Medical Education
Refer to: Gerber WG, Massad RJ: Training physicians for primary care: Trends and hazards (Medical Education). West J Med 127:426432, Nov 1977
Training Physicians for Primary Care: Trends and Hazards WILLIAM G. GERBER, MD, San Francisco, and ROBERT J. MASSAD, MD,
Iowa
City
Programs to train physicians more effectively for careers in primary care are being organized within academic departments in internal medicine and pediatrics, while the number of training programs in family practice continues to grow rapidly. However, the field of primary care training is expanding without a common vocabulary and with inadequate communication between the specialties involved. If decisions concerning health care policy are to be made rationally, the development of multiple distinct models for primary health care delivery must be encouraged and these models must then be evaluated. The distinction between family practice and family medicine must be made clear if the latter discipline is to realize its potential application to all specialties. The relative exclusion of family practice from universities and the absence of experienced practitioners in university primary care programs are conditions that threaten the future of both types of programs and deserve thoughtful attention from medical educators.
IT APPEARS that America's system of medical education has begun to address purposefully the problem of meeting this country's need for primary health care. In frequent contributions to the recent medical literaturel-5 and at a succession of national conferences, representatives from internal medicine and pediatrics have discussed strategies to prepare their trainees more effectively for the practice of primary care. Programs for this purpose have recently been established in a numFrom the Family Practice Residency Program, University of California, San Francisco, School of Medicine, San Francisco peneral Hospital. Dr. Massad is now at the Department of Family Practice, University of Iowa. Reprint requests to: William G. Gerber, MD, Family Practice Residency Program, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110.
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NOVEMBER 1977 * 127 * 5
ber of our medical schools with the support of the federal government and private foundations. Along with this development, graduate training programs in family pr ctice have experienced a growth that not even the specialty's most ardent supporters could have predicted when it was established in 1969. Petersdorf¢ recently has described the present state of physician maldistribution in the United States, which he ascribes to a lack of planning, coordination and control over the growth of specialties in the past 30 years. There are indications that the field of primary care will replicate that unplanned growth. The primary care movement
TRAINING FOR PRIMARY CARE
is growing rapidly without a common vocabulary and with minimal communication between the specialties involved. Rather than a coordinated effort to train sufficient numbers of physicians for primary care careers, the field has divided into fractions which at best ignore and at worst compete with each other. The purpose of this article is to briefly review the history of the growth of the primary care movement in this country; to offer some definitions of terms which may begin to provide us with a common vocabulary; to describe the major models of primary care training being developed; to outline some current trends which we believe must be reversed, and to make several recommendations for the field.
Background Two documents-The Millis report7 and the Willard report8 -are important reference points in the history of the primary care movement in the United States. In 1966 the Citizens Commission on Graduate Medical Education, chaired by John S. Millis, PhD, presented its recommendations. Among them was the establishment of a new specialty to train primary physicians in the continuous, comprehensive care of families. In 1964 the Council of Medical Education of the American Medical Association appointed the Ad Hoc Committee on Education for Family Practice, chaired by William R. Willard, MD. The findings of the committee were summarized in the Willard report, issued in 1966. It held that family practice was a viable primary care model and that "major efforts should be instituted promptly to encourage the development of new programs for the education of large numbers of family physicians" through the development of new sources of funding and the conferring of specialty status on the discipline. It also urged that "medical schools and teaching hospitals . . . explore the possibility of developing models of family practice, in cooperation with the practicing
profession."8 By the mid- 1960's, legislative and funding bodies began to express interest in promoting and supporting primary care. This interest was followed by the establishment of the American Board of Family Practice and the conferring of specialty status on general practitioners in 1969. Funds were made available from state, federal and private sources for establishing training programs in the new specialty. The resulting increase
in the number of family practice programs and their graduates is impressive: in July 1969 there were 20 family practice residency programs; in July 1976 there were 293. Until recently, therefore, family practice has represented the major thrust in the movement to train primary care physicians in the United States. Although the number of postgraduate training programs in family practice has increased dramatically, the specialty is only beginning to make its presence known in undergraduate medical education. In July 1976 more than 25 American medical schools reported that they had no department or division of family practice. Of the 79 departments in existence, 13 were less than a year old. This relative absence of academic family practice can be partially explained by its unorthodox manner of development. Most specialties evolve slowly from within the profession as new, research based, narrow fields of expertise practiced by a few physicians located primarily within universities. The specialty of family practice arose comparatively abruptly, as a result of societal and legislative pressure, and represented a broad area of medicine which had long been practiced by a large segment of the profession based outside universities. So when the new specialty was established in 1969 it lacked a solid base in academic centers on which to build its research and teaching activities. As our medical schools have explored the potential establishment of departments of family practice and family practice residencies, they have faced major obstacles. The first has been the problem of faculty recruitment. Universities have been forced to recruit most family practice faculty members from the ranks of practicing physicians. This situation has been difficult because traditional criteria for appointment of medical school faculty fit the majority of family practice candidates poorly. Few have been universitytrained; many are former general practitioners whose formal training consists of an internship years before. Few have published, fewer still have done research. Many have taught, but usually in peripheral capacities, such as office preceptorships. To start such a person at an academic rank and salary competitive with the rewards of practice requires making clinical experience equivalent to activities in research, teaching and publishing for purposes of appointment and promotion. In short, the political realities of university procedure and the very small number of traditionally THE WESTERN JOURNAL OF MEDICINE
