Training Physicians for Primary Care: Trends and Hazards

Programs to train physicians more effectively for careers in primary care are being organized within academic departments in internal medicine and pediatrics, while the number of training programs in family practice continues to grow rapidly. However, the field of primary care training is expanding without a common vocabulary and with inadequate communication between the specialties involved.If decisions concerning health care policy are to be made rationally, the development of multiple distinct models for primary health care delivery must be encouraged and these models must then be evaluated.The distinction between family practice and family medicine must be made clear if the latter discipline is to realize its potential application to all specialties.The relative exclusion of family practice from universities and the absence of experienced practitioners in university primary care programs are conditions that threaten the future of both types of programs and deserve thoughtful attention from medical educators.     

Alberta's Rural Physician Action Plan: an integrated approach to education,recruitment and retention

This paper describes the development and characteristics of a comprehensive, integrated and sustained program for the education, recruitment and retention of physicians for rural practice in Alberta--the Rural Physician Action Plan. The participation of key stakeholders (including government, the provincial medical association, the licensing authority, faculties of medicine, practising rural physicians and regional health authorities) and a sustained program budget have been key organizational issues for success. Critical to the effectiveness of this program has been the focus on professional and lifestyle issues targeting 3 distinct groups: physicians in training, physicians in practice, and rural communities and health authorities. Substantial program funding since 1991-92 of up to $3 million per year has increased rural-based activities significantly. For example, 87% of medical students and 91% of residents in family medicine in Alberta now experience 4 weeks or more of rural practice. The authors believe that the historic issues and recent trends militating against recruitment and retention of rural physicians will continue unchecked without comprehensive and sustained approaches such as Alberta''s Rural Physician Action Plan.     

A Statewide Approach to Health Care Personnel Maldistribution—The California Area Health Education Center System

An Area Health Education Center (AHEC) system has been established in California to address the maldistribution of physicians and other health care professionals. The AHEC program uses educational incentives to recruit and retain health care personnel in underserved areas by linking the academic resources of university health science centers with local educational and clinical facilities. The medical schools, working in partnership with urban or rural AHECs throughout the state, are implementing educational programs to attract trainees and licensed professionals to work in underserved communities. The California AHEC project entered its fifth year in October of 1983 with the participation of all eight medical schools and the Charles Drew Postgraduate School of Medicine, 35 other health professions schools, 17 independent AHECs and more than 400 clinical training sites. Educational programs are reaching more than 22,000 students and practicing health professionals throughout California. We review the current status of the California AHEC system and use the AHEC programs at Loma Linda University to illustrate the effect this intervention is having.     

Curriculum change needed at Yale

The United States Congress has recently passed an important bill entitled, The Health Professionals Assistance Act of 1976. It seeks to right physician maldistribution in the country and curtail the over specialization of medical practitioners. Quotas have been set in terms of the number of medical school graduates who must enter primary care training programs over the next few years. Failure to comply risks loss of the federal capitation grant of twenty-one hundred dollars per student or about one million dollars a year in Yale''s case.The causes of physician maldistribution are discussed. Partial blame is ascribed to the medical schools themselves and recommendations are made for curriculum changes which if adopted may achieve better physician distribution without further government inroads into medical school affairs.     

The Primary Care Network: A New Type of HMO for Private Practice Physicians

A new type of health maintenance organization has been developed to encourage primary care physicians in private practice to become coordinators and financial managers for all medical care. Each patient chooses one internist, family or general physician, or pediatrician and must be referred by that physician for all hospital admissions and care by specialists. The primary care physician authorizes all payments from his own account for care provided to his patients. He shares any deficit or surplus remaining at the end of the year.Hospital admission rates and length of stay are lower than those of Blue Cross, with only one of three dollars paid to hospitals. The plan is providing care to 38,000 persons with 750 participating physicians in Northern California, Washington and Utah.This plan represents an attempt by physicians to control costs without government regulation.     

Public Policy Review—A Ten-Year Progress Report on a Family Practice Residency Network in Northern California

We are now beginning to be able to evaluate the results of the rapid growth of family practice residency training programs during the past decade. Because this growth has been supported by federal and state funds, it is particularly important to review these programs to measure their progress toward the public policy goals established by legislation. The University of California, Davis, School of Medicine has been an innovator and leader in training family physicians. Graduates of the UC Davis Network of Family Practice Residency Programs are locating in medically underserved areas and are helping to respond to the perceived problems of specialty and geographic maldistribution of physicians.     

Practice patterns of family physicians with 2-year residency v. 1-year internship training: do both roads lead to Rome?

