents in primary care to reflect the types of environments in which high-quality primary care can best be provided, with use of “models of efficient, interdisciplinary, patient-friendly care in academic medical centers and exemplary community-based practices.” Although I agree with these sentiments, if these training settings do not reflect practice in the real world, we run the risk of alienating potential future primary care trainees with “bait and switch” tactics. Unfortunately, although the chronic care model, for example, provides a reasonable blueprint for how such care could be structured,3 implementation is precluded by the current health insurance and health care systems in the United States. A recent article on the Pursuing Perfection initiative suggests that, even with substantial grant funding, such exemplary practices are not financially sustainable.4 It seems unlikely that anything short of complete reform of the U.S. health care system will make primary care attractive to large numbers of medical students.
4 ReferencesBarry G. Saver, M.D., M.P.H.
University of Washington, Seattle, WA 98115
saver@u.washington. edu 1
Whitcomb ME ,Cohen JJ . The future of primary care medicine. N Engl J Med 2004;351:710-712
Full Text | Web of Science | Medline2
Fincher R-ME . The road less traveled -- attracting students to primary care. N Engl J Med 2004;351:630-632
Full Text | Web of Science | Medline3
Epping-Jordan JE ,Pruitt SD ,Bengoa R ,Wagner EH . Improving the quality of health care for chronic conditions. Qual Saf Health Care 2004;13:299-305
CrossRef | Web of Science | Medline4
Kolata G. Health plan that cuts costs raises doctors' ire. New York Times. August 11, 2004:A1.
To the Editor:
Students shun primary care because primary care today is unattractive. We are trapped in a catch-22. Insurers, both commercial and governmental, try to reduce payments for medical care whenever possible. When they reduce their payments per visit, we increase the number of visits. So they cut payments again. If more patients are to be seen, visits must be shorter, and problems simple and discrete. Indeed, the coding system rewards us for seeing new patients with acute problems. People do not go to school for decades at tremendous expense to work on a production line, and that is what primary care has become. “Productivity” — patients per hour, not improved health — has become critical, whether we work for ourselves or others.
Yet there are many patients with complex, chronic illnesses who need our help. If we are paid the same for everyone, we cannot afford to see them. The solution? First, we need to be compensated for work done without the patient present, as are other professionals.1 Second, insurers should pay more for complex cases and less for easy ones.2 That approach may require some form of national health insurance.
2 ReferencesCaroline M. Poplin, M.D., J.D.
6113 Wynnwood Rd., Bethesda, MD 208161
Poplin C . Productivity in primary care: work smarter, not harder. Arch Intern Med 2000;160:1231-1233
CrossRef | Web of Science | Medline2
Robinson JC . Reinvention of health insurance in the consumer era. JAMA 2004;291:1880-1886
CrossRef | Web of Science | Medline
To the Editor:
The problem behind the impending primary care crisis is systemic, not educational. To avert this crisis, we need a national health policy that includes channeling of postgraduate medical-education dollars into high-priority specialties, forgiveness of educational debt for students who choose careers in primary care, narrowing of the income gap between primary care and other specialties, elimination of onerous bureaucracy, creation of information systems that assess quality and reward high-quality care, and coverage, including disease-management services, for all chronically ill patients.
For 15 years, managed care and the marketplace tried to correct imbalances in our health care system. If Whitcomb and Cohen want to blame academia for a crisis that involves the entire practice world, let them. However, the baby boomers are here, and the need for affordable, continuous care is acute. We do not have time for ineffective solutions. We can either ask our representatives to support a coordinated health care policy or simply hope that patients — who include us — find a doctor who accepts their insurance.
Samuel Cykert, M.D.
Moses Cone Hospital, Greensboro, NC 27401
sam.cykert@mosescone. com To the Editor:
We agree with much of what Whitcomb and Cohen say in their Sounding Board article, including their recommendation that primary care residency programs evolve to meet the demands of changing demographic characteristics and health care needs in the United States. The suggestion that such initiatives are not being pursued, however, is incorrect.
