Primary Medical Care and Training Programs in General Internal Medicine
ROBERT H. CREDE, M.D. San Francisco, California
Recent comments on available physician manpower, including assessments of the numbers and distribution of various types of physician specialists in the United States, have stressed the need for more physicians who will function as primary care (first contact) practitioners and deliver continuous, comprehensive care [l-3]. Academic medical centers are responsible for exploring the educational implications of such manpower needs and developing residency programs in primary care appropriate to their academic goals and available resources
[4,51.
From the Division of Ambulatory and Community Medicine, and the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. Requests for reprints should be addressed to Dr. Robert H. Crede, Division of Ambulatory and Community Medicine, A 405, University of California, 3rd and Parnassus, San Francisco, California 94143. Manuscript accepted February 27, 1976.
156
August 1976
In response to these needs, the Division of Ambulatory and Community Medicine in cooperation with the Departments of Medicine and Pediatrics of the University of California, San Francisco, School of Medicine, assisted by a grant from the Robert Wood Johnson Foundation, has instituted a 36-month primary care residency training program to prepare physicians for practice in general internal medicine or general pediatrics. The two track program (medicine and pediatrics) will provide residents with the skills needed to deliver family-oriented primary care in an ambulatory setting as well as the requisite experience in treating general medical or pediatric patients, who require hospitalization, and will qualify them to take the certification examinations given by the American Boards of Internal Medicine or Pediatrics. Residency training programs in medicine or pediatrics have traditionally stressed hospital based experience, usually emphasizing subspecialties in the latter part of a two or three year program. Such residencies, when followed by one or two years of subspecialty fellowship, prepare internists and pediatricians whose interests and motivation are usually in the direction of subspecialty practice. It is not surprising that graduates of such traditional programs are much more comfortable in the area of their subspecialty and would be, perhaps, less effective with those patients’ problems they considered to be outside their range of expertise. This is to be expected if their previous training has not offered adequate supervised clinical experience in handling a wide range of simple to complicated medical and psychosocial problems on an ambulatory basis. The office practice of general medicine and pediatrics requires an ability to handle such problems, which in many instances constitute the majority of clinical problems confronting such practitioners [6-61. It is clear that any program designed to train primary care physicians must provide the opportunity to develop skills and attitudes needed for this aspect of patient care while maintaining a high level of basic biomedical knowledge [9]. In the past two years, several articles have appeared which discuss the content of primary care [ 10,l I], outline the philosophy of primary care training programs in internal medicine [ 121 or describe operating primary care residency training programs [ 131.
The American Journal of Medicine
Volume 61
PRIMARY MEDICAL CARE AND TRAINING PROGRAMS-CREDE
The thoughtful article by Goroll et al. [ 141 is the most recent description of a primary care internal medicine training program we have seen. The University of California, San Francisco, Primary Care Residency Program emphasizes continuous, comprehensive patient care and trains the internal medicine and pediatric residents to work together with a nurse practitioner in the delivery of family-oriented care. Such a model may have a somewhat limited applicability in the “real world” of practice, but it does seem suitable for those medium- to large-sized multispecialty group practices that wish to offer familyoriented care to their patients without operating a family practice unit. Currently, there is a high level of interest in the role of the middle-level practitioners (nurse practitioners, physician assistants) in the delivery of primary health care [ 15-181. Such practitioners may assume a greater and more important role in health care delivery in the future, and the experience that general medical or general pediatric residents receive in working effectively with such practitioners may well anticipate a health care delivery pattern for their future practice [ 191. The following paragraphs outline several major concepts of the University of California, San Francisco program which are presented from the viewpoint of the internal medicine track but which also apply in general to the pediatric track. (1) Sound Base in Parent Discipline. All housestaff should have a sound base in their parent discipline, either internal medicine or pediatrics, so that