Are there differences in patterns of practice between actively practising physicians who have been certified after a 2-year family practice residency and matched physicians without certification who have completed the standard 1-year internship? With the use of billing files prepared by the British Columbia Medical Association a group of 65 family practice certificants in active practice in British Columbia was compared with a control group of 130 internship trainees matched by year and school of graduation, category of billing (i.e., solo or group) and region. A wide range of practice features was assessed for the fiscal years 1984-85, 1985-86 and 1986-87. No differences were detected between the groups in 1986-87 for the following practice variables: number of patients (1888 and 1842 respectively), number of personal services billed for (7265 and 7173), number of personal services per patient (3.9), amount of funding for personal services ($140,192 and $140,100) and amount per patient for personal services ($77 and $79). Age-adjusted costs for male and female patients were similar in the two groups. Of six services thought to be influenced by type of training, only maternity care generated a significantly higher number of billings in the study group (341 v. 249). These results suggest that there is no demonstrable effect of training on patterns of practice. However, the question of the effect of training on quality of care and whether the 2-year residency may have a longer effect on practice patterns should be the focus of future research.     

Continuing Medical Education Tuition: A Survey of Charges

A survey was carried out on the tuition charged for continuing medical education (CME) programs offered by a variety of providers. These included schools of medicine throughout the United States, national organizations and societies, state-wide organizations and societies located in California, and a small group of hospitals in or near Sacramento, California.The fees charged for continuing medical education (expressed in this article as the amount in dollars that a physician must pay for one hour of approved Category I credit) may vary from nothing to more than $20 an hour. The average charge per hour for CME courses sponsored by medical colleges in the United States ranged from none to $11.19 during 1976 and 1977. Recent data indicate that most schools have increased tuition for CME courses because of inflation. Many schools of medicine provide CME through grand rounds, conferences and special lectures at no cost to participants. Similarly, in a small sample of hospitals in California, CME was found to be available at a minimal charge to physicians.Some CME programs are more costly because fees may include the expenses of honored visiting faculty, and costs of food or social activities. There may be further expense if travel is required, although these additional costs may be offset by the benefits of study in a relaxed atmosphere away from practice and office pressures.     

TAX-SUPPORTED MEDICAL CARE FOR CALIFORNIA'S CHILDREN—Where Should It Be Going?

The multiplication of separate governmental agencies providing health services to California''s children, the increasing difficulties in staffing tax-supported health agencies and the recent studies of the quality of care under these programs, have all pointed to an urgent need for prompt decisions on certain basic questions about the function of tax-supported medical care for children of dependent families.Fourteen separate kinds of health services are currently provided through public funds at an annual cost to California taxpayers of $52,000,000. These funds underwrite an uncoordinated, fragmented, patchwork quilt of medical care for some 500,000 children. Coordination and integration of these services through “one door” with uniform eligibility requirements and maximum utilization of private physicians'' services that meet appropriate standards is needed now. California physicians have an urgent responsibility to provide leadership in the development of more effective and more economical organization and distribution of higher quality medical care services for California''s children dependent on public support.     

Quality of care in family practice: does residency training make a difference?

As the proportion of physicians who enter residency training in family practice steadily increases, so does the need to evaluate the impact of their training and postgraduate education on the quality of care in their practices. We audited the practices of 120 randomly selected family physicians in Ontario, who were separated into four groups: nonmembers of the College of Family Physicians of Canada (CFPC), members of the CFPC with no certification in family medicine, certificated members without residency training in family medicine and certificated members with residency training in family medicine. The practices were assessed according to predetermined criteria for charting, procedures in periodic health examination, quality of medical care and use of indicator drugs. Generally the scores were significantly higher for CFPC members with residency training in family medicine than for those in the other groups, nonmembers having the lowest scores. Patient questionnaires indicated no difference in satisfaction with specific aspects of care between the four groups. Self-selection into residency training and CFPC membership may account for some of the results; nevertheless, the findings support the contention that residency training in family medicine should be mandatory for family physicians.     

A survey of postgraduate training for family practice.

The results of a survey of Canadian primary care physicians for the Canadian Medical Association (CMA''s) Task Force on Education for the Provision of Primary Care Services are reported. Recent Canadian medical school graduates in primary care practice reported that the three major training routes (rotating and mixed internships and family medicine residencies) each prepared them differently for practice. The graduates of 2-year family medicine residencies were more satisfied with their preparation than were the graduates of the other major training routes. A 2- or 3-year family medicine residency was preferred by 50% of the respondents, although only 33% of them had actually taken one of these routes. There was considerable agreement in the respondents'' assessments of the types of postgraduate education needed for primary care practice. The results of this survey were consistent with the recommendations in the final report of the CMA''s task force.     

What Is So Special About a Family Physician?

