40
TRAINING AND EDUCATION OF PHYSICI ANS * MORTON D. BOGDONOFF, M.D. Executive Associate Dean Cornell University Medical College New York, N.Y.
T HE characteristics of the practicing physician and of the system of patient care which may be most effective in fulfilling the widely held expectations for medical care for our society have been discussed here by Dr. David E. Rogers. He has also described the problems of the geographic maldistribution of physicians and of the unusual emphasis by practicing physicians upon subspecialty disciplines. The title of this presentation, chosen by the designers of the present conference, suggests that during the past several years the physician's education and training have been among the sources of the problem. It is a widely held opinion that the dramatic change in the facilities and curricula of medical schools which occurred after World War II has had an important effect upon the location and character of the practicing physicians of our country. The last 25 years have seen an extraordinary expansion in biomedical research, and the major part of that research has been conducted by the faculties of university medical centers. These faculties, with their intense interest in the development of new knowledge in highly specialized fields, have been perceived as not being sufficiently concerned with the details of primary general medical care. It has been generally believed that the geographic and subspecialty maldistribution of physicians derives primarily from the curricular content of undergraduate education and that the faculty