both during the period of training and later on in practice they would function as equals with their peers in the scope and depth of their biomedical knowledge and clinical skills. Therefore, approximately the first 18 months of the 36-month training program are essentially indistinguishable from the traditional programs in the two departments. Depending on our experience and the evaluation of our residents, we may expand or contract the period devoted to conventional training in the traditional program. However, housestaff need some identification with the Primary Care Program from the beginning of their internship, and therefore for the first 18 months they spend one-half day a week in the Multispecialty Primary Care Clinic, which is the main base for the ambulatory patient care operations of this training program. In this one-half day a week, each new internal medicine housestaff member gradually accumulates a group of patients and families who look to him, his pediatric housestaff counterpart and the nurse practitioner as the primary source of continuing care. (2) increased Emphasis on Common Problems Seen in Ambulatory Patients. Primary care housestaff have increased experience in dealing with common medical and psychosocial problems in an ambulatory setting beginning in the first year of training. The formal
teaching program for residents in the internal medicine track includes lectures, demonstrations and seminars with emphasis on common problems in general internal medicine. In addition, residents are given the opportunity to develop skills and knowledge that are necessary for the management of common emotional (including “psychosomatic”), dermatologic, neurologic and nonsurgical orthopedic problems seen in general office practice, as well as those skills and technics necessary to diagnose and treat common gynecologic problems. (3) A Unique Outpatient Clinic Designed for the Primary Care Training Program. The Multispecialty Primary Care Clinic has been developed as a separate patient care unit in the University of California, San Francisco Ambulatory Care Center. Because it is contiguous with the General Medical Clinics of the Department of Medicine, faculty and housestaff working in the primary care and in the traditional medicine residency programs have an opportunity to share learning experiences. This clinic is also a major site of medical student teaching where senior medical students are taking a required full-time clerkship in family-oriented primary care. Primary care residents are actively involved in medical student education, as occurs on hospital teaching services. The Multispecialty Primary Care Clinic is organized as a family-oriented group practice, with an internist, a pediatrician, a psychiatrist and/or clinical psychologist, and a nurse practitioner as the core personnel to provide comprehensive care to family members and individuals. Complete coverage, 24 hours a day, all year long is provided by housestaff (those in the last 18 months of the program) with faculty back up. A full range of medical and allied health specialists are available to this clinic to provide instruction and consultation so that comprehensive health services are available to patients. (4) Coordination of Multidisciplinary Activities in Training and Patient Care. Every effort is made to coordinate the family-oriented patient care activities of the residents in the internal medicine track with those of the residents of the pediatric track, while they are practicing in the Multispecialty Primary Care Clinic. Medical and pediatric residents and nurse practitioners are organized as teams, which facilitates family-centered care, thus improving communication and interpersonal contacts between the families and the members of the team. The nurse practitioners are an integral par-tof a patient care team and participate in housestaff training sessions thereby enhancing the ability of both to function as team members. As previously mentioned, housestaff have the opportunity to utilize the services of clinical pharmacists, social workers, dietitians, family counselors and rehabilitation specialists as needed for comprehensive patient care. In addition, such working relationships
August1976
The American Journal of Medicine
Volume 01
157
PRIMARY
MEDICAL CARE AND TRAINING PROGRAMS-CREDE