Around a core of common, acute and chronic, recurrent health problems, a family physician must marshall the traditional episodic management for both inpatient and outpatient illness. He must also be especially adept at recently emerging routines of prevention and early detection. He provides individual and familial psychologic support and counselling, for both its therapeutic and preventive values. In addition, he must relate the individual care of his patient and the patient''s family to the community as a whole. In doing this he will use not only his own skills but those of lay health volunteers, trained allied health care professionals and skilled subspecialists in the limited medical disciplines.The proper preparation of family physicians for this complicated role has far-reaching implications for change in both medical education and medical practice.     

Coronary Care Units—The Status in California

In order to determine the status of Coronary Care Unit activity in California hospitals, especially as it pertains to nurse training, a survery was conducted by the California State Department of Public Health. More than 95 percent of hospitals that were questioned responded. Only one-third of the hospitals reported they neither had a unit nor plans to build one. All units in operation were either directed by an individual medical director or by a Coronary Care Unit Committee.The survey indicated that in some hospitals with operational units, nurses were not permitted to perform life-saving resuscitative procedures. All operational units reported in-service education programs of some type. Many hospitals indicated they would like to have Coronary Care Unit training programs to which they could send nurses. The reasons why nurses may not perform important resuscitative procedures are discussed as well as the need for Coronary Care Unit training programs for both physicians and nurses in California.     

Uncompensated and undercompensated care provided by San Francisco Medical Society physicians.

Practicing physician members of the San Francisco Medical Society were surveyed regarding reimbursement rates for medical care provided to underinsured and uninsured patients. Of 394 respondents, about $51,000 per physician practice was written off as uncompensated care or services not billed for in 1985. An average of 7% of each physician''s patients was estimated to be "no-pay" or charity patients, accounting for $19,000 of this total. Almost $32,000 was reported as being uncompensated care, or that which is billed but not paid. In addition to these amounts, an average of $32,000 was reported as being discounted from the usual fee levels by government insurance programs. Extrapolating these results to the physician membership of the local medical society indicates that physicians in San Francisco may be providing as much as $81 million in uncompensated or charity care annually. These results emphasize that private practitioners are providing a significant amount of medical care at reduced or charity rates, an amount that can be expected to increase given present trends. Substantial changes are needed if the burden of providing medical care to poor and uninsured Americans is not to fall disproportionately on private providers.     

State‐Level Estimates of Annual Medical Expenditures Attributable to Obesity*

Objective: To provide state‐level estimates of total, Medicare, and Medicaid obesity‐attributable medical expenditures. Research Methods and Procedures: We developed an econometric model that predicts medical expenditures. We used this model and state‐representative data to quantify obesity‐attributable medical expenditures. Results: Annual U.S. obesity‐attributable medical expenditures are estimated at $75 billion in 2003 dollars, and approximately one‐half of these expenditures are financed by Medicare and Medicaid. State‐level estimates range from $87 million (Wyoming) to $7.7 billion (California). Obesity‐attributable Medicare estimates range from $15 million (Wyoming) to $1.7 billion (California), and Medicaid estimates range from $23 million (Wyoming) to $3.5 billion (New York). Discussion: These estimates of obesity‐attributable medical expenditures present the best available information concerning the economic impact of obesity at the state level. Policy makers should consider these estimates, along with other factors, in determining how best to allocate scarce public health resources. However, because they are associated with large SE, these estimates should not be used to make comparisons across states or among payers within states.     

Adolescent health care in a large multispecialty prepaid group practice. Who provides it and how well are they doing?

Adolescents are at risk for pregnancy, sexually transmitted diseases, suicide, homicide, accidents, and substance abuse. Adolescent medicine involves an overlap of many skills needed to provide routine medical care, as well as care for those conditions that require psychosocial assessment. We report the results of a mail survey covering care of this age group by practitioners of pediatrics, internal medicine, obstetrics and gynecology, family practice, and adolescent medicine in a large, multispecialty, prepaid group practice. The mail survey covered 10 areas of adolescent care. Adolescent medicine physicians expressed the highest level of perceived knowledge and competence in these areas, with family practitioners ranked second. More than 50% of internists and pediatricians felt only fair to poor competence for a variety of adolescent conditions, whereas a third of internists and pediatricians reported that they liked to care for adolescents. Physicians in all 4 of the primary care specialties reported a need for a teen health center for both consultation and education. These results are similar to those reported for pediatricians and primary care physicians in private practice and for residents in internal medicine.     

Impact of education and network for avian influenza H5N1 in human: knowledge, clinical practice, and motivation on medical providers in Vietnam

Background

Knowledge, clinical practice, and professional motivation of medical providers relating to H5N1 infection have an important influence on care for H5N1 patients who require early diagnosis and early medical intervention.

