Letters to the Editor Candice Chen, MD, MPH Assistant research professor, School of Public Health and Health Services, George Washington University, Washington, DC; [email protected].
Robert Phillips, MD, MSPH Vice president for research and policy, American Board of Family Medicine, Washington, DC.
Fitzhugh Mullan, MD Murdock Head Professor of Medicine and Health Policy, School of Public Health and Health Services, George Washington University, Washington, DC.
Andrew Bazemore, MD, MPH Director, Robert Graham Center, Washington, DC.
References 1 U.S. Congress, House of Representatives, Committee on Ways and Means. Medicare and Health Care Chartbook. Washington, DC: U.S. Government Printing Office; May 17, 1999. 2 Oliver TR, Grover A, Lee PR. Variations in Medicare Payments for Graduate Medical Education. Oakland, Calif: California HealthCare Foundation; 2001. 3 Grover A. GME and the future of the pathologist workforce. Presented at: 2013 CAP Policy Meeting; May 6, 2013; Washington, DC. http://www.cap.org/apps/ docs/advocacy/policy_meeting/gme.pdf. Accessed September 6, 2013. 4 Coggeshall LT. Planning for medical progress through education; a report submitted to the Executive Council of the Association of American Medical Colleges. Evanston, Ill: Association of American Medical Colleges; 1965.
How Can We Get Students to Choose Primary Care Careers? To the Editor: Although Jolly et al found that the steady decline in medical trainees’ interest in primary care careers may be leveling off, it is estimated that by 2020, a shortage of about 46,000 primary care physicians will exist.2 Today’s primary care practice is characterized less by actually caring for patients and more by an endless stream of administrative tasks—filling out forms and answering phone calls. Medical students know very well that this environment has created a generation of overworked physicians with high levels of burnout, loss of enthusiasm, and a decreased sense of accomplishment,3 and I believe that many trainees have been avoiding primary care careers for these reasons. To improve primary care’s image we must increase the primary care workforce so that the burden is less for each physician. 1
Primary care training must change to keep up with the changing landscape of primary care practice. In very simple terms, this might be accomplished by making primary care training more practical—two years of college, three years of medical school with only limited basic science instruction, and three years of residency in community care centers, not hospitals. This approach would put more primary care physicians into the workforce faster. With more physicians seeing patients, the primary care workload would decrease collectively, lessening burnout and increasing job satisfaction. With the promise of less drudgery, more students would be attracted to primary care careers. Another way to ease the burden on primary care physicians is to allow advanced practice registered nurses (APRNs) to provide some primary care services. Although this suggestion is controversial, APRNs have great potential to make the lives of primary care physicians more manageable and to make primary care services more available. This takes on more importance than ever before because the Affordable Care Act will greatly increase the number of individuals seeking primary care services. APRNs are endorsed by the Institute of Medicine as qualified to practice independently within the limits of their education and training.4 APRNs already are practicing independently in 16 states.5 To increase interest in primary care careers, we must first make these careers more manageable for those already in them. Doing so may require drastic measures, such as changing primary care education and allowing APRNs to provide more primary care services, but the future of the primary care workforce and patient safety are at stake. It is impossible for these already-overworked physicians to work safely if they work any harder. Edward Joseph Volpintesta, MD President, Bethel Medical Group, Bethel, Connecticut; [email protected].
References 1 Jolly P, Erikson C, Garrison G. U.S. graduate medical education and physician specialty choice. Acad Med. 2013;88:468–474. 2 O’Reilly KB. Primary care’s match day rebound still comes up short. amednews. com. Posted March 25, 2013. http://
Academic Medicine, Vol. 88, No. 12 / December 2013
www.amednews.com/article/20130325/ profession/130329978/4/. Accessed September 30, 2013.. 3 MedEd Update. Match results highlight growing shortage of residency slots. April 2013. http://www.ama-assn.org/ams/ pub/meded/2013-april/2013-april.shtml. Accessed September 30, 2013. 4 Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. 5 Aizenman NC. Nurses can practice without physician supervision in many states. Washington Post. March 24, 2013. http:// articles.washingtonpost.com/2013-03-24/ national/37989896_1_nurse-practitionerphysician-primary-care-practices. Accessed September 30, 2013.
To the Editor: I belong to a species facing extinction: I am a general internist. Each year, I watch the majority of internal medicine residency graduates turn away from general practice to start fellowship training. Jolly et al1 recently studied primary care selection in residency and reported that 57% of new internal medicine residents in 2010 were predicted to subspecialize, leaving 43% to remain in general internal medicine. While this number is more optimistic than other reports, how can the generalist survive if less than half of graduating residents are choosing this profession, which is already facing a serious shortage? I propose leveraging the Patient-Centered Medical Home (PCMH) model to implement two interventions at the graduate medical education (GME) level to explicitly encourage internal medicine residents to remain in general practice. The PCMH may help alleviate the provider shortage through increased use of midlevel providers and decreased frequency of patient visits. For PCMHs to be successful, however, physicians will need to be outstanding clinicians, leaders, and educators. So, what can be done at the GME level to retain the top residents in general practice? Many generalists value their unique role and holistic approach to patient care. It is time to make our values clear by sharing them explicitly with our residents. To achieve this, I propose melding two recommended GME interventions in the PCMH model to increase interest in general practice: (1) improvements in ambulatory supervision and (2) increased mentorship from experienced faculty.