427
TRAINING FOR PRIMARY CARE
suitable candidates for faculty positions have resulted in the specialty of family practice having limited representation in universities. The family practice movement consequently is the first major development in American medical education that has occurred outside of our universities since the Flexner report of 1910. The focus of primary care training might have remained extramural indefinitely, were it not for the fact that some of the most respected personalities in medical education have continued to urge our medical schools to take the lead in educating physicians for primary care. The Pellegrino report to the Executive Committee of the Association of American Medical Colleges in 1968 echoed the Willard report in urging that medical schools assume a central role in the "redefinition and rehabilitation of the role of the general physician."9 Hillard Jason and other medical educators have pointed out that medical schools focus on secondary and tertiary care, while most of their graduates end up doing primary care.10 In The Education of Physicians for Primary Care, an important and thoughtful document, Alpert and Charney" put it succinctly: It would seem that Pediatrics and Internal Medicine need to reach some rational decisions in relation to family practice. Either they ought to relinquish their role in primary care education and practice-and also recruit
proportionately fewer medical graduates to their own fields-or else acknowledge their own obligations to primary care and reassess their educational efforts with this in mind. To continue to recruit the majority of medical students without accepting the fact that most of them should be prepared largely to practice primary care strikes us as almost unethical, given our current shortage of primary care physicians. In addition to this intellectual prodding, a
second factor which has shifted the attention of our medical schools to primary care has been the increasing number of medical students applying for family practice residencies. In 1976 more than 2,500 graduating students applied for the approximately 1,935 available first year positions. Many are outstanding students who are choosing family practice because it is their only opportunity for graduate training in primary care. They represent an attractive pool of applicants for university training programs in the traditional specialties which can be captured only if their needs for primary care training can be met in those
settings. Third, and maybe most important, there has been financial pressure on the medical schools for the development of primary care training. Since 428
NOVEMBER 1977 * 127 * 5
the late 1960's financial support of the basic science research structure and, thereby, much of the medical school faculty, has been shrinking. At the same time, federal, state and private agencies have become more willing to 'und research and training in primary care. Faced with the alternative o> abandoning the primary care field to family prac-ice or developing primary care programs more co etpatible with their own goals and needs, it is ui lerstandable that our medical schools have not ur 'versally accepted the concept that internal medic ale and pediatrics should relinquish their role in primary care education. Following a flurry of confer nces in the primary care field in the last few sears encouraging their development, residencies itt internal medicine and pediatrics have begun to :'ppear which are specifically designed to prepar their graduates for careers in primary care. The ;e programs differ from family practice residencie- in two important aspects. First, they are all withbn medical school systems. Second, they are being organized within or closely allied to already existing departments in the medical schools. At present, then, family practice programs are growing rapidly, but primarily apart from universities, while primary care programs in internal medicine and pediatrics are being established almost exclusively within our medical schools. Therefore, we are witnessing a two-pronged movement in primary care training.
Definitions Primary care, family practice, general practice and family medicine are terms that are being widely used without general agre ement about what they mean. Thus far in this discussion we have not been concerned with their precise meanings. However,- if we are to avoid false issues and effectively address real ones, wCe must start with a common understanding of these terms. For the remainder of this discussion, the following definitions will be used: Primary care has been referred to as primary medicine and given a three-part definition by Alpert and Charney: Primary medicine medicine assumes tient regardless of Primary medicine
is first-contact medicine . . . Primary longitudinal responsibility for the pathe presence or absence of disease . serves as the "integrationist" for the
patient."
Family practice is primary care delivered by a
TRAINING FOR PRIMARY CARE
physician in multiple specialty areas to people of all ages and both sexes. Several authors have addressed themselves to the distinction between general practitioners and family practitioners;13-15 our emphasis would be on the specific training in primary care given to the latter. Family medicine has been well defined and defended by Ransom and Vandervoort"6 as a distinct academic discipline. In their words: Family medicine is an emerging discipline concerned with the relationship of life in small groups to health, illness and care. Its focus is on the ecology of relations among individuals in families and between families and their surrounding environment. (This term family is used in the broadest sense to describe any group of intimates with a history and a future.) Family medicine aims toward understanding and changing health problems that cannot be managed successfully by dealing exclusively with the individual and his or her illness, abstracted from the pattern of recurrent interpersonal situations that shape and transform a human life.
Family health care is primary care delivered by a health professional to people of all ages and both sexes in the context of a family systems approach. It implies that the practitioner is grounded in the discipline of family medicine and applies its principles to his practice. Janeway' has said it is "based . . . on family medicine, focuses on the family, and is an attempt to combine health promotion and illness care for the
family."