The Future of Family Medicine project has defined a new model of practice1 — one that incorporates evidence-based continuing medical education, the use of clinical-practice guidelines for quality improvement, and models for the management of chronic disease.2 The newest program requirements of the Accreditation Council for Graduate Medical Education with regard to family medicine address health care teams, information-technology resources, and competency targets.3 Patients who seek care at an academic center are those who lack a “primary care home”; they do not represent the failures of community-based primary care physicians, whose patients rarely go to academic centers.4
Whitcomb and Cohen's closing comment ignores Phillips and Starfield's documentation of the fact that throughout the world, a strong base of primary care physicians results in favorable health indicators and reduced costs.5
5 ReferencesMichael Fleming, M.D.
American Academy of Family Physicians, Shreveport, LA 71115-5207Mark S. Johnson, M.D., M.P.H.
Association of Departments of Family Medicine, Newark, NJ 07103Jeannette South-Paul, M.D.
Society of Teachers of Family Medicine, Pittsburgh, PA 152611
Annals of Family Medicine. The Future of Family Medicine Project. 2004. (Accessed December 16, 2004, at http://www.annfammed.org/content/vol2/suppl_1/index.shtml.)
2
American Academy of Family Physicians. AAFP board doubles evidence-based CME credit. 2004. (Accessed December 16, 2004, at http://www.aafp.org/x28746.xml.)
3
Accreditation Council for Graduate Medical Education home page. (Accessed December 16, 2004, at http://www.acgme.org/.)
4
Green LA ,Fryer GE Jr ,Yawn BP ,Lanier D ,Dovey SM . The ecology of medical care revisited. N Engl J Med 2001;344:2021-2025
Full Text | Web of Science | Medline5
Phillips RL JR, Starfield B. Why does a U.S. primary care physician workforce crisis matter? Am Fam Physician 2003;68:1494-6. [Corrected in Am Fam Physician 2004;70:440, 442, 445-6.]
To the Editor:
Because of their loyalty to primary medicine, Fincher and also Whitcomb and Cohen miss a crucial factor: family practice is no longer a viable specialty. The exponential growth of medical knowledge prevents any single physician from being adequately versed in all areas of medicine.
There is another solution: increasing the number of well-trained nurse practitioners, a strategy that would fill the need for primary care and allow medical students to pursue specialty training. The quality of care provided by nurse practitioners has been shown to be similar to that provided by family physicians.1 Moreover, like family physicians, nurse practitioners refer complex cases to specialists, thereby improving patients' care, since the most highly qualified clinicians then provide treatment.
Some of the anxiety physicians feel about nonphysician clinicians can be allayed in several ways: by increasing the number of physicians who teach in these graduate programs, by increasing the exposure of nurse-practitioner students to clinical settings, and by setting up collaborative practices between physicians and nurse practitioners.
1 ReferencesTerry A. Rustin, M.D.
University of Texas Health Science Center at Houston, Houston, TX 77030
terry.a. rustin@uth. tmc. edu 1
Mundinger MO ,Kane RL . Health outcomes among patients treated by nurse practitioners or physicians. JAMA 2000;283:2521-2524
CrossRef | Web of Science | Medline
Author/Editor Response
In our article, we acknowledge that a number of factors undoubtedly affect how medical students view primary care practice as a career choice. Rather than rehash ground that has been covered in some detail elsewhere, we chose to introduce an additional factor into the equation — namely, students' lack of exposure to the rewards of caring for patients with chronic illness during many of their clinical rotations in medical school. We also note that residency programs in internal medicine and family medicine are not currently designed to prepare residents adequately for the challenges and gratifications of primary care practice — a fact that is not lost on medical students. We do not suggest that this is the only reason why more students are not choosing residency programs in those disciplines. We do suggest that it will be necessary to redesign those residency programs if the current trends in students' specialty choices are to be reversed. It is encouraging that leaders in family medicine and internal medicine are now calling for changes. Unfortunately, however, no changes have been made to date, nor have the leaders of the disciplines specified what those changes should be.
Michael E. Whitcomb, M.D.
Jordan J. Cohen, M.D.
Association of American Medical Colleges, Washington, DC 20037Author/Editor Response
Essentially, I am in agreement with Drs. Saver, Poplin, and Rustin. An important goal for medical educators is to identify exemplary practices of satisfied physicians for use as clinical teaching sites. As I note in my Perspective article, I also agree that we must revamp our health care and reimbursement systems: the United States should be able to provide adequate health care for all its citizens. Finally, midlevel practitioners are valuable resources in helping to extend the provision of health care and may become even more essential primary caregivers in light of advancing technology and methods of communication.
Ruth-Marie E. Fincher, M.D.
Medical College of Georgia School of Medicine, Augusta, GA 30912
rfincher@mail.mcg. edu
