Why Education Reform is Needed

What are the strengths of primary care training?

Time spent in primary care clinics presents trainees with many wonderful, unique opportunities that are critical to overall medical education. These include opportunities to:

  • Form meaningful, long-term relationships with patients
  • Better understand patients within their unique biopsychosocial contexts
  • Think about population health, health systems, and health policy, and to explore the relationship of each to individual patients
  • Focus on prevention and wellness promotion
  • Become an expert and responsible diagnostician with a wide breadth of knowledge

How are people currently trained in primary care?

Medical training takes place at three stages: medical school (often called undergraduate medical education, or UGME), residency (often called graduate medical education, or GME) and, after the completion of formal training, continuing medical education (CME). While every medical school and residency program is unique, the basis of outpatient primary care training is very similar across institutions and programs.

UGME: Most students are exposed to outpatient primary care in the context of a rotation such as pediatrics, internal medicine, and family medicine (which not all medical schools offer.) The majority of time in these rotations is spent on inpatient hospital wards, giving students very limited exposure to outpatient primary care practice and role models in this field. Many medical schools either offer an elective in or require a longitudinal outpatient clinic experience in which students spend one half day a week in an ambulatory clinic.

GME: The same is true of most residencies in pediatrics and internal medicine, with trainees spending the majority of their time on inpatient wards. A growing number of residency programs offer primary care tracks in which residents get more outpatient time than other residents. All residencies require trainees to have a continuity clinic to follow patients regularly over one to three years. This clinic usually takes place one half-day a week, often while trainees have concurrent responsibilities on busy inpatient services, which presents a number of challenges.

CME: In order to maintain certification, all board-certified physicians are required to accrue a certain number of continuing education credits per year through attendance at conferences, seminars, and webinars. These educational offerings vary in content and degree of coordination.

Why is there a call to change primary care training?

There are many who believe the current mode of training does not do justice to the strengths of primary care, is not enough to prepare trainees for real-life practice, and may even discourage trainees from pursuing primary care careers. Primary care medicine has become increasingly team-based, patient-centered, interdisciplinary, proactive, and technologically supported; yet educational programming has lagged behind, creating a possibility that trainees will not graduate with the skills needed to thrive in today’s healthcare environment. As a field with its share of troubles, primary care must address these issues in order to attract, prepare, and retain trainees.

What are the current challenges in primary care education?

Limited exposure to role models and a supportive primary care community
This weakness is often tied to limited primary care exposure overall. It is exacerbated by the fact that primary care doctors often practice in relative isolation and do not come together as a community as visibly as hospital-based specialties do. This lack of community can breed frustration and is sometimes expressed as warnings to trainees to avoid the field altogether.

Limited exposure to alternative models of care
Primary care is changing and so are the models of care through which it is delivered. In general, trainees are exposed to only traditional models of primary care, in which the physician is responsible for the majority of patient care with limited support from staff and other health professionals. Models of care like the patient-centered medical home (PCMH) and the use of health information technology are altering the landscape of primary care practice, but students and residents often have little access to these more progressive examples. These models actively embrace clinical innovations and quality improvement; inclusion of these activities is likely to broaden the appeal of primary care to trainees. Without adequate exposure to alternative models of care or to the clinician-innovators involved in these models, trainees may miss seeing some of the most exciting aspects of primary care. 

Need for faculty development
New models of primary care are new for everyone, including many of the faculty responsible for training the next generation of primary care providers. Many faculty members are understandably anxious about simultaneously learning and teaching new primary care practices. This is particularly difficult for faculty who are not familiar with or do not philosophically ascribe to the values and practices endorsed by newer models of care.

Lack of time in primary care outpatient environments
This issue underpins all the others; for example, lack of time is a major factor in lack of positive exposure. Because the case mix in primary care is heterogeneous and patients’ stories play out over the course of months to years, it is less amendable to rotations or half-day clinic experiences than other specialties or inpatient medicine. While inpatient experiences are no doubt critical, there must be a balance so that trainees have an equal opportunity to appreciate and learn primary care.

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