Training Models Having reviewed the growth of family practice programs and the recent development of primary care programs, we will now describe the training models being utilized by these programs. Among the primary care programs being established, several different models appear to be emerging. The first type can be labeled the singlespecialty model. This type of program is a residency in either internal medicine or pediatrics which has an emphasis on primary care and whose graduates will be board eligible in one or the other specialty. The training is of the traditional length but with an emphasis on outpatient medicine. Presumably, a graduate of such a program has received training more relevant to a primary care practice than his traditionally trained counterpart. The second model of primary care training that we have identified is the team model in which residents in internal medicine and pediatrics are trained to work together in the delivery of primary health care. The residents are scheduled to be
in the ambulatory facility together and training includes attention to the principles of teamwork and collaboration. The third identifiable model produces a graduate trained in at least two specialty areas of primary care. This multispecialty model presents two distinct variations. In the first, the resident is trained in internal medicine and pediatrics. In one such program the resident "majors" in one specialty and "minors" in the other. The graduate is board eligible in his "major" and is expected to serve as a generalist in that specialty, taking care of both ambulatory patients and those requiring hospital care. He is expected to practice ambulatory primary care in his "minor" and to be competent to care for most of the problems of that specialty area. The second multispecialty model adds to the resident's training in internal medicine and pediatrics outpatient skills in other specialty areas such as orthopedics, gynecology, dermatology and the like. Again, depending on whether the "major" has been in the area of internal medicine or pediatrics, he is board eligible in that specialty at the conclusion of this program. Compared with the single specialty model, both of these programs might be expected to produce a graduate who sacrifices depth of knowledge for breadth of practice. Some of these programs attempt to compensate for this additional breadth by extending the duration of the residency one year. The fourth distinct model of primary care training programs is family practice. As with primary care programs, there are differences between family practice residencies. However, all family practice programs share certain basic elements. Important among these is the requirement for a Family Practice Center in every program. A family practice resident spends a substantial portion of his or her time in the model unit, caring for patients in a continuing relationship and taking care of most of their health needs. Generally, this outpatient time grows from 10 percent in the first year to 50 percent in the third year, with time alloted weekly over the three years to assure continuity. The amount of time spent on other specialty services varies between programs but there are established minimums for internal medicine and pediatrics. In addition, family practice residencies are similar in their commitment to teaching the resident skills in other specialty areas which include outpatient orthopedics; ear, nose and throat; ophthalmology; gynecology, and obTHE WESTERN JOURNAL OF MEDICINE
429
TRAINING FOR PRIMARY CARE
stetrics. The graduate of a family practice residency is a primary care specialist expected to be capable of caring for most of the health needs of a patient population of all ages and both sexes. The fifth and last primary care training model to be discussed is family health care. All of the programs previously outlined could, with the addition of family medicine to their curricula, be described as family health care programs. The unfortunate reality is that few programs teaching primary care teach family health care. There are many reasons for this, prominent among which is the infancy of the discipline of family medicine. Few of the professionals who have directed their attention to the interaction between the family and health and illness patterns can apply this knowledge at the level of patient care and thereby make it a valuable curricular addition to a residency training program. The net result is that relatively few primary care or family practice programs teach family health care. Happily, both family practice and the newer primary care programs are experimenting with the application of family medicine to primary care delivery and we are hopeful that this area will be vigorously explored. Current Trends We have reviewed the recent growth of the primary care movement in this country, defined some of the terms which are identified with it and outlined the most common models of primary care programs in this country. We will now examine two of the trends in the movement and discuss some of their potential consequences. There is widespread terminological confusion in the primary care field. If we are to develop a rational, economical primary health care system for this country, we must encourage the development of distinct models of primary care delivery and then evaluate their comparative effectiveness. But we can do neither if we do not carefully define the models and understand their similarities and differences. The immediate danger of the existing confusion is that funding agencies share the mystification which has occurred and that funds meant to stimulate innovation are in fact supporting traditional models. Analysis of certain primary care programs, for example, shows an emphasis on ambulatory care with major concentration in medicine and pediatrics and minor exposure to training in office gynecology, orthopedics and minor surgical
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NOVEMBER 1977 * 127 * 5
procedures. We question the difference between the graduate of such a program and the graduate of a family practice residency and wonder why it should be supported as an innovative experiment in medical education? The more far-reaching danger is that we will not evaluate these models adequately. There are questions to be answered that are of overwhelming importance to the establishment of a rational health policy. The validity of the evaluation depends on acknowledging of the differences that exist between the various delivery models. How does an internist-pediatrician team compare with a family physician? What is the cost effectiveness of each approach? Does significant and sufficient communication take place between teammates and is the relationship with the family better or worse than if a single physician fills both roles? Does this last question matter? Are there benefits in the greater depth of training of the internist and pediatrician and how do these affect quality of care and costs compared with the breadth of training of the family physician? In order to obtain valid answers to these and many other pressing questions, the models to be evaluated must be clear and distinct. The lack of a clear terminology also threatens the future of family medicine and family health care. To the extent that both remain synonymous with family practice they will not receive adequate recognition or support, nor can they be fairly evaluated. Family medicine is a theoretical perspective and a body of knowledge with potential application to any medical practice. It places the patient in the context of his environment, puts the medical intervention in a broader perspective, and expands the diagnostic and therapeutic possibilities of the physician to include the impact of the family on the disease process and the impact of the therapy on the patient's support system. It is as valid to a surgical subspecialist as it is to a primary care physician. As such, it deserves a prominent place in the undergraduate medical curriculum as a part of the knowledge base utilized by all clinicians. It also deserves support so that its academic base and its clinical application can be expanded. Family health care is the application of family medicine to the care of families. It is not the sole domain of the family physician, but can be provided by other primary care providers or teams who care for all family members. It is our hypoth-
TRAINING FOR PRIMARY CARE
esis that the addition of a family medicine perspective to a primary care practice results in a measurable difference in the style and outcome of the practice. However, until family medicine and family health care are distinguished from family practice, this hypothesis cannot be widely explored. The second trend which requires comment is the two-pronged nature of the primary care movement in this country. Family practice residency training is located predominately in community hospitals while the development of residencies in primary care has occurred within the university setting. We are concerned about both elements of this movement. The success of family practice at this time is measured primarily by the growth in the number of residencies, the large number of highly qualified applicants seeking admission to those programs, and the financial support which family practice has received from various agencies concerned with the deficit in primary care physicians. However, unless it develops strong university programs, this success may be transient. As alternative solutions to the primary care shortage are offered by the medical schools, funds will almost certainly be diverted to those programs. As they become available, the medical students who now see family practice as their only viable choice for a career in primary care may also be diverted. Neither of these consequences will result from the proven advantage of one model over the other, or even from the higher quality of one form of training over the other. They will occur naturally if role models for primary care exist within the medical school and similar exposure to family physicians does not. If family practice is to become a fully accepted specialty within our medical schools, attitudes of existing faculty must change and academic family practice must recognize its responsibility in promoting this change. Every specialty has an area of expertise which it is obliged to refine and develop and family practice is no exception. The new specialty is faced with a challenge: to prove and delineate its area of expertise; to teach its skills; to develop its research base. If this does not occur, family practice will contribute to its own demise in the academic setting and its full potential as a viable form of primary care will never be realized. Our second concern about the split in the movement is that primary care may not be taught at
all in university-based programs in internal medicine and pediatrics. Primary care is a specific style of practice that incorporates skills that are not being taught in traditional residencies in internal medicine and pediatrics. However, those responsible for the establishment of most of the emerging primary care residencies in this country are traditional academicians who have had no practice experience; or, if they have, it has not been in primary care. Many of the faculty members of these programs are being-recruited from within the medical schools, merely moving from one funding source to another with a change of title but no change of perspective. Consequently, students and residents may be taught primary care by persons with no experience or expertise in the field. It is possible that they may not be taught primary care at all, but merely take a traditional medical or pediatric residency, with more time allocated to outpatient care, when little or no teaching takes place. If this trend continues and university-based primary care programs do not develop faculties in which there is experience, skill and interest in primary care, primary care physicians will not be produced in our medical schools, and medical schools will not participate in the evolution or growth of primary care in this country. This would obviously be a serious setback to the primary care movement.
