Primary Care Graduate Medical Education Research Articles

Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) Health Education in Primary Care Graduate Medical Education Programs: A National Survey of Program Directors

Lesbian, gay, bisexual, transgender, queer, and other sexual and/or gender minority (LGBTQ+) people experience numerous health disparities. Graduate medical education (GME) programs need curricula to address these disparities. We sought to characterize curricula related to LGBTQ+ health in primary care specialty (internal medicine, combined internal medicine/pediatrics, family medicine, pediatrics, and geriatric medicine) GME, and to identify barriers experienced by program directors (PDs) in incorporating LGBTQ+ curriculum. We conducted a national survey study of PDs in August–October 2020 via Qualtrics. Overall, 292 of 1,571 eligible PDs responded (18.6%). Nearly a third of PDs (n= 96%; 32.9%) indicated that their program did not include any didactic training about LGBTQ+ health. Those who did indicated a mean of 5.4–5.7 hours in each year from PGY1-3 dedicated to LGBTQ+ health. Didactic and clinical training about LGBTQ+ health was overwhelmingly focused on content related to sexual health. PDs who indicated they had ‘out’ faculty were more likely to include didactic and clinical training on multiple aspects of LGBTQ+ health. Our results identify a significant gap and a need for the integration of LGBTQ+ content into primary care GME curricula with additional focus placed on domains associated with known mental and physical health disparities, beyond sexual health, and inclusion of transgender and gender diverse health needs. Programs may aim to accomplish this through recruitment of LGBTQ+ health educators, invitations to content experts in the field, and adaptation of existing resources to teach about LGBTQ+ health.

Sailing the 7C's: Starfield Revisited as a Foundation of Family Medicine Residency Redesign.

Amidst a pandemic that has acutely highlighted longstanding failings of the US health care system and the graduate medical education (GME) enterprise that serves it, educators prepare to embark on another revision of the program requirements for family medicine GME. We propose in this article a conceptual framework to guide this endeavor, built on a foundation of the core functions that Barbara Starfield suggested might explain primary care's salutary effects. We first revisit these "4C's"-first Contact, Continuity, Comprehensiveness, and Coordination-and how they might inform design thinking in primary care GME guideline revision. We also propose the addition of Community engagement, patient-Centeredness, and Complexity. Training residents to deliver on these "7C's," functions critical to the delivery of high-performing primary care, is essential if family medicine residency graduates are to serve the clearly articulated, but unrealized, quadruple aim for US health care: improved patient experience and population health at lower costs while preserving clinician well-being. Finally, we highlight and illustrate examples of four critical enablers of these 7C core functions of primary care that must be accommodated in training guidelines and reform, suggesting a need for resident competencies in Team-based, Tool- and Technology-enabled, Tailored ("4T's") care of patients and populations.

Changes in Primary Care Graduate Medical Education Are Not Correlated With Indicators of Need: Are States Missing an Opportunity to Strengthen Their Primary Care Workforce?

Federal and state graduate medical education (GME) funding exceeds $15 billion annually. It is critical to understand mechanisms to align undergraduate medical education (UME) and GME to meet workforce needs. This study aimed to determine whether states' primary care GME (PCGME) trainee growth correlates with indicators of need. Data from the American Medical Association Physician Masterfile, the Association of American Medical Colleges, the American Association of the Colleges of Osteopathic Medicine, and the U.S. Census were analyzed to determine how changes between 2002 and 2012 in PCGME trainees-a net primary care physician (PCP) production estimate-correlated with state need using three indicators: (1) PCP-to-population ratio, (2) change in UME graduates, and (3) population growth. Nationally, PCGME trainees declined by 7.1% from the net loss of 679 trainees (combined loss of 54 postgraduate year 1 trainees in internal medicine, family medicine, and pediatrics and addition of 625 fellowship trainees in those specialties). The median state PCGME decline was 2.7%. There was no correlation between the percent change in states' PCGME trainees and PCP-to-population ratio (r = -0.06) or change in UME graduates (r = 0.17). Once adjusted for population growth, PCGME trainees declined by 15.3% nationally; the median state decline was 9.7%. There is little relationship between PCGME trainee growth and state need indicators. States should capitalize on opportunities to create explicit linkages between UME, GME, and population need; strategically allocate Medicaid GME funds; and monitor the impact of workforce policies and training institution outputs.

Advancing educational continuity in primary care residencies: an opportunity for patient-centered medical homes.

