The Future of Primary Care Medicine
http://www.100md.com
《新英格兰医药杂志》
During the early and mid-1990s, a consensus emerged among physicians and health care policymakers that the United States would have a substantial surplus of physicians by the end of the decade. Most people who held this view also believed that the surplus would be limited to non–primary care physicians and that, by contrast, the supply of physicians planning to practice primary care medicine would be barely adequate. This view was supported by the decrease in the late 1980s and early 1990s in the number of graduating medical students who chose residency training in specialties that could lead to careers in primary care practice.
Now, only a few years later, studies are beginning to suggest that the country may soon be facing an overall shortage of physicians, and market signals suggest that, in some regions, shortages may already exist in some specialties. If these suggestions prove valid, what might they mean for the supply of primary care practitioners? After all, if the numbers were viewed as barely adequate when the aggregate supply of physicians was thought to be excessive, what is likely to happen if the aggregate supply itself proves inadequate?
Figure 1 shows the numbers of graduates of U.S. medical schools who were matched during the past 15 years with residency programs — in internal medicine, family medicine, pediatrics, and the combination of internal medicine and pediatrics — that might lead to careers in primary care practice. These data underestimate the total number of graduates entering such programs, because they do not include graduates of foreign medical schools who entered them or U.S. graduates who did so outside of the National Resident Matching Program. Nonetheless, Figure 1 reflects the trends in U.S. graduates' interest in pursuing careers as primary care physicians.
Figure 1. Match Results According to Primary Care Specialty, 1989 through 2003.
Data are from the National Resident Matching Program.
The number of students who were matched with these programs increased each year from 1992 through 1997. In 1998, the number began to decrease, and it has decreased every year since. Family practice is the specialty most clearly associated with the practice of primary care medicine, and the marked decline in the number of students who were matched in this specialty is especially noteworthy for several reasons. When the decline began in 1998, future practice opportunities in primary care were still thought to be more plentiful than those in other specialties, for which the supply of physicians was still considered to be excessive. In addition, by that time, medical schools had made concerted efforts to increase the number of their graduates who chose careers in primary care.
Given the growing perception that the overall supply of physicians may be insufficient to meet future needs, the recent trend may be the harbinger of a real crisis in primary care medicine — a crisis even more severe than the one predicted in the early 1990s. If we are to avoid such a crisis, we must have a firm grasp of the factors contributing to the sharp decline in students' interest in primary care.
The usual explanations for this waning interest are undoubtedly valid. Some students decide that primary care is not sufficiently remunerative, that its demands are not compatible with their lifestyle expectations, or that it fails to provide enough intellectual stimulation to sustain their interest. But an additional possibility, albeit an apparently paradoxical one, is that the decline is due in part to the successful efforts by medical schools to increase students' exposure to primary care practice. How can this be? And if it is true, what might be done about it?
To understand this dynamic, it is important to recognize what students observe about primary care practice during medical school. In most schools, students spend some time during their first two years in the offices of community-based primary care practitioners, where they observe the reality of this type of practice and gain insight into the challenge of caring for patients with a wide range of conditions, including serious chronic diseases. As a rule, students seem to enjoy and value these experiences, and they rate their preceptors — the practitioners with whom they spend time — as highly effective teachers.
But students see another aspect of primary care medicine as they rotate through the required inpatient clerkships that occupy most of the last two years of medical school. During these clerkships, they once again observe patients with chronic diseases, many of whom have been hospitalized because of inadequate or inappropriate treatment of their underlying diseases. And although students may see how the episodic conditions that precipitate hospitalization are managed, they cannot help but notice how little attention the attending physicians and residents devote to considering how hospitalization might have been avoided through better outpatient management.
Moreover, during the time they spend in outpatient care settings, few students (or residents) have the opportunity to observe the provision of optimal care for patients with chronic diseases. Few outpatient teaching sites have established contemporary models of chronic-disease management, in which teams of health care professionals are guided by the principles of patient-centered care and are supported by the information-technology systems needed to provide high-quality ambulatory care. As a consequence, we believe that the clerkships discourage many students from pursuing residency training in a primary care specialty, because they are concerned that they will not be adequately prepared to meet the responsibilities of such a practice.
If residency programs were designed to impart the knowledge, skills, and attitudes needed to care for patients with chronic diseases, students who were genuinely interested in meeting the most important challenge facing medicine — providing high-quality ambulatory care for such patients — would recognize the exciting opportunity that primary care medicine offers. Instead of being discouraged by some of the realities of primary care practice, particularly lower incomes and greater demands on their time, more students might find in this specialty precisely what they were seeking when they chose to pursue a career in medicine.1 However, as others have noted, neither family practice nor internal medicine — the two specialties that provide most of the care for adults with chronic diseases — has yet redesigned its residency programs to encompass the knowledge, skills, and attitudes residents must have to care for such patients.2,3 Unless these changes are made — and made soon — the practice of primary care medicine seems destined to become the province of nurses and other nonphysician health care professionals.
Source Information
From the Association of American Medical Colleges, Washington, D.C.
References
Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA 2002;288:889-893.
Wiest FC, Ferris TG, Gokhale M, Campbell EG, Weissman JS, Blumenthal D. Preparedness of internal medicine and family practice residents for treating common conditions. JAMA 2002;288:2609-2614.
Showstack J, Lurie N, Larson EB, Rothman AA, Hasmiller S. Primary care: the next renaissance. Ann Intern Med 2003;138:268-272.