Recommendations * Those responsible for financial encouragement and ongoing support of primary care programs must make their investments carefully. It is their responsibility to ensure that they are in fact supporting true primary care programs, and to look closely at the models they are considering to encourage real diversity. * Thorough understanding and acknowledgment of the various models of primary care must take place. This is an essential step if we are to evaluate the different variables between models and plan effectively for the future. * Family medicine must gain the recognition and interdisciplinary support it needs to develop as a new academic field and it must be shown that the family health care model which results from its application to primary care is a significant variable. * Family practice, especially those programs in academic settings, must generate a research base which will show clearly those unique areas THE WESTERN JOURNAL OF MEDICINE
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,of knowledge and skill which make it a specialty. * Primary care programs in the university must prove their commitment to producing real primary care practitioners by recruiting faculty members with extensive primary care experience. * The university must adopt new standards for faculty appointment and promotion which recognize skill in teaching and patient care. REFERENCES 1. Petersdorf RG: Internal medicine and family practice: Controversies, conflict and compromise. N Engl J Med 293:326-332, 1975 2. Proger S: A career in ambulatory medicine. N Engl J Med 292:1318-1324, 1975 3. Berarducci AA, Delbanco TL, Rabkin HT: The teaching hospital and primary care. N Engl J Med 292:615-620, 1975 4. Almy TP: Primary care and departments of internal medicine. Arch Intern Med 134:771-773, 1974 5. The internist and primary care (Editorial). Arch Intern Med 134:780-781, 1974 6. Petersdorf RG: Health manpower: Numbers, distribution, quality. Ann Intern Med 82:694-701, 1975
7. Citizens Commission on Graduate Medical Education (John S. Millis, Chairman): The Graduate Education of Physicians. Chicago, Council on Medical Education, American Medical Association, 1966 8. Ad Hoc Committee on Education for Family Practice (William R. Willard, Chairman): Meeting the Challenge of Family Practice-Report to the AMA Council on Medical Education. Chicago, American Medical Association, 1966 9. Ad Hoc Committee on Medical Schools and the AAMC in Relation to Training for Family Practice (Edmund D. Pellegrino, Chairman): Planning for comprehensive and continuing care of patients through education-Report to the Executive Council, Association of American Medical Colleges. J Med Educ 43: 751-759, Jun 1968 10. Jason H: The relevance of medical educat:on to medical practice. JAMA 212:2092-2095, 1970 11. Alpert JJ, Charney E: The Education of Physicians for Primary Care. DHEW Publication No [HRA] 74-3133. US Department of Health, Education and Welfare, 1973 12. Ingelfinger FJ: League for beleaguered internists. N Engl J Mcd 292:589-590, 1975 13. Baker C: What's different about family medicine? J Med Educ 49:229-235, 1974 14. Deisher J B: What is so special about a family physician? West J Med 121:521-529, 1974 15. Geyman JP: Conversion of the general practice residency to family practice. JAMA 215:1802-1807, 1971 16. Ransom DC, Vandervoort HE: The development of family medicine: Problematic trends. JAMA 225:1098-1102, 1973 17. Janeway CA: Family medicine-Fad or for real? N Engl J Med 291:337-343, 1974
Nonindications for Inhaled Corticosteroids in Asthma Obviously, inhaled corticosteroids should not be introduced in a patient whose airis obstructed.... When a patient has an obstructive bronchial disease, you have to clear the airway before the drug is introduced. Day-to-day adjunctive therapy should be given and it is unwise to use these drugs unless alternative treatment programs have significant disadvantages because we don't know the long-term effects of inhaled steroids on the bronchial tree. It is not recommended for an asthmatic patient who has only infrequent, moderate-to-severe flareups of asthma. In this instance, bronchodilators, fluids, short-burst steroids-preferably prednisone -will usually reverse the disease. They are not that effective for exercise-induced that they may not be parbronchospasm and there is even some indication ticularly effective for severe pollen-induced, self-limited, seasonal asthma. For exercise-induced bronchospasms, cromolyn or theophylline, or both, are probably better to use. way
.
.
.
-BERNARD A. BERMAN, MD, Boston Extracted from Audio-Digest Pediatrics, Vol. ,22, No. 17, in the Audio-'Digest Foundation's subscription series of tape-recorded programs. For subscription information: 1577 East Chevy Chase Drive, Glendale, CA 91206.