offer opportunities for interdisciplinary health care team experience. (5) Opportunities to Develop Areas of Interest in Depth. In the last 18 months of the 36-month program, there is increasing experience in the ambulatory setting, predominately in the Multispecialty Primary Care Clinic. However, there is flexibility in the program which allows internal medicine track residents to obtain more indepth experience by working in subspecialty clinics. Our experience to date has shown that rotations through Cardiac, Gastrointestinal, Rheumatology, ThyroidEndocrine-Metabolic and Chest Clinics have been very profitable for our advanced primary care housestaff. Preventive. medicine, occupational health, family counseling and rehabilitation are some of the areas emphasized in the training of our primary care residents that are not usually stressed in more traditional programs. In addition, opportunities to work with faculty involved in health services research may stimulate the interest of our housestaff to study the operations of the local unit in some depth. For limited periods, residents may spend one or two half days per week assigned to governmental or private community based agencies that deliver primary care. Such assignments give an added dimension to their clinical experience, and acquaints them with the operation and management of extramural organized patient care programs. (6) Continuity of Care. In order to develop a proper primary care model, residents in the internal medicine track must be able to follow and assume responsibility for the care both in and out of the hospital of those patients to whom they are giving continuing comprehensive care. For this reason, the program permits internal medicine track residents in the Multispecialty Primary Care Clinic to hospitalize their patients on the Adult
Primary Care Service. The housestaff assumes responsibility for the day-today care of the patient under the supervision of an attending faculty internist from the Primary Care Residency Program. This responsibility for patients, both in the hospital and in the outpatient setting, is an important difference between the internal medicine primary care track and traditional training program. This seems appropriate as part of a supervised learning experience in continuing care of patients because it is consistent with the way the residents will practice as internists on completion of their training. Every effort is made to achieve an appropriate mix of patients so that the residents’ patient care experiences will not be too dissimilar from those they will have in later practice. We anticipate that the University of California, San Francisco campus will soon participate in a privately financed prepaid health plan of limited size and that the residents in the Primary Care Residency Program will serve as the primary care physicians to this group of patients. We believe that the combination of patients seen in the General Medical wards of this academic medical center, plus the patient population of the Multispecialty Primary Care Clinic, gives our primary care internal medicine residents a broad experience in the diagnosis and management of common and esoteric medical problems and will therefore give them the necessary attitudes and skills for the effective practice of general internal medicine. Our faculty has been impressed by the high calibre of applicants seeking training in this new Primary Care Residency Program, signifying an important shift in the career goals of many outstanding graduates of American medical schools. Such young physicians will form an important resource of skilled primary care physicians, a stated goal of current public policy.
REFERENCES 1. 2. 3.
4. 5. 6.
7. 8. 9. 10.
156
Petersdrof RG: Health manpower: numbers, distribution, quality. Ann Intern Med 82: 694, 1975. Schonfeld HK et al.: Numbers of physicians required for primary medical care. N Engl J Med 286: 571, 1972. Endicott KM: The distribution of physkians geographically and by specialty. Read before the Institute of Medicine, National Academy of Sciences, May 8, 1974. Rogers DE: Medical academe and the problems of health care provision. Arch Intern Med 135: 1364, 1975. Ebert RV: Training of the internist as a primary physician. Arch intern Med 76: 653, 1972. The National Ambulatory Medical Care Survey 1973 Summary: p 21, 26,29,30, National Center for Health Sciences: Vital and Health Statistics Series 13 Number 2 1, Department of HEW Publication No (HRA) 76-1772. Ebert RV: lot cit. Reitermeier RJ et al.: Participation by internists in primary care. Arch Intern Med 135: 255, 1975. Burnam JF: What one internist does in his practice. Ann Intern Med 78: 437, 1973. Silver HK. McAtee P: A descriptive definition of the scope and
August 1976
The American Journal of Medicine
11.
12. 13. 14. 15. 16. 17. 18. 19.
Volume 61
content of primary care. Pediatrics 56: 957, 1975. Alpert J, Charney E: The Education of Physicians for Primary Care, Section I: What is Primary Medicine, p 1, Department of HEW Publication No (HRA) 74-3113. Young LE: Changes in the postdoctoral education of internists? Ann Intern Med 83: 728, 1975. Perlman LV et al.: Training for primary care. Arch Intern Med 133: 448, 1974. Goroll AH et al.: Residency training in primary care internal medicine. Ann Intern Med 83: 872. 1975. Sadler AM: New health practitioner education: problems and issues. J Med Educ 50 (suppl): 67, 1975. Lewis CF: The trainina of new health manaower. J Med Educ F~ 50 (suppl): 75, 197-5. Spitzer WO et al.: The Burlington randomized trial of the nurse practitioner. N Engl J Med 290: 251, 1974. Runyan JW Jr: The Memphis chronic disease program. JAMA 231: 264. 1975. Gardner HH, Ouimette R: A nurse-physician team approach in a private internal medicine practice. Arch Intern Med 134: 956, 1974.