Continuity of care is a core value of patients and primary care physicians, yet in graduate medical education (GME), creating effective clinical teaching environments that emphasize continuity poses challenges. In this Perspective, the authors review three dimensions of continuity for patient care-informational, longitudinal, and interpersonal-and propose analogous dimensions describing continuity for learning that address both residents learning from patient care and supervisors and interprofessional team members supporting residents' competency development. The authors review primary care GME reform efforts through the lens of continuity, including the growing body of evidence that highlights the importance of longitudinal continuity between learners and supervisors for making competency judgments. The authors consider the challenges that primary care residency programs face in the wake of practice transformation to patient-centered medical home models and make recommendations to maximize the opportunity that these practice models provide. First, educators, researchers, and policy makers must be more precise with terms describing various dimensions of continuity. Second, research should prioritize developing assessments that enable the study of the impact of interpersonal continuity on clinical outcomes for patients and learning outcomes for residents. Third, residency programs should establish program structures that provide informational and longitudinal continuity to enable the development of interpersonal continuity for care and learning. Fourth, these educational models and continuity assessments should extend to the level of the interprofessional team. Fifth, policy leaders should develop a meaningful recognition process that rewards academic practices for training the primary care workforce.

Rural Primary Care Physician Workforce Expansion: An Opportunity for Bipartisan Legislation

The primary care physician workforce crisis has eluded solution for many years. Concerns raised 5 years ago about nadir of interest in primary care careers by medical students are now realized, as the proportion of residency graduates from our nation's teaching hospitals entering primary care careers, particularly to underserved rural areas, has hit an all-time low.1,2 There is an estimated shortage of 16 000 primary care physicians (PCPs) necessary to meet today's needs; this deficit will grow to 52 000 in the next decade.3 An aging population, with an aging population of physicians themselves, will exacerbate this situation. When the Affordable Care Act (ACA) is fully implemented, more than 25 million newly insured Americans will rely not only on the existing deficient physician workforce but also on physicians currently in training. We believe that expansion of primary care graduate medical education (GME) to address this shortage is urgently needed, and represents an opportunity for bipartisan support of GME expansion legislation.

Fixing the Primary Care Pipeline: The Role of Teaching Health Centers

Fixing the Primary Care Pipeline: The Role of Teaching Health Centers

Commentary

Traditional medical schools in modern academic health centers make discoveries, create new knowledge and technology, provide innovative care to the sickest patients, and educate future academic and practicing physicians. Unfortunately, the growth of the research and clinical care missions has sometimes resulted in a loss of emphasis on the general professional education of medical students. The author concludes that it may not be practical for many established medical schools to functionally return to the reason they were created: for the education of medical students.He had the opportunity to discover a different model of medical student education at the first new MD-granting medical school created in the United States in 25 years (in 2000), the Florida State University College of Medicine. He was initially skeptical about how its distributed regional campuses model, using practicing primary care physicians to help medical students learn in mainly ambulatory settings, could be effective. But his experience as a faculty member at the school convinced him that the model works very well.He proposes a better alignment of form and function for many established medical schools and an extension of the regional community-based model to the formation of community-based primary care graduate medical education programs determined by physician workforce needs and available resources.

Commentary

The primary-care-oriented Teaching Health Center Graduate Medical Education (THCGME) program funded by the Patient Protection and Affordable Care Act of 2010 offers opportunities to explore alternative solutions to such graduate medical education (GME) policy issues as institutional indirect educational costs, variations in trainee-related productivity gains, and the program costs of GME innovations. THCGME reporting requirements may also provide data on the impact of various educational innovations on career choice and clinical care as well as other information that could be useful in devising a more transparent and equitable system of support for GME.THCGME program advocates should, however, be cautious in applying any lessons learned to broader GME policy reform. Unlike the THCGME funding, Medicare GME payments are part of the Medicare entitlement, tied to provision of clinical services and financed outside the annual congressional appropriations process. Pressure on domestic discretionary spending makes substantially expanded appropriations for the THCGME program an unlikely path for widespread reform. Absent secure "all-payer financing" of GME, residency program sponsors lack sufficient Medicare funds to cover all GME costs and must favor investments in specialties that meet local concerns, not long-term national workforce priorities. Nonetheless, the THCGME program provides an exciting opportunity to improve and to study primary care GME. Furthermore, the organizational infrastructures established, program leaders developed, data collected, and lessons learned from the program can inform more fundamental change in U.S. GME payment policy.