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NOVEMBER 1977 * 127 * 5
Refer to: Gerber WG, Massad RJ: Training physicians for primary care: Trends and hazards (Medical Education). West J Med 127:426432, Nov 1977
Training Physicians for Primary Care: Trends and Hazards WILLIAM G. GERBER, MD, San Francisco, and ROBERT J. MASSAD, MD,
Iowa
City
Programs to train physicians more effectively for careers in primary care are being organized within academic departments in internal medicine and pediatrics, while the number of training programs in family practice continues to grow rapidly. However, the field of primary care training is expanding without a common vocabulary and with inadequate communication between the specialties involved. If decisions concerning health care policy are to be made rationally, the development of multiple distinct models for primary health care delivery must be encouraged and these models must then be evaluated. The distinction between family practice and family medicine must be made clear if the latter discipline is to realize its potential application to all specialties. The relative exclusion of family practice from universities and the absence of experienced practitioners in university primary care programs are conditions that threaten the future of both types of programs and deserve thoughtful attention from medical educators.
IT APPEARS that America's system of medical education has begun to address purposefully the problem of meeting this country's need for primary health care. In frequent contributions to the recent medical literaturel-5 and at a succession of national conferences, representatives from internal medicine and pediatrics have discussed strategies to prepare their trainees more effectively for the practice of primary care. Programs for this purpose have recently been established in a numFrom the Family Practice Residency Program, University of California, San Francisco, School of Medicine, San Francisco peneral Hospital. Dr. Massad is now at the Department of Family Practice, University of Iowa. Reprint requests to: William G. Gerber, MD, Family Practice Residency Program, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110.
426
NOVEMBER 1977 * 127 * 5
ber of our medical schools with the support of the federal government and private foundations. Along with this development, graduate training programs in family pr ctice have experienced a growth that not even the specialty's most ardent supporters could have predicted when it was established in 1969. Petersdorf¢ recently has described the present state of physician maldistribution in the United States, which he ascribes to a lack of planning, coordination and control over the growth of specialties in the past 30 years. There are indications that the field of primary care will replicate that unplanned growth. The primary care movement
TRAINING FOR PRIMARY CARE
is growing rapidly without a common vocabulary and with minimal communication between the specialties involved. Rather than a coordinated effort to train sufficient numbers of physicians for primary care careers, the field has divided into fractions which at best ignore and at worst compete with each other. The purpose of this article is to briefly review the history of the growth of the primary care movement in this country; to offer some definitions of terms which may begin to provide us with a common vocabulary; to describe the major models of primary care training being developed; to outline some current trends which we believe must be reversed, and to make several recommendations for the field.
Background Two documents-The Millis report7 and the Willard report8 -are important reference points in the history of the primary care movement in the United States. In 1966 the Citizens Commission on Graduate Medical Education, chaired by John S. Millis, PhD, presented its recommendations. Among them was the establishment of a new specialty to train primary physicians in the continuous, comprehensive care of families. In 1964 the Council of Medical Education of the American Medical Association appointed the Ad Hoc Committee on Education for Family Practice, chaired by William R. Willard, MD. The findings of the committee were summarized in the Willard report, issued in 1966. It held that family practice was a viable primary care model and that "major efforts should be instituted promptly to encourage the development of new programs for the education of large numbers of family physicians" through the development of new sources of funding and the conferring of specialty status on the discipline. It also urged that "medical schools and teaching hospitals . . . explore the possibility of developing models of family practice, in cooperation with the practicing
profession."8 By the mid- 1960's, legislative and funding bodies began to express interest in promoting and supporting primary care. This interest was followed by the establishment of the American Board of Family Practice and the conferring of specialty status on general practitioners in 1969. Funds were made available from state, federal and private sources for establishing training programs in the new specialty. The resulting increase
in the number of family practice programs and their graduates is impressive: in July 1969 there were 20 family practice residency programs; in July 1976 there were 293. Until recently, therefore, family practice has represented the major thrust in the movement to train primary care physicians in the United States. Although the number of postgraduate training programs in family practice has increased dramatically, the specialty is only beginning to make its presence known in undergraduate medical education. In July 1976 more than 25 American medical schools reported that they had no department or division of family practice. Of the 79 departments in existence, 13 were less than a year old. This relative absence of academic family practice can be partially explained by its unorthodox manner of development. Most specialties evolve slowly from within the profession as new, research based, narrow fields of expertise practiced by a few physicians located primarily within universities. The specialty of family practice arose comparatively abruptly, as a result of societal and legislative pressure, and represented a broad area of medicine which had long been practiced by a large segment of the profession based outside universities. So when the new specialty was established in 1969 it lacked a solid base in academic centers on which to build its research and teaching activities. As our medical schools have explored the potential establishment of departments of family practice and family practice residencies, they have faced major obstacles. The first has been the problem of faculty recruitment. Universities have been forced to recruit most family practice faculty members from the ranks of practicing physicians. This situation has been difficult because traditional criteria for appointment of medical school faculty fit the majority of family practice candidates poorly. Few have been universitytrained; many are former general practitioners whose formal training consists of an internship years before. Few have published, fewer still have done research. Many have taught, but usually in peripheral capacities, such as office preceptorships. To start such a person at an academic rank and salary competitive with the rewards of practice requires making clinical experience equivalent to activities in research, teaching and publishing for purposes of appointment and promotion. In short, the political realities of university procedure and the very small number of traditionally THE WESTERN JOURNAL OF MEDICINE