ROBERT H. CREDE, M.D. San Francisco, California
Recent comments on available physician manpower, including assessments of the numbers and distribution of various types of physician specialists in the United States, have stressed the need for more physicians who will function as primary care (first contact) practitioners and deliver continuous, comprehensive care [l-3]. Academic medical centers are responsible for exploring the educational implications of such manpower needs and developing residency programs in primary care appropriate to their academic goals and available resources
[4,51.
From the Division of Ambulatory and Community Medicine, and the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California. Requests for reprints should be addressed to Dr. Robert H. Crede, Division of Ambulatory and Community Medicine, A 405, University of California, 3rd and Parnassus, San Francisco, California 94143. Manuscript accepted February 27, 1976.
156
August 1976
In response to these needs, the Division of Ambulatory and Community Medicine in cooperation with the Departments of Medicine and Pediatrics of the University of California, San Francisco, School of Medicine, assisted by a grant from the Robert Wood Johnson Foundation, has instituted a 36-month primary care residency training program to prepare physicians for practice in general internal medicine or general pediatrics. The two track program (medicine and pediatrics) will provide residents with the skills needed to deliver family-oriented primary care in an ambulatory setting as well as the requisite experience in treating general medical or pediatric patients, who require hospitalization, and will qualify them to take the certification examinations given by the American Boards of Internal Medicine or Pediatrics. Residency training programs in medicine or pediatrics have traditionally stressed hospital based experience, usually emphasizing subspecialties in the latter part of a two or three year program. Such residencies, when followed by one or two years of subspecialty fellowship, prepare internists and pediatricians whose interests and motivation are usually in the direction of subspecialty practice. It is not surprising that graduates of such traditional programs are much more comfortable in the area of their subspecialty and would be, perhaps, less effective with those patients’ problems they considered to be outside their range of expertise. This is to be expected if their previous training has not offered adequate supervised clinical experience in handling a wide range of simple to complicated medical and psychosocial problems on an ambulatory basis. The office practice of general medicine and pediatrics requires an ability to handle such problems, which in many instances constitute the majority of clinical problems confronting such practitioners [6-61. It is clear that any program designed to train primary care physicians must provide the opportunity to develop skills and attitudes needed for this aspect of patient care while maintaining a high level of basic biomedical knowledge [9]. In the past two years, several articles have appeared which discuss the content of primary care [ 10,l I], outline the philosophy of primary care training programs in internal medicine [ 121 or describe operating primary care residency training programs [ 131.
The American Journal of Medicine
Volume 61
PRIMARY MEDICAL CARE AND TRAINING PROGRAMS-CREDE
The thoughtful article by Goroll et al. [ 141 is the most recent description of a primary care internal medicine training program we have seen. The University of California, San Francisco, Primary Care Residency Program emphasizes continuous, comprehensive patient care and trains the internal medicine and pediatric residents to work together with a nurse practitioner in the delivery of family-oriented care. Such a model may have a somewhat limited applicability in the “real world” of practice, but it does seem suitable for those medium- to large-sized multispecialty group practices that wish to offer familyoriented care to their patients without operating a family practice unit. Currently, there is a high level of interest in the role of the middle-level practitioners (nurse practitioners, physician assistants) in the delivery of primary health care [ 15-181. Such practitioners may assume a greater and more important role in health care delivery in the future, and the experience that general medical or general pediatric residents receive in working effectively with such practitioners may well anticipate a health care delivery pattern for their future practice [ 191. The following paragraphs outline several major concepts of the University of California, San Francisco program which are presented from the viewpoint of the internal medicine track but which also apply in general to the pediatric track. (1) Sound Base in Parent Discipline. All housestaff should have a sound base in their parent discipline, either internal medicine or pediatrics, so that both during the period of training and later