Methods/Principal Findings

Novel educational programs including training and workshops for medical providers relating to H5N1 infection in Vietnam were originally created and implemented in 18 provincial hospitals in northern Vietnam between 2008 and 2010. A self-administered, structured questionnaire survey was conducted in 8 provincial hospitals where both educational training and workshops were previously provided. A total of 326 medical providers, including physicians, nurses, and laboratory technicians who attended or did not attend original programs were enrolled in the survey. Knowledge, clinical attitudes and practice (KAP), including motivation surrounding caring for H5N1 patients, were evaluated. The study indicated a high level of knowledge and motivation in all professional groups, with especially high levels in laboratory technicians. Conferences and educational programs were evaluated to be the main scientific information resources for physicians, along with information from colleagues. The chest radiographs and the initiation of antiviral treatment in the absence of RT-PCR result were identified as gaps in education. Factors possibly influencing professional motivation for caring for H5N1 patients included healthcare profession, the hospital where the respondents worked, age group, attendance at original educational programs and at educational programs which were conducted by international health-related organizations.

Conclusions

Educational programs provide high knowledge and motivation for medical providers in Vietnam caring for H5N1 patients. Additional educational programs related to chest radiographs and an initiation of treatment in the absence of RT-PCR are needed. Networking is also necessary for sharing updated scientific information and practical experiences. These enhanced KAPs by educational programs and integrated systems among hospitals should result in appropriate care for H5N1 patients and may reduce morbidity and mortality.     

Nurse practitioners in primary care III. The southern Ontario randomized trial

A group of nurses who formerly had performed office functions received a special university-based educational program designed to prepare them to assume much of primary care management as nurse practitioners. The associated family physicians would shift their role to general supervision and attention to difficult clinical problems. To test this new form of practice, two complementary randomized trials have been conducted in south-central Ontario. The particular trial reported here was intended to assess the influence of the educational program on the changing roles of the professional personnel. The nurses of 14 family medical practices, with the physicians'' support and commitment to participation, applied for the new training. Seven applicants were randomly selected to receive the training and their corresponding practices became the experimental group, while the remaining nurses and practices were retained as controls. During the subsequent year of investigation important changes occurred in professional roles of the experimental group. Nurse practitioners spent more time in clinical activities than conventional office nurses. The shift was not at the expense of time devoted to clinical work by physicians. Doctors delegated more professional activities to nurse practitioners than to conventional nurses. Except for remuneration (affected by legal constraints) job satisfaction among experimental physicians and nurses remained high after one year of experience with the new method.     

Future role of neurologists.

Clinical neurologists in the health care system of the future should have a multifaceted role. Advances in the basic understanding of the nervous system and therapeutics of neurologic disease have created, for the first time in human history, an ethical imperative to correctly diagnose neurologic disease. In many situations, the neurologists may function as a consultant and principal physician for patients with primary nervous system disorders including Parkinson''s disease, multiple sclerosis, Alzheimer''s disease, epilepsy, migraine, cerebrovascular disease, movement disorders, and neuromuscular disease. Other important roles for neurologists include the training of future physicians, both neurologists and primary care physicians, the application of cost-effective approaches to care, and the support of health care delivery research and academic programs that link basic research efforts to the development of new therapy. To be successful, future residency training programs should include joint certification opportunities in both neurology and general medicine, and training programs for clinical investigators should be expanded. Despite its threats to specialists, managed care should also provide opportunities for new alliances among neurologists, other specialists, and primary care physicians that will both improve patient care and increase efficiency and cost-effectiveness.     

Continuing medical education about AIDS--a needs assessment.

The incidence of the acquired immunodeficiency syndrome (AIDS) among Latinos and African Americans nationally and in Los Angeles has risen substantially. No data exist to indicate which physicians (or groups of physicians) provide care to these groups, however. To better plan AIDS educational programs, efforts were made to identify those physicians whose offices were located in areas with high proportions of nonwhites. Many physicians in these areas--30% of all office-based primary care physicians in Los Angeles--were found to be graduates of international medical schools. A survey of a stratified random sample of international medical graduates revealed that compared with a random sample of United States medical graduates, they had a greater proportion of nonwhite patients, often of an ethnicity similar to theirs; practiced in areas with a greater proportion of Asians and lower family incomes; had fewer patients infected with the immunodeficiency virus (HIV) in their practices; and were more avoidant of such patients. As the incidence of HIV infection increases among minority groups, means need to be developed to ensure their access to counseling and screening, as well as treatment with the latest available agents. Options include imaginative and engaging approaches to continuing medical education for all physicians and the creation of separate public sector infrastructures to meet the HIV-related needs of these communities.