Kim A. Bateman, M.D.
Primary Care Physician
Ephraim Medical Clinic
Carolyn V. Brown, M.D., M.P.H.
Assistant Professor
Department of Obstetrics & Gynecology
University of Vermont
Judy Ressallat, M.S.N., M.P.A.
Director
Government Relations
National Association School Nurses, Inc.
Heather Reynolds, M.S.N.
Assistant Professor
School of Nursing
Yale University
Jane Sabes, M.P.A.
Lisa B. Wallenstein, M.D., F.A.C.P. *
Associate Chair
Department of Medicine
Albert Einstein Medical Center
Eric Whitaker, M.D., M.P.H.
Resident Physician
Primary Care Internal Medicine Program
San Francisco General Hospital
* Presenter
At each stage of the life cycle, we will approach decision-making from the perspective of the provider, and we will recommend strategies to enhance the attractiveness of primary care as a career choice. We would like to emphasize again that we will use examples from a limited number of disciplines but that our approach is interdisciplinary.
The life cycle voyage encompasses five stages:
- Kindergarten to college
- Admissions to professional school
- Professional education
- Postgraduate education
- Practice
We will focus on the first four, which emphasize the importance of recruitment and education. The first step in our voyage spans the years from kindergarten through college. Please imagine that I am a fourteen-year-old junior high school student beginning to think beyond the world of the playground. We suggest that a nurse in every school district would go a long towards solving our manpower crisis. The school nurse could achieve the following:
We next meet our potential primary care provider as she is graduating from college. She has spent the summers working in a family physician's office. She has returned to her high school and worked with the school nurse one afternoon each week. She loves kids, and she's committed to a career in general pediatrics. She is graduating from a small liberal arts college in her hometown. She has majored in psychology and has good grades and reasonable MCAT's. She's engaged to her childhood sweetheart and they plan to settle in the town of 35,000 in which they both grew up.
Is our friend more likely than the average applicant to choose a career in primary care? Yes, she absolutely is. Unfortunately, she is also less likely than the average applicant to be accepted into medical school. This raises two issues. First, can we develop a methodology to choose students more likely to pursue primary care? Second, can we as a nation and health care system deal with the legal, moral and ethical implications of preferential admissions? Our answer to both is yes, we can, and yes, we must if we are to achieve the objectives of Healthy People 2000.
Our friend is accepted and enrolled in medical school and will have four years to decide on her career direction. She is at a medical school which is like most medical schools in the country. It has no family medicine department, limited or no opportunity for primary care perceptorship experience in the pre-clinical years, and no role models of primary care providers as faculty. It emphasizes inpatient rather than outpatient education in the third and fourth years, has an institutional commitment to biomedical research but not to primary care, and relies on NIH funding to a modest extent.
We would argue that our friend is likely to change her mind, and that she'll pursue a specialist rather than a generalist career direction. We would like to share a brief anecdote which illustrates the process by which health professions education favors specialism. Our spokesperson is a member of the Admissions Committee of the medical school. Each year, she interviews 100 applicants; of these, 50 are accepted. Forty are committed to primary care by virtue of their experience, background, or idealism. Four years later, the line forms outside her office as twenty of the forty come in to apologize for changing their career direction and choosing specialty residency programs.
Why does this happen and why is it so common? What can we do about it? We believe there is room for intervention on several fronts:
We would like to comment briefly on the issues of financing and institutional ethic. With respect to financing, we propose a percentage adjustment to NIH grants related to the professional school output of primary care providers. We would leave the methodology to individual health professions schools; we would measure the outcome.
We would like to offer one additional anecdote; this one offers a commentary on the notion of an institutional ethic. The Temple University School of Medicine in Primary Care Institute was established in 1991. The class graduating next week experienced no changes in curriculum or financing. They did, however, have role models (at a distance) who are senior faculty committed to primary care (including several whose commitment is relatively new). The Dean and Associate Deans fully support the mission statement of the Primary Care Institute, and there is a clearly recognized institutional commitment. For the first time in six years, the percentage of the graduating class entering primary care residency programs has increased.
We now turn to postgraduate education. Our friend is graduating from medical school and choosing a residency program (and/or specialty). Once again, we use medical training as a paradigm but believe the approach is broadly applicable. Three factors will have major influence on her decision:
Again, there is room for intervention in at least four arenas: curriculum, role models, institutional ethic, and financing, financing of graduate medical education has become the responsibility of the federal government (HCFA in particular), and we would like to focus on this opportunity. We would make two recommendations. The first is that we reexamine GME reimbursement for direct and indirect costs. Specifically, we would increase the allowance for outpatient training, and, most importantly, increase the incentive for primary care training and increase the disincentive for specialty and subspecialty training.
Our second recommendation involves consideration of a restructuring of the reimbursement system. In this model, the HCFA allocation would be tied to the percentage of residents in primary care practice five years after completion of training. Again, reimbursement to hospitals training primary care providers would be increased, and reimbursement to hospitals training tertiary care providers would be decreased.
This second approach offers the advantage of encouraging individual solutions. We suspect there are regional and local differences in the factors which influence career choice. This proposal gives hospitals interested in maintaining optimal GME support several options, including the following:
We suspect that several other innovative and effective strategies would be developed by hospitals interested in maximizing their GME support.
Our friend has completed a residency program in pediatrics, and she's on the verge of deciding between subspecialty fellowship training and primary care practice. The following are likely to have a role in her decision:
The issue of attractiveness is complex but certainly reflects three considerations:
At this juncture, issues of deployment (and later retention) are prominent. The current level of discrepancy in physician payment for primary and tertiary care certainly discourages providers from choosing and remaining in primary care settings. The hassle factor is another deterrent to primary care and, some would argue, an equally important factor. We believe a comprehensive program of loan forgiveness, tied to deployment as a primary care provider, holds great promise for expanding the availability of primary care providers. We would recommend that the loan forgiveness initiative of the National Health Service Corps be expanded to address the national need for primary care providers.
In summary, we have used the life cycle model to define an approach to nurturing health professionals for primary care. We believe that health care policy must encourage primary care career choice if we are to meet the challenges of Healthy People 2000.