427
TRAINING FOR PRIMARY CARE
suitable candidates for faculty positions have resulted in the specialty of family practice having limited representation in universities. The family practice movement consequently is the first major development in American medical education that has occurred outside of our universities since the Flexner report of 1910. The focus of primary care training might have remained extramural indefinitely, were it not for the fact that some of the most respected personalities in medical education have continued to urge our medical schools to take the lead in educating physicians for primary care. The Pellegrino report to the Executive Committee of the Association of American Medical Colleges in 1968 echoed the Willard report in urging that medical schools assume a central role in the "redefinition and rehabilitation of the role of the general physician."9 Hillard Jason and other medical educators have pointed out that medical schools focus on secondary and tertiary care, while most of their graduates end up doing primary care.10 In The Education of Physicians for Primary Care, an important and thoughtful document, Alpert and Charney" put it succinctly: It would seem that Pediatrics and Internal Medicine need to reach some rational decisions in relation to family practice. Either they ought to relinquish their role in primary care education and practice-and also recruit
proportionately fewer medical graduates to their own fields-or else acknowledge their own obligations to primary care and reassess their educational efforts with this in mind. To continue to recruit the majority of medical students without accepting the fact that most of them should be prepared largely to practice primary care strikes us as almost unethical, given our current shortage of primary care physicians. In addition to this intellectual prodding, a
second factor which has shifted the attention of our medical schools to primary care has been the increasing number of medical students applying for family practice residencies. In 1976 more than 2,500 graduating students applied for the approximately 1,935 available first year positions. Many are outstanding students who are choosing family practice because it is their only opportunity for graduate training in primary care. They represent an attractive pool of applicants for university training programs in the traditional specialties which can be captured only if their needs for primary care training can be met in those
settings. Third, and maybe most important, there has been financial pressure on the medical schools for the development of primary care training. Since 428
NOVEMBER 1977 * 127 * 5
the late 1960's financial support of the basic science research structure and, thereby, much of the medical school faculty, has been shrinking. At the same time, federal, state and private agencies have become more willing to 'und research and training in primary care. Faced with the alternative o> abandoning the primary care field to family prac-ice or developing primary care programs more co etpatible with their own goals and needs, it is ui lerstandable that our medical schools have not ur 'versally accepted the concept that internal medic ale and pediatrics should relinquish their role in primary care education. Following a flurry of confer nces in the primary care field in the last few sears encouraging their development, residencies itt internal medicine and pediatrics have begun to :'ppear which are specifically designed to prepar their graduates for careers in primary care. The ;e programs differ from family practice residencie- in two important aspects. First, they are all withbn medical school systems. Second, they are being organized within or closely allied to already existing departments in the medical schools. At present, then, family practice programs are growing rapidly, but primarily apart from universities, while primary care programs in internal medicine and pediatrics are being established almost exclusively within our medical schools. Therefore, we are witnessing a two-pronged movement in primary care training.
Definitions Primary care, family practice, general practice and family medicine are terms that are being widely used without general agre ement about what they mean. Thus far in this discussion we have not been concerned with their precise meanings. However,- if we are to avoid false issues and effectively address real ones, wCe must start with a common understanding of these terms. For the remainder of this discussion, the following definitions will be used: Primary care has been referred to as primary medicine and given a three-part definition by Alpert and Charney: Primary medicine medicine assumes tient regardless of Primary medicine
is first-contact medicine . . . Primary longitudinal responsibility for the pathe presence or absence of disease . serves as the "integrationist" for the
patient."
Family practice is primary care delivered by a
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physician in multiple specialty areas to people of all ages and both sexes. Several authors have addressed themselves to the distinction between general practitioners and family practitioners;13-15 our emphasis would be on the specific training in primary care given to the latter. Family medicine has been well defined and defended by Ransom and Vandervoort"6 as a distinct academic discipline. In their words: Family medicine is an emerging discipline concerned with the relationship of life in small groups to health, illness and care. Its focus is on the ecology of relations among individuals in families and between families and their surrounding environment. (This term family is used in the broadest sense to describe any group of intimates with a history and a future.) Family medicine aims toward understanding and changing health problems that cannot be managed successfully by dealing exclusively with the individual and his or her illness, abstracted from the pattern of recurrent interpersonal situations that shape and transform a human life.
Family health care is primary care delivered by a health professional to people of all ages and both sexes in the context of a family systems approach. It implies that the practitioner is grounded in the discipline of family medicine and applies its principles to his practice. Janeway' has said it is "based . . . on family medicine, focuses on the family, and is an attempt to combine health promotion and illness care for the
family."