on in practice they would function as equals with their peers in the scope and depth of their biomedical knowledge and clinical skills. Therefore, approximately the first 18 months of the 36-month training program are essentially indistinguishable from the traditional programs in the two departments. Depending on our experience and the evaluation of our residents, we may expand or contract the period devoted to conventional training in the traditional program. However, housestaff need some identification with the Primary Care Program from the beginning of their internship, and therefore for the first 18 months they spend one-half day a week in the Multispecialty Primary Care Clinic, which is the main base for the ambulatory patient care operations of this training program. In this one-half day a week, each new internal medicine housestaff member gradually accumulates a group of patients and families who look to him, his pediatric housestaff counterpart and the nurse practitioner as the primary source of continuing care. (2) increased Emphasis on Common Problems Seen in Ambulatory Patients. Primary care housestaff have increased experience in dealing with common medical and psychosocial problems in an ambulatory setting beginning in the first year of training. The formal
teaching program for residents in the internal medicine track includes lectures, demonstrations and seminars with emphasis on common problems in general internal medicine. In addition, residents are given the opportunity to develop skills and knowledge that are necessary for the management of common emotional (including “psychosomatic”), dermatologic, neurologic and nonsurgical orthopedic problems seen in general office practice, as well as those skills and technics necessary to diagnose and treat common gynecologic problems. (3) A Unique Outpatient Clinic Designed for the Primary Care Training Program. The Multispecialty Primary Care Clinic has been developed as a separate patient care unit in the University of California, San Francisco Ambulatory Care Center. Because it is contiguous with the General Medical Clinics of the Department of Medicine, faculty and housestaff working in the primary care and in the traditional medicine residency programs have an opportunity to share learning experiences. This clinic is also a major site of medical student teaching where senior medical students are taking a required full-time clerkship in family-oriented primary care. Primary care residents are actively involved in medical student education, as occurs on hospital teaching services. The Multispecialty Primary Care Clinic is organized as a family-oriented group practice, with an internist, a pediatrician, a psychiatrist and/or clinical psychologist, and a nurse practitioner as the core personnel to provide comprehensive care to family members and individuals. Complete coverage, 24 hours a day, all year long is provided by housestaff (those in the last 18 months of the program) with faculty back up. A full range of medical and allied health specialists are available to this clinic to provide instruction and consultation so that comprehensive health services are available to patients. (4) Coordination of Multidisciplinary Activities in Training and Patient Care. Every effort is made to coordinate the family-oriented patient care activities of the residents in the internal medicine track with those of the residents of the pediatric track, while they are practicing in the Multispecialty Primary Care Clinic. Medical and pediatric residents and nurse practitioners are organized as teams, which facilitates family-centered care, thus improving communication and interpersonal contacts between the families and the members of the team. The nurse practitioners are an integral par-tof a patient care team and participate in housestaff training sessions thereby enhancing the ability of both to function as team members. As previously mentioned, housestaff have the opportunity to utilize the services of clinical pharmacists, social workers, dietitians, family counselors and rehabilitation specialists as needed for comprehensive patient care. In addition, such working relationships
August1976
The American Journal of Medicine
Volume 01
157
PRIMARY
MEDICAL CARE AND TRAINING PROGRAMS-CREDE
offer opportunities for interdisciplinary health care team experience. (5) Opportunities to Develop Areas of Interest in Depth. In the last 18 months of the 36-month program, there is increasing experience in the ambulatory setting, predominately in the Multispecialty Primary Care Clinic. However, there is flexibility in the program which allows internal medicine track residents to obtain more indepth experience by working in subspecialty clinics. Our experience to date has shown that rotations through Cardiac, Gastrointestinal, Rheumatology, ThyroidEndocrine-Metabolic and Chest Clinics have been very profitable for our advanced primary care housestaff. Preventive. medicine, occupational health, family counseling and rehabilitation are some of the areas emphasized