Editorial

Abstract

Primary care has become an important public policy issue as a result of the growing imbalance between specialists and primary care practitioners in the national workforce. This has resulted in the appointment of national commissions, sponsorship of annual primary care days in medical schools, funding for curriculum innovations that promote primary care, and research into the determinants of primary care career choice by medical students. During the past several years, students have been selecting primary care residency positions in increasing numbers, especially in family medicine. In addition, we know more about what attracts students to primary care careers. These include both institutional influences, such as public medical schools that require a clerkship in family medicine (1), and personal preferences for primary care values, including continuity of care, longitudinal interactions, holistic care, having a close personal relationship with patients, and health promotion (2,3). Students selecting family medicine are more likely to have made that decision before they enter medical school than their counterparts who select other medical specialties. We also know that 45% of students make their specialty choice during the third year of medical school and that their choices are influenced by their clerkship experience (4). Traditionally, primary care has been associated with the disciplines of internal medicine, family medicine, and pediatrics. More recently medicine/pediatrics and obstetrics and gynecology may also be included. However, this disciplinary identity is really a definition of convenience. Primary care is more accurately defined by an approach to patient care. In addition to the values identified above, it involves managing the health-care resources of the patient and a defined population while serving as clinician, healer, manager, consultant, and interpreter of specialist recommendations. Primary care educational experiences should provide students with exposure to common illnesses, a mix of patients, an approach to caring for patients in their social settings, and managing resources for defined populations. This approach to primary care education is structured in a wide variety of ways nationally. These range from doctoring courses in the first 2 years of medical school, to integrated primary care clerkships, to discipline-specific clerkships in internal medicine, pediatrics, family medicine, and women’s health. Two important educational policy questions arise from this broader definition of primary care. Does any one medical specialty/clerkship (eg, internal medicine) prepare third-year medical students better for primary care knowledge, skills, and attitudes than the others (eg, family medicine and pediatrics)? Does the geographic location where education occurs make a difference in learning (eg, academic medical centers vs rural or remote clinical sites)? The answers to these questions might have important implications for curriculum development and specialty and site selection for clinical experiences in all 4 years of medical school, as well as for accreditation and licensing requirements. In this issue, Irigoyen et al (5) compare the effects of experience in four different specialties (internal medicine, family medicine, pediatrics, and medicine/pediatrics) and three geographic locations (urban, suburban, and rural sites) on learning primary care. They report that specialty had no effect on student satisfaction, patient volume, clerkship grade, or score on a standardized patient examination. In contrast, rural location did have a significant effect on student satisfaction and patient volume. These findings are helpful in demonstrating that the core concepts, practice patterns, and skills of primary care can be learned equally well in any primary care specialty and that rural or community settings are excellent places to learn these skills. However, we should also note that although rural sites enjoyed greater student satisfaction, they did not produce greater learning. This study’s results could be used to argue that there is no need to require clinical experience in the three primary care specialties for graduation and licensure. However, I believe that there are still valid reasons for maintaining required clinical experiences in all three primary care specialties of internal medicine, family medicine, and pediatrics. These include different experiences with diverse patient populations, practice styles, practice culture, and role models. Although the core knowledge may be the same, the cultures of each specialty are distinctly different. This includes variations in history and physical examination skills, clinical procedures performed, case presentation styles, and formats for write-ups. Such variations provide students with exposure to the rich texture of medicine. This needs to be experienced first hand. Am J Med. 1999;106:596-597. From the University of California, San Francisco, California. Requests for reprints should be addressed to David M. Irby, PhD, University of California, Box 0410, San Francisco, California 94143. Manuscript received January 19, 1999, and accepted January 19, 1999.