Related Letters:
Attracting Students to Primary Care
Saver B. G., Poplin C. M., Cykert S., Fleming M., Johnson M. S., South-Paul J., Rustin T. A., Whitcomb M. E., Cohen J. J., Fincher R.-M. E.(Michael E. Whitcomb, M.D.)
Now, only a few years later, studies are beginning to suggest that the country may soon be facing an overall shortage of physicians, and market signals suggest that, in some regions, shortages may already exist in some specialties. If these suggestions prove valid, what might they mean for the supply of primary care practitioners? After all, if the numbers were viewed as barely adequate when the aggregate supply of physicians was thought to be excessive, what is likely to happen if the aggregate supply itself proves inadequate?
Figure 1 shows the numbers of graduates of U.S. medical schools who were matched during the past 15 years with residency programs — in internal medicine, family medicine, pediatrics, and the combination of internal medicine and pediatrics — that might lead to careers in primary care practice. These data underestimate the total number of graduates entering such programs, because they do not include graduates of foreign medical schools who entered them or U.S. graduates who did so outside of the National Resident Matching Program. Nonetheless, Figure 1 reflects the trends in U.S. graduates' interest in pursuing careers as primary care physicians.
Figure 1. Match Results According to Primary Care Specialty, 1989 through 2003.
Data are from the National Resident Matching Program.
The number of students who were matched with these programs increased each year from 1992 through 1997. In 1998, the number began to decrease, and it has decreased every year since. Family practice is the specialty most clearly associated with the practice of primary care medicine, and the marked decline in the number of students who were matched in this specialty is especially noteworthy for several reasons. When the decline began in 1998, future practice opportunities in primary care were still thought to be more plentiful than those in other specialties, for which the supply of physicians was still considered to be excessive. In addition, by that time, medical schools had made concerted efforts to increase the number of their graduates who chose careers in primary care.
Given the growing perception that the overall supply of physicians may be insufficient to meet future needs, the recent trend may be the harbinger of a real crisis in primary care medicine — a crisis even more severe than the one predicted in the early 1990s. If we are to avoid such a crisis, we must have a firm grasp of the factors contributing to the sharp decline in students' interest in primary care.
The usual explanations for this waning interest are undoubtedly valid. Some students decide that primary care is not sufficiently remunerative, that its demands are not compatible with their lifestyle expectations, or that it fails to provide enough intellectual stimulation to sustain their interest. But an additional possibility, albeit an apparently paradoxical one, is that the decline is due in part to the successful efforts by medical schools to increase students' exposure to primary care practice. How can this be? And if it is true, what might be done about it?
To understand this dynamic, it is important to recognize what students observe about primary care practice during medical school. In most schools, students spend some time during their first two years in the offices of community-based primary care practitioners, where they observe the reality of this type of practice and gain insight into the challenge of caring for patients with a wide range of conditions, including serious chronic diseases. As a rule, students seem to enjoy and value these experiences, and they rate their preceptors — the practitioners with whom they spend time — as highly effective teachers.
But students see another aspect of primary care medicine as they rotate through the required inpatient clerkships that occupy most of the last two years of medical school. During these clerkships, they once again observe patients with chronic diseases, many of whom have been hospitalized because of inadequate or inappropriate treatment of their underlying diseases. And although students may see how the episodic conditions that precipitate hospitalization are managed, they cannot help but notice how little attention the attending physicians and residents devote to considering how hospitalization might have been avoided through better outpatient management.
Moreover, during the time they spend in outpatient care settings, few students (or residents) have the opportunity to observe the provision of optimal care for patients with chronic diseases. Few outpatient teaching sites have established contemporary models of chronic-disease management, in which teams of health care professionals are guided by the principles of patient-centered care and are supported by the information-technology systems needed to provide high-quality ambulatory care. As a consequence, we believe that the clerkships discourage many students from pursuing residency training in a primary care specialty, because they are concerned that they will not be adequately prepared to meet the responsibilities of such a practice.
If residency programs were designed to impart the knowledge, skills, and attitudes needed to care for patients with chronic diseases, students who were genuinely interested in meeting the most important challenge facing medicine — providing high-quality ambulatory care for such patients — would recognize the exciting opportunity that primary care medicine offers. Instead of being discouraged by some of the realities of primary care practice, particularly lower incomes and greater demands on their time, more students might find in this specialty precisely what they were seeking when they chose to pursue a career in medicine.1 However, as others have noted, neither family practice nor internal medicine — the two specialties that provide most of the care for adults with chronic diseases — has yet redesigned its residency programs to encompass the knowledge, skills, and attitudes residents must have to care for such patients.2,3 Unless these changes are made — and made soon — the practice of primary care medicine seems destined to become the province of nurses and other nonphysician health care professionals.
Source Information
From the Association of American Medical Colleges, Washington, D.C.
References
Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA 2002;288:889-893.
Wiest FC, Ferris TG, Gokhale M, Campbell EG, Weissman JS, Blumenthal D. Preparedness of internal medicine and family practice residents for treating common conditions. JAMA 2002;288:2609-2614.
Showstack J, Lurie N, Larson EB, Rothman AA, Hasmiller S. Primary care: the next renaissance. Ann Intern Med 2003;138:268-272.
Related Letters:
Attracting Students to Primary Care
Saver B. G., Poplin C. M., Cykert S., Fleming M., Johnson M. S., South-Paul J., Rustin T. A., Whitcomb M. E., Cohen J. J., Fincher R.-M. E.(Michael E. Whitcomb, M.D.)