Training Models Having reviewed the growth of family practice programs and the recent development of primary care programs, we will now describe the training models being utilized by these programs. Among the primary care programs being established, several different models appear to be emerging. The first type can be labeled the singlespecialty model. This type of program is a residency in either internal medicine or pediatrics which has an emphasis on primary care and whose graduates will be board eligible in one or the other specialty. The training is of the traditional length but with an emphasis on outpatient medicine. Presumably, a graduate of such a program has received training more relevant to a primary care practice than his traditionally trained counterpart. The second model of primary care training that we have identified is the team model in which residents in internal medicine and pediatrics are trained to work together in the delivery of primary health care. The residents are scheduled to be
in the ambulatory facility together and training includes attention to the principles of teamwork and collaboration. The third identifiable model produces a graduate trained in at least two specialty areas of primary care. This multispecialty model presents two distinct variations. In the first, the resident is trained in internal medicine and pediatrics. In one such program the resident "majors" in one specialty and "minors" in the other. The graduate is board eligible in his "major" and is expected to serve as a generalist in that specialty, taking care of both ambulatory patients and those requiring hospital care. He is expected to practice ambulatory primary care in his "minor" and to be competent to care for most of the problems of that specialty area. The second multispecialty model adds to the resident's training in internal medicine and pediatrics outpatient skills in other specialty areas such as orthopedics, gynecology, dermatology and the like. Again, depending on whether the "major" has been in the area of internal medicine or pediatrics, he is board eligible in that specialty at the conclusion of this program. Compared with the single specialty model, both of these programs might be expected to produce a graduate who sacrifices depth of knowledge for breadth of practice. Some of these programs attempt to compensate for this additional breadth by extending the duration of the residency one year. The fourth distinct model of primary care training programs is family practice. As with primary care programs, there are differences between family practice residencies. However, all family practice programs share certain basic elements. Important among these is the requirement for a Family Practice Center in every program. A family practice resident spends a substantial portion of his or her time in the model unit, caring for patients in a continuing relationship and taking care of most of their health needs. Generally, this outpatient time grows from 10 percent in the first year to 50 percent in the third year, with time alloted weekly over the three years to assure continuity. The amount of time spent on other specialty services varies between programs but there are established minimums for internal medicine and pediatrics. In addition, family practice residencies are similar in their commitment to teaching the resident skills in other specialty areas which include outpatient orthopedics; ear, nose and throat; ophthalmology; gynecology, and obTHE WESTERN JOURNAL OF MEDICINE
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stetrics. The graduate of a family practice residency is a primary care specialist expected to be capable of caring for most of the health needs of a patient population of all ages and both sexes. The fifth and last primary care training model to be discussed is family health care. All of the programs previously outlined could, with the addition of family medicine to their curricula, be described as family health care programs. The unfortunate reality is that few programs teaching primary care teach family health care. There are many reasons for this, prominent among which is the infancy of the discipline of family medicine. Few of the professionals who have directed their attention to the interaction between the family and health and illness patterns can apply this knowledge at the level of patient care and thereby make it a valuable curricular addition to a residency training program. The net result is that relatively few primary care or family practice programs teach family health care. Happily, both family practice and the newer primary care programs are experimenting with the application of family medicine to primary care delivery and we are hopeful that this area will be vigorously explored. Current Trends We have reviewed the recent growth of the primary care movement in this country, defined some of the terms which are identified with it and outlined the most common models of primary care programs in this country. We will now examine two of the trends in the movement and discuss some of their potential consequences. There is widespread terminological confusion in the primary care field. If we are to develop a rational, economical primary health care system for this country, we must encourage the development of distinct models of primary care delivery and then evaluate their comparative effectiveness. But we can do neither if we do not carefully define the models and understand their similarities and differences. The immediate danger of the existing confusion is that funding agencies share the mystification which has occurred and that funds meant to stimulate innovation are in fact supporting traditional models. Analysis of certain primary care programs, for example, shows an emphasis on ambulatory care with major concentration in medicine and pediatrics and minor exposure to training in office gynecology, orthopedics and minor surgical
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procedures. We question the difference between the graduate of such a program and the graduate of a family practice residency and wonder why it should be supported as an innovative experiment in medical education? The more far-reaching danger is that we will not evaluate these models adequately. There are questions to be answered that are of overwhelming importance to the establishment of a rational health policy. The validity of the evaluation depends on acknowledging of the differences that exist between the various delivery models. How does an internist-pediatrician team compare with a family physician? What is the cost effectiveness of each approach? Does significant and sufficient communication take place between teammates and is the relationship with the family better or worse than if a single physician fills both roles? Does this last question matter? Are there benefits in the greater depth of training of the internist and pediatrician and how do these affect quality of care and costs compared with the breadth of training of the family physician? In order to obtain valid answers to these and many other pressing questions, the models to be evaluated must be clear and distinct. The lack of a clear terminology also threatens the future of family medicine and family health care. To the extent that both remain synonymous with family practice they will not receive adequate recognition or support, nor can they be fairly evaluated. Family medicine is a theoretical perspective and a body of knowledge with potential application to any medical practice. It places the patient in the context of his environment, puts the medical intervention in a broader perspective, and expands the diagnostic and therapeutic possibilities of the physician to include the impact of the family on the disease process and the impact of the therapy on the patient's support system. It is as valid to a surgical subspecialist as it is to a primary care physician. As such, it deserves a prominent place in the undergraduate medical curriculum as a part of the knowledge base utilized by all clinicians. It also deserves support so that its academic base and its clinical application can be expanded. Family health care is the application of family medicine to the care of families. It is not the sole domain of the family physician, but can be provided by other primary care providers or teams who care for all family members. It is our hypoth-
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esis that the addition of a family medicine perspective to a primary care practice results in a measurable difference in the style and outcome of the practice. However, until family medicine and family health care are distinguished from family practice, this hypothesis cannot be widely explored. The second trend which requires comment is the two-pronged nature of the primary care movement in this country. Family practice residency training is located predominately in community hospitals while the development of residencies in primary care has occurred within the university setting. We are concerned about both elements of this movement. The success of family practice at this time is measured primarily by the growth in the number of residencies, the large number of highly qualified applicants seeking admission to those programs, and the financial support which family practice has received from various agencies concerned with the deficit in primary care physicians. However, unless it develops strong university programs, this success may be transient. As alternative solutions to the primary care shortage are offered by the medical schools, funds will almost certainly be diverted to those programs. As they become available, the medical students who now see family practice as their only viable choice for a career in primary care may also be diverted. Neither of these consequences will result from the proven advantage of one model over the other, or even from the higher quality of one form of training over the other. They will occur naturally if role models for primary care exist within the medical school and similar exposure to family physicians does not. If family practice is to become a fully accepted specialty within our medical schools, attitudes of existing faculty must change and academic family practice must recognize its responsibility in promoting this change. Every specialty has an area of expertise which it is obliged to refine and develop and family practice is no exception. The new specialty is faced with a challenge: to prove and delineate its area of expertise; to teach its skills; to develop its research base. If this does not occur, family practice will contribute to its own demise in the academic setting and its full potential as a viable form of primary care will never be realized. Our second concern about the split in the movement is that primary care may not be taught at
all in university-based programs in internal medicine and pediatrics. Primary care is a specific style of practice that incorporates skills that are not being taught in traditional residencies in internal medicine and pediatrics. However, those responsible for the establishment of most of the emerging primary care residencies in this country are traditional academicians who have had no practice experience; or, if they have, it has not been in primary care. Many of the faculty members of these programs are being-recruited from within the medical schools, merely moving from one funding source to another with a change of title but no change of perspective. Consequently, students and residents may be taught primary care by persons with no experience or expertise in the field. It is possible that they may not be taught primary care at all, but merely take a traditional medical or pediatric residency, with more time allocated to outpatient care, when little or no teaching takes place. If this trend continues and university-based primary care programs do not develop faculties in which there is experience, skill and interest in primary care, primary care physicians will not be produced in our medical schools, and medical schools will not participate in the evolution or growth of primary care in this country. This would obviously be a serious setback to the primary care movement.