in the training of our primary care residents that are not usually stressed in more traditional programs. In addition, opportunities to work with faculty involved in health services research may stimulate the interest of our housestaff to study the operations of the local unit in some depth. For limited periods, residents may spend one or two half days per week assigned to governmental or private community based agencies that deliver primary care. Such assignments give an added dimension to their clinical experience, and acquaints them with the operation and management of extramural organized patient care programs. (6) Continuity of Care. In order to develop a proper primary care model, residents in the internal medicine track must be able to follow and assume responsibility for the care both in and out of the hospital of those patients to whom they are giving continuing comprehensive care. For this reason, the program permits internal medicine track residents in the Multispecialty Primary Care Clinic to hospitalize their patients on the Adult
Primary Care Service. The housestaff assumes responsibility for the day-today care of the patient under the supervision of an attending faculty internist from the Primary Care Residency Program. This responsibility for patients, both in the hospital and in the outpatient setting, is an important difference between the internal medicine primary care track and traditional training program. This seems appropriate as part of a supervised learning experience in continuing care of patients because it is consistent with the way the residents will practice as internists on completion of their training. Every effort is made to achieve an appropriate mix of patients so that the residents’ patient care experiences will not be too dissimilar from those they will have in later practice. We anticipate that the University of California, San Francisco campus will soon participate in a privately financed prepaid health plan of limited size and that the residents in the Primary Care Residency Program will serve as the primary care physicians to this group of patients. We believe that the combination of patients seen in the General Medical wards of this academic medical center, plus the patient population of the Multispecialty Primary Care Clinic, gives our primary care internal medicine residents a broad experience in the diagnosis and management of common and esoteric medical problems and will therefore give them the necessary attitudes and skills for the effective practice of general internal medicine. Our faculty has been impressed by the high calibre of applicants seeking training in this new Primary Care Residency Program, signifying an important shift in the career goals of many outstanding graduates of American medical schools. Such young physicians will form an important resource of skilled primary care physicians, a stated goal of current public policy.
REFERENCES 1. 2. 3.
4. 5. 6.
7. 8. 9. 10.
156
Petersdrof RG: Health manpower: numbers, distribution, quality. Ann Intern Med 82: 694, 1975. Schonfeld HK et al.: Numbers of physicians required for primary medical care. N Engl J Med 286: 571, 1972. Endicott KM: The distribution of physkians geographically and by specialty. Read before the Institute of Medicine, National Academy of Sciences, May 8, 1974. Rogers DE: Medical academe and the problems of health care provision. Arch Intern Med 135: 1364, 1975. Ebert RV: Training of the internist as a primary physician. Arch intern Med 76: 653, 1972. The National Ambulatory Medical Care Survey 1973 Summary: p 21, 26,29,30, National Center for Health Sciences: Vital and Health Statistics Series 13 Number 2 1, Department of HEW Publication No (HRA) 76-1772. Ebert RV: lot cit. Reitermeier RJ et al.: Participation by internists in primary care. Arch Intern Med 135: 255, 1975. Burnam JF: What one internist does in his practice. Ann Intern Med 78: 437, 1973. Silver HK. McAtee P: A descriptive definition of the scope and
August 1976
The American Journal of Medicine
11.
12. 13. 14. 15. 16. 17. 18. 19.
Volume 61
content of primary care. Pediatrics 56: 957, 1975. Alpert J, Charney E: The Education of Physicians for Primary Care, Section I: What is Primary Medicine, p 1, Department of HEW Publication No (HRA) 74-3113. Young LE: Changes in the postdoctoral education of internists? Ann Intern Med 83: 728, 1975. Perlman LV et al.: Training for primary care. Arch Intern Med 133: 448, 1974. Goroll AH et al.: Residency training in primary care internal medicine. Ann Intern Med 83: 872. 1975. Sadler AM: New health practitioner education: problems and issues. J Med Educ 50 (suppl): 67, 1975. Lewis CF: The trainina of new health manaower. J Med Educ F~ 50 (suppl): 75, 197-5. Spitzer WO et al.: The Burlington randomized trial of the nurse practitioner. N Engl J Med 290: 251, 1974. Runyan JW Jr: The Memphis chronic disease program. JAMA 231: 264. 1975. Gardner HH, Ouimette R: A nurse-physician team approach in a private internal medicine practice. Arch Intern Med 134: 956, 1974.
