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Researchers Comment on Stoeckle/Grossman Editorial In their editorial, "Primary Care: Improving Treatment and Learning Outside the Hospital",' Stoeckle and Grossman underscore several critical issues regarding the delivery of primary care services in an academic medical center (AMC) with which we are in complete agreement. We do feel, however, that they misread or misconstrued some points in commenting on our report2 to the Journal. First, we do not propose to reorganize only the outpatient clinic (OPC) as these reviewers assert; rather we agree that a one class system of health care would be best for patients. Secondly, the overriding reason for improving primary care is to insure improved patient care. That, too, should be the ultimate purpose of medical education. Whether an argument for better education will prove more persuasive to decisionmakers in the AMC is problematic; the issue is improved health both through better patient care and through improved medical education. The example of the Duke/Watts Family Medical Center (FMC) referred to in our report amply illustrates many of Stoeckle and Grossman's points, as well as our own. In the FMC a one class system of primary care is provided in a modem, well-equipped facility, by residents and faculty to a patient population that reflects the racial and AJPH February 1979, Vol. 69, No. 2
socioeconomic structure of the community. The medical staff has background and interest in primary practice and is involved in the development and the evaluation of competence in primary care. The resident's educational experience centers on care of the patient and family. Whether or not the institutional resistance suggested by Stoeckle and Grossman can be overcome in the AMC awaits the evaluation of time. Certainly, "directions on behalf of ambulatory patients should be as much a future challenge to AMC's as that of maintaining their past accomplishments."' I Finally, we were perhaps remiss in our article not to point out that there are variations in the degree of integration of services among the clinics at Duke and that Pediatrics is probably the most integrated ambulatory service. Stephen B. Thacker, MD Chief, Consolidated Surveillance and Communications Activity DHEW, CDC, Atlanta andfrom Duke University Medical Center: Eva J. Salber, MD Professor, Community and Family Medicine Carolee Osborne Administrative Assistant Family Medicine Program Lawrence H. Muhlbaier, MS Research Associate Community and Family Medicine
REFERENCES 1. Stoeckle JD and Grossman JH: Primary care: improving treatment and learning outside the hospital. Editorial, Am J Public Health 68:833, 1978. 2. Thacker, SB, Salber EJ, et al: Primary health care in an academic medical center. Am J Public Health 68:853, 1978.
Comments on Two-Class Clinic System Study I have read with great interest the article by Thacker, et al, entitled, "Primary Care in the Academic Medical Center" (AJPH, Vol. 68, No. 9, pg. 353-357). Its description of the twoclass clinic system sounds similar to that at many urban teaching centers, the effects of which should be a concern to all. Although supportive of the goal of one medical system for all, I wish to raise several questions which should be used in evaluating such proposals. First, will a unified clinic structure protect poor people's access to outpatient services? Many institutions suffer financial losses in their public outpatient clinics, due in part to low Medicaid reimbursement. These losses are currently tolerated because the public clinics play a central role in training students in ambulatory care while also funneling patients to the hospital's inpatient services. To the extent that these training and referral functions can be transfered to private clinics, public clinic use is often discouraged through cutbacks, reorganizations, and relocations. Local experience has shown that many consolidations of private and public clinics are usually effectuated with the hope that poor people will not find their way to the private clinics, thus decreasing their financial burden on the hospital. Second, will the special services needed by poor people be retained by the private clinics? Indigent patients have special medical, mental, and social health needs that are not shared by their private counterparts. Merging the clinics may decrease the availability of counseling and advisory services, social workers, nutritional aides, special transportation services, etc. These services make caring for the indigent 177
Researchers Comment on Stoeckle/Grossman Editorial In their editorial, "Primary Care: Improving Treatment and Learning Outside the Hospital",' Stoeckle and Grossman underscore several critical issues regarding the delivery of primary care services in an academic medical center (AMC) with which we are in complete agreement. We do feel, however, that they misread or misconstrued some points in commenting on our report2 to the Journal. First, we do not propose to reorganize only the outpatient clinic (OPC) as these reviewers assert; rather we agree that a one class system of health care would be best for patients. Secondly, the overriding reason for improving primary care is to insure improved patient care. That, too, should be the ultimate purpose of medical education. Whether an argument for better education will prove more persuasive to decisionmakers in the AMC is problematic; the issue is improved health both through better patient care and through improved medical education. The example of the Duke/Watts Family Medical Center (FMC) referred to in our report amply illustrates many of Stoeckle and Grossman's points, as well as our own. In the FMC a one class system of primary care is provided in a modem, well-equipped facility, by residents and faculty to a patient population that reflects the racial and AJPH February 1979, Vol. 69, No. 2
socioeconomic structure of the community. The medical staff has background and interest in primary practice and is involved in the development and the evaluation of competence in primary care. The resident's educational experience centers on care of the patient and family. Whether or not the institutional resistance suggested by Stoeckle and Grossman can be overcome in the AMC awaits the evaluation of time. Certainly, "directions on behalf of ambulatory patients should be as much a future challenge to AMC's as that of maintaining their past accomplishments."' I Finally, we were perhaps remiss in our article not to point out that there are variations in the degree of integration of services among the clinics at Duke and that Pediatrics is probably the most integrated ambulatory service. Stephen B. Thacker, MD Chief, Consolidated Surveillance and Communications Activity DHEW, CDC, Atlanta andfrom Duke University Medical Center: Eva J. Salber, MD Professor, Community and Family Medicine Carolee Osborne Administrative Assistant Family Medicine Program Lawrence H. Muhlbaier, MS Research Associate Community and Family Medicine
REFERENCES 1. Stoeckle JD and Grossman JH: Primary care: improving treatment and learning outside the hospital. Editorial, Am J Public Health 68:833, 1978. 2. Thacker, SB, Salber EJ, et al: Primary health care in an academic medical center. Am J Public Health 68:853, 1978.
Comments on Two-Class Clinic System Study I have read with great interest the article by Thacker, et al, entitled, "Primary Care in the Academic Medical Center" (AJPH, Vol. 68, No. 9, pg. 353-357). Its description of the twoclass clinic system sounds similar to that at many urban teaching centers, the effects of which should be a concern to all. Although supportive of the goal of one medical system for all, I wish to raise several questions which should be used in evaluating such proposals. First, will a unified clinic structure protect poor people's access to outpatient services? Many institutions suffer financial losses in their public outpatient clinics, due in part to low Medicaid reimbursement. These losses are currently tolerated because the public clinics play a central role in training students in ambulatory care while also funneling patients to the hospital's inpatient services. To the extent that these training and referral functions can be transfered to private clinics, public clinic use is often discouraged through cutbacks, reorganizations, and relocations. Local experience has shown that many consolidations of private and public clinics are usually effectuated with the hope that poor people will not find their way to the private clinics, thus decreasing their financial burden on the hospital. Second, will the special services needed by poor people be retained by the private clinics? Indigent patients have special medical, mental, and social health needs that are not shared by their private counterparts. Merging the clinics may decrease the availability of counseling and advisory services, social workers, nutritional aides, special transportation services, etc. These services make caring for the indigent 177