Recommendations * Those responsible for financial encouragement and ongoing support of primary care programs must make their investments carefully. It is their responsibility to ensure that they are in fact supporting true primary care programs, and to look closely at the models they are considering to encourage real diversity. * Thorough understanding and acknowledgment of the various models of primary care must take place. This is an essential step if we are to evaluate the different variables between models and plan effectively for the future. * Family medicine must gain the recognition and interdisciplinary support it needs to develop as a new academic field and it must be shown that the family health care model which results from its application to primary care is a significant variable. * Family practice, especially those programs in academic settings, must generate a research base which will show clearly those unique areas THE WESTERN JOURNAL OF MEDICINE
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,of knowledge and skill which make it a specialty. * Primary care programs in the university must prove their commitment to producing real primary care practitioners by recruiting faculty members with extensive primary care experience. * The university must adopt new standards for faculty appointment and promotion which recognize skill in teaching and patient care. REFERENCES 1. Petersdorf RG: Internal medicine and family practice: Controversies, conflict and compromise. N Engl J Med 293:326-332, 1975 2. Proger S: A career in ambulatory medicine. N Engl J Med 292:1318-1324, 1975 3. Berarducci AA, Delbanco TL, Rabkin HT: The teaching hospital and primary care. N Engl J Med 292:615-620, 1975 4. Almy TP: Primary care and departments of internal medicine. Arch Intern Med 134:771-773, 1974 5. The internist and primary care (Editorial). Arch Intern Med 134:780-781, 1974 6. Petersdorf RG: Health manpower: Numbers, distribution, quality. Ann Intern Med 82:694-701, 1975
7. Citizens Commission on Graduate Medical Education (John S. Millis, Chairman): The Graduate Education of Physicians. Chicago, Council on Medical Education, American Medical Association, 1966 8. Ad Hoc Committee on Education for Family Practice (William R. Willard, Chairman): Meeting the Challenge of Family Practice-Report to the AMA Council on Medical Education. Chicago, American Medical Association, 1966 9. Ad Hoc Committee on Medical Schools and the AAMC in Relation to Training for Family Practice (Edmund D. Pellegrino, Chairman): Planning for comprehensive and continuing care of patients through education-Report to the Executive Council, Association of American Medical Colleges. J Med Educ 43: 751-759, Jun 1968 10. Jason H: The relevance of medical educat:on to medical practice. JAMA 212:2092-2095, 1970 11. Alpert JJ, Charney E: The Education of Physicians for Primary Care. DHEW Publication No [HRA] 74-3133. US Department of Health, Education and Welfare, 1973 12. Ingelfinger FJ: League for beleaguered internists. N Engl J Mcd 292:589-590, 1975 13. Baker C: What's different about family medicine? J Med Educ 49:229-235, 1974 14. Deisher J B: What is so special about a family physician? West J Med 121:521-529, 1974 15. Geyman JP: Conversion of the general practice residency to family practice. JAMA 215:1802-1807, 1971 16. Ransom DC, Vandervoort HE: The development of family medicine: Problematic trends. JAMA 225:1098-1102, 1973 17. Janeway CA: Family medicine-Fad or for real? N Engl J Med 291:337-343, 1974
Nonindications for Inhaled Corticosteroids in Asthma Obviously, inhaled corticosteroids should not be introduced in a patient whose airis obstructed.... When a patient has an obstructive bronchial disease, you have to clear the airway before the drug is introduced. Day-to-day adjunctive therapy should be given and it is unwise to use these drugs unless alternative treatment programs have significant disadvantages because we don't know the long-term effects of inhaled steroids on the bronchial tree. It is not recommended for an asthmatic patient who has only infrequent, moderate-to-severe flareups of asthma. In this instance, bronchodilators, fluids, short-burst steroids-preferably prednisone -will usually reverse the disease. They are not that effective for exercise-induced that they may not be parbronchospasm and there is even some indication ticularly effective for severe pollen-induced, self-limited, seasonal asthma. For exercise-induced bronchospasms, cromolyn or theophylline, or both, are probably better to use. way
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-BERNARD A. BERMAN, MD, Boston Extracted from Audio-Digest Pediatrics, Vol. ,22, No. 17, in the Audio-'Digest Foundation's subscription series of tape-recorded programs. For subscription information: 1577 East Chevy Chase Drive, Glendale, CA 91206.
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