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Robert Phillips, MD, MSPH Vice president for research and policy, American Board of Family Medicine, Washington, DC.
Fitzhugh Mullan, MD Murdock Head Professor of Medicine and Health Policy, School of Public Health and Health Services, George Washington University, Washington, DC.
Andrew Bazemore, MD, MPH Director, Robert Graham Center, Washington, DC.
References 1 U.S. Congress, House of Representatives, Committee on Ways and Means. Medicare and Health Care Chartbook. Washington, DC: U.S. Government Printing Office; May 17, 1999. 2 Oliver TR, Grover A, Lee PR. Variations in Medicare Payments for Graduate Medical Education. Oakland, Calif: California HealthCare Foundation; 2001. 3 Grover A. GME and the future of the pathologist workforce. Presented at: 2013 CAP Policy Meeting; May 6, 2013; Washington, DC. http://www.cap.org/apps/ docs/advocacy/policy_meeting/gme.pdf. Accessed September 6, 2013. 4 Coggeshall LT. Planning for medical progress through education; a report submitted to the Executive Council of the Association of American Medical Colleges. Evanston, Ill: Association of American Medical Colleges; 1965.
How Can We Get Students to Choose Primary Care Careers? To the Editor: Although Jolly et al found that the steady decline in medical trainees’ interest in primary care careers may be leveling off, it is estimated that by 2020, a shortage of about 46,000 primary care physicians will exist.2 Today’s primary care practice is characterized less by actually caring for patients and more by an endless stream of administrative tasks—filling out forms and answering phone calls. Medical students know very well that this environment has created a generation of overworked physicians with high levels of burnout, loss of enthusiasm, and a decreased sense of accomplishment,3 and I believe that many trainees have been avoiding primary care careers for these reasons. To improve primary care’s image we must increase the primary care workforce so that the burden is less for each physician. 1
Primary care training must change to keep up with the changing landscape of primary care practice. In very simple terms, this might be accomplished by making primary care training more practical—two years of college, three years of medical school with only limited basic science instruction, and three years of residency in community care centers, not hospitals. This approach would put more primary care physicians into the workforce faster. With more physicians seeing patients, the primary care workload would decrease collectively, lessening burnout and increasing job satisfaction. With the promise of less drudgery, more students would be attracted to primary care careers. Another way to ease the burden on primary care physicians is to allow advanced practice registered nurses (APRNs) to provide some primary care services. Although this suggestion is controversial, APRNs have great potential to make the lives of primary care physicians more manageable and to make primary care services more available. This takes on more importance than ever before because the Affordable Care Act will greatly increase the number of individuals seeking primary care services. APRNs are endorsed by the Institute of Medicine as qualified to practice independently within the limits of their education and training.4 APRNs already are practicing independently in 16 states.5 To increase interest in primary care careers, we must first make these careers more manageable for those already in them. Doing so may require drastic measures, such as changing primary care education and allowing APRNs to provide more primary care services, but the future of the primary care workforce and patient safety are at stake. It is impossible for these already-overworked physicians to work safely if they work any harder. Edward Joseph Volpintesta, MD President, Bethel Medical Group, Bethel, Connecticut; [email protected].
References 1 Jolly P, Erikson C, Garrison G. U.S. graduate medical education and physician specialty choice. Acad Med. 2013;88:468–474. 2 O’Reilly KB. Primary care’s match day rebound still comes up short. amednews. com. Posted March 25, 2013. http://
Academic Medicine, Vol. 88, No. 12 / December 2013
www.amednews.com/article/20130325/ profession/130329978/4/. Accessed September 30, 2013.. 3 MedEd Update. Match results highlight growing shortage of residency slots. April 2013. http://www.ama-assn.org/ams/ pub/meded/2013-april/2013-april.shtml. Accessed September 30, 2013. 4 Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies Press; 2011. 5 Aizenman NC. Nurses can practice without physician supervision in many states. Washington Post. March 24, 2013. http:// articles.washingtonpost.com/2013-03-24/ national/37989896_1_nurse-practitionerphysician-primary-care-practices. Accessed September 30, 2013.
To the Editor: I belong to a species facing extinction: I am a general internist. Each year, I watch the majority of internal medicine residency graduates turn away from general practice to start fellowship training. Jolly et al1 recently studied primary care selection in residency and reported that 57% of new internal medicine residents in 2010 were predicted to subspecialize, leaving 43% to remain in general internal medicine. While this number is more optimistic than other reports, how can the generalist survive if less than half of graduating residents are choosing this profession, which is already facing a serious shortage? I propose leveraging the Patient-Centered Medical Home (PCMH) model to implement two interventions at the graduate medical education (GME) level to explicitly encourage internal medicine residents to remain in general practice. The PCMH may help alleviate the provider shortage through increased use of midlevel providers and decreased frequency of patient visits. For PCMHs to be successful, however, physicians will need to be outstanding clinicians, leaders, and educators. So, what can be done at the GME level to retain the top residents in general practice? Many generalists value their unique role and holistic approach to patient care. It is time to make our values clear by sharing them explicitly with our residents. To achieve this, I propose melding two recommended GME interventions in the PCMH model to increase interest in general practice: (1) improvements in ambulatory supervision and (2) increased mentorship from experienced faculty.
1789
