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://

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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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New internal medicine residents should be welcomed at the door of a PCMH by an experienced general internist, who will serve as the resident’s clinical and professional mentor throughout his or her residency. Consistent supervision in the clinic may improve the ambulatory experience with more accurate assessment and timely feedback on milestone achievement. Combining mentorship with a strong and longitudinal ambulatory experience is the key to explicitly supporting our future generalists. It is time for all clinicians to honor the important role played by primary care. If we utilize the PCMH framework to structure consistent mentorship, we may be able to save the general internist from extinction. Mark P. Tschanz, DO Senior medical officer, USS Essex, and general internist, US Navy, San Diego, California; tschanmp@ lhd2.navy.mil.

Reference 1 Jolly P, Erikson C, Garrison G. U.S. graduate medical education and physician specialty choice. Acad Med. 2013;88:468–474.

Medical Student Education in the EMR Era Requires Access to the EMR To the Editor: In their recent article, Tierney et al1 discuss potential roles of the electronic medical record (EMR) in developing core competencies, including interpersonal and communication skills. We agree that the EMR is an essential tool in developing this competency, and we share the authors’ concern that limiting students’ EMR use to templates and copy/paste functions impairs the development of clinical reasoning and documentation skills. These skills cannot be developed if students are denied access to the EMR and the ability to document in a meaningful manner. Many medical schools are not fully including students in the EMR.2,3 It is our experience that often this is because of individual institutions’ interpretation of the Centers for Medicare and Medicaid

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Services (CMS) guidelines. In an effort to achieve compliance, some schools are denying students any access beyond documenting the review of systems and/or past family/social history; other schools limit students to read-only access. While there must be close attention paid to how students’ EMR documentation is used by physicians, CMS guidelines clearly state: “Students may document services in the medical record”4 [emphasis added]. The Association of American Medical Colleges states that student documentation of patient encounters serves an essential function and is an important educational outcome.5 With mounting work hours restrictions, it is important that schools make the process of patient care more efficient with all team members contributing to their fullest ability. Student learning should not be sacrificed out of inappropriate fear of compliance rules. Institutions can remain in com­ pliance with CMS guidelines without limiting students’ ability to document and, by extension, develop necessary clinical reasoning and documentation skills. We agree with the Alliance for Clinical Education that “students must document in the patient’s chart” and that there should be a “call for a unified policy among medical educators regarding medical student documentation in”6 EMRs. Karly Pippitt, MD Director, Medical Student Education in Family Medicine, Department of Family and Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah; [email protected].

Adam Stevenson, MD Associate dean for student affairs, University of Utah School of Medicine, Salt Lake City, Utah.

Wayne Samuelson, MD Vice dean for education, University of Utah School of Medicine, Salt Lake City, Utah.

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in academic internal medicine settings. Acad Med. 2009;84:1698–1704. Hammoud MM, Margo K, Christner JG, Fisher J, Fischer SH, Pangaro LN. Opportunities and challenges in integrating electronic health records into undergraduate medical education: A national survey of clerkship directors. Teach Learn Med. 2012;24:219–224. Centers for Medicare and Medicaid Services. Pub 100-02 Medicare Claims Processing, Transmittal 2303. Baltimore, MD: CMS; Sept 14, 2011. Association of American Medical Colleges. Report I: Learning Objectives for Medical Student Education, Guidelines for Medical Schools. Washington, DC: Association of American Medical Colleges; 1998. Hammoud MM, Dalymple JL, Christner JG, et al. Medical student documentation in electronic health records: A collaborative statement from the Alliance for Clinical Education. Teach Learn Med. 2012;24: 257–266.

In Reply: My colleagues and I thank Drs. Pippitt, Stevenson, and Samuelson for emphasizing this component of our article. As they point out, one factor at play in limiting medical student access to electronic charting is the fear of running afoul of guidelines established by the Centers for Medicare and Medicaid Services, despite Medicare claims process guidelines stating otherwise. We agree that medical student documentation is an essential component of medical education and refer to Gliatto and colleagues’ excellent description of the considerations at stake in the decision of whether to allow medical students to document in the electronic medical record (EMR).1 As we note in our article, the educational and clinical value of medical student documentation may be enhanced by customizing note templates for medical learner use and emphasizing the Reporter-InterpreterManager-Educator/EMR scheme as a means of bolstering thoughtful and guided use of EMR charting by medical trainees.2 Michael J. Tierney, MD

References 1 Tierney MJ, Pageler NM, Kahana M, Pantaleoni JL, Longhurst CA. Medical education in the electronic medical record (EMR) era: Benefits, challenges, and future directions. Acad Med. 2013;88:748–752. 2 Mintz M, Narvarte HJ, O’Brien KE, Papp KK, Thomas M, Durning SJ. Use of electronic medical records by physicians and students

Staff physician, Compensation and Pension and Ambulatory Care, VA Palo Alto Healthcare System, Palo Alto, California; [email protected].

Christopher A. Longhurst, MD, MS Chief medical information officer, Lucile Packard Children’s Hospital, and associate professor of clinical pediatrics, Stanford University School of Medicine, Palo Alto, California.

Academic Medicine, Vol. 88, No. 12 / December 2013

How can we get students to choose primary care careers?

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