Teaching Primary Care in Community Health Centers: Addressing the Workforce Crisis for the Underserved

Universal coverage and multiple initiatives to improve health care delivery are crucial components of health care reform. However, the missing link has been a plan to rapidly address the primary care workforce crisis for the underserved. The authors propose a link between primary care graduate medical education and care for the underserved in community health centers, where expansion will be necessary for the anticipated increase in Medicaid and insured patients. This can be achieved by establishing primary care teaching health centers in expanded community health centers, which have established a patient-centered medical home practice environment. Residents would receive their final year of training in these centers, and then have the incentive of National Health Service Corps debt repayment if they subsequently practice in an underserved area. Primary care residents being trained in this setting would immediately increase the clinical capacity of community health centers and ultimately expand the primary care physician workforce. This proposal addresses the primary care physician workforce crisis and the associated key problems of limited access for the underserved and suboptimal primary care graduate medical education.

Results of a Nationwide Veterans Affairs Initiative to Align Graduate Medical Education and Patient Care

Planning for the US physician workforce is imprecise. Prevailing policy generally advocates more training in primary care specialties. To describe a program to increase primary care graduate medical education (GME) in a large academic health system-the Veterans Health Administration of the Department of Veterans Affairs (VA). In 1995, a VA advisory panel recommended a 3-year plan to eliminate 1000 specialist training positions and add 750 primary care positions. After assessing the impact of the first year of these changes on patient care, the VA implemented modifications aimed at introducing primary care curricula for training of internal medicine subspecialists, neurologists, and psychiatrists. The change in strategy was in response to the call for better alignment of GME with local patient care and training needs to provide coordinated, continuous care for seriously and chronically ill patients. The VA health system, including 172 hospitals, 773 ambulatory and community-based clinics, 206 counseling centers, and 132 nursing homes. A total of 8900 VA residency training positions affiliated with 107 medical schools. Proportion of residents in primary care training during the 3-year alignment. Over 3 years, primary care training in the VA increased from 38% to 48% of funded positions. Of this total, 39% of the increase was in internal medicine subspecialties, neurology, and psychiatry. In this case study of GME realignment, national policy was driven more by local patient care issues than by a perceived national need for primary care or specialty positions.

Differences in curriculum emphasis in US undergraduate and generalist residency education programmes.

Little attention has been paid to the differential emphasis undergraduate and graduate medical education programmes place on the broad competencies that will be needed for practice in an increasingly managed health care environment. The purpose of this study was to determine differences in emphasis that undergraduate and primary care graduate medical education programmes are currently placing on 33 broad practice competencies, compared with the emphasis they ideally would like to give them, and the barriers they perceive to curriculum change. Subjects were surveyed by mailed questionnaire. A reminder postcard and follow-up mailing were sent to non-respondents. US allopathic medical schools. Academic deans identified by the Association of American Medical Colleges (AAMC) and generalist (family medicine, internal medicine, paediatrics and obstetrics-gynaecology) residency programme directors identified by the American Council on Graduate Medical Education (ACGME). Findings revealed that residency programmes placed greater emphasis on the study's broad curriculum topics than did undergraduate medical education programmes. Statistically significant differences were found in current emphasis for 12 topics and ideal emphasis for six topics. Both groups identified an already crowded curriculum and inadequate funding as the top two barriers to curriculum change. The differences in curriculum emphases and perceived barriers to curriculum change most probably reflect the different realities of undergraduate and graduate medical education programmes, i.e. academics vs. a focus on immediate practice realities.

IV. Grants

IV. Grants

Financing ambulatory care education in internal medicine

As graduate medical education (GME) shifts to ambulatory settings, it is critical that financing follow suit. However, present financing of GME by Medicare is linked to payment for inpatient service, and few other payors pay explicitly for education. Human capital theory suggests that hospitals will be unwilling to finance GME unless their expenses are reimbursed. Reform of Medicare should include changes in how residents' time in ambulatory settings is counted, incentives for primary care education, and direction of funds to medical educators (rather than hospital administrators). Other federal initiatives could include changes in U.S. Department of Veterans Affairs (VA) support of residents and in Title VII grants. Non-federal payors also should contribute to paying for GME. Physician payment reform could help finance primary care GME, and an additional payment for bills submitted by physician-teachers should be considered. Medical educators must share responsibility by assuring that residencies are operated efficiently and that national needs for physicians are not subjugated to local service requirements.