Training Tomorrow's Comprehensive Primary Care Internists: A Way Forward for Internal Medicine Education

Abstract

The ground has shifted in US health care. With President Obama's reelection in November 2012, the Affordable Care Act is here to stay, and tens of millions of Americans soon will gain access to health insurance. Numerous experiments are underway to better organize and coordinate care at the levels of the individual practice, the “medical neighborhood,” and the larger health system.1–,5 Underlying these activities is a fundamental switch from a reactive care system oriented toward sickness (in which individual providers were paid for discrete elements of care) to a proactive care system oriented toward wellness, where teams and systems share accountability for the health of individual patients and populations. How can internal medicine graduate medical education (GME) help meet this challenge? This article presents the evidence-based recommendations and opinions of selected leaders in general internal medicine based on iterative conversations before, during, and after the 2011 Society of General Internal Medicine (SGIM) Education Summit. Recognizing that today's physician training programs may not adequately prepare physicians for tomorrow's models of health care delivery,6,7 there have been many calls over the past decade for medical education reform.8–,14 As we consider the future of US health reform, it is clear we need to address at least 3 interdependent problems. We must (1) improve quality, (2) drive out waste, and (3) expand the notion of health care to include the social determinants of health that account for 70% of the burden of disease.15 These problems require us to reconsider the formation of tomorrow's workforce. Our article focuses on the specific implications of US health reform for internal medicine GME. We describe the required competencies that will allow tomorrow's comprehensive primary care internist to thrive in a proactive US care system. We then propose 3 recommendations for reforming internal medicine GME training to foster that vision. The SGIM Education Summit In 2011, the Josiah Macy Jr Foundation and others sponsored and advised a SGIM Education Summit to address 2 questions: (1) What are the educational implications of current practice transformations to primary care home models? (2) What must we do differently to prepare internal medicine residents for their futures practicing in and leading patient-centered medical homes? The summit included 7 work groups,16 with each group having engaged in prework literature reviews and conference calls to generate preliminary recommendations. A single face-to-face meeting was convened where work groups' concepts and recommendations were shared, debated, and refined. This report is the result of deliberations among the policy work group members.