Abstract
Creating a new model to train a high-quality primary care workforce is of great interest to American health care stakeholders. There is consensus that effective educational approaches need to be combined with a rewarding work environment, emphasize a good work/life balance, and a focus on achieving meaningful outcomes that center on patients and the public. Still, significant barriers limit the numbers of clinicians interested in pursuing careers in primary care, including low earning potential, heavy medical school debt, lack of respect from physician colleagues, and enormous burdens of record keeping. To enlarge and energize the pool of primary care trainees, we look especially at changes that focus on institutions and the practice environment. Students and residents need training environments where primary care clinicians and interdisciplinary teams play a crucially important role in patient care. For a variety of reasons, many academic medical centers cannot easily meet these standards. The authors propose that a major part of primary care education and training be re-located to settings in high-performing health systems built on comprehensive integrated care models where primary care clinicians play a principle role in leadership and care delivery.
Highlights
BACKGROUNDExtensive national and international research, consistent over time, has clearly documented the importance of primary care in achieving high-functioning health care delivery and superior health outcomes.[1,2,3] When primary care is readily available, health care costs are lowered, quality of care is higher, patient satisfaction improves, and unnecessary (and potentially harmful) care drops.[4,5] Drivers of change in the USA, such as the aging population, health care reform, increased rates of chronic disease, the greater use of technology in health care, expand-
One of the most significant challenges to the field of internal medicine is the development of the hospital medicine specialty.[8]. While it is a generalist discipline, hospitalists do not provide the kind of comprehensive community-based care that is usually conveyed by the term Bprimary care.^ The regular shift work and the focus on acute care and rapid patient turnover have further drained the pool of potential primary care physicians from the core generalist disciplines of internal medicine, family medicine, and pediatrics
Across the US, there are a number of delivery systems that offer coordinated primary care including integrated systems, such as Kaiser Permanente, Geisinger, and many of the new federally qualified health centers (FQHCs) that provide comprehensive primary and specialty care
Summary
Extensive national and international research, consistent over time, has clearly documented the importance of primary care in achieving high-functioning health care delivery and superior health outcomes.[1,2,3] When primary care is readily available, health care costs are lowered, quality of care is higher, patient satisfaction improves, and unnecessary (and potentially harmful) care drops.[4,5] Drivers of change in the USA, such as the aging population, health care reform, increased rates of chronic disease, the greater use of technology in health care, expand-. One of the most significant challenges to the field of internal medicine is the development of the hospital medicine specialty.[8] While it is a generalist discipline, hospitalists do not provide the kind of comprehensive community-based care that is usually conveyed by the term Bprimary care.^ The regular shift work and the focus on acute care and rapid patient turnover have further drained the pool of potential primary care physicians from the core generalist disciplines of internal medicine, family medicine, and pediatrics Other changes such as the primary care physician shortage, access issues, and the cost of care have spurred alternative approaches to delivering primary care services, including the increased use of non-physician clinicians, urgent care and retail clinics, and team approaches to the management of illness.[9,10,11] Most evidence shows non-physician clinicians (NPCs) improve timeliness of care and patient satisfaction and that in low-complexity problems the quality of care is comparable between NPCs and PCPs.[5,12,13] These changes will likely place primary care physicians (PCPs) in important roles managing complex patients and conditions, leaving routine and preventive care to non-physician clinicians. Individual factors Students come to medical school with strong interest in primary care, which declines over time Students select specialty training based on accrued debt Burnout in medical school and resident role models has an impact on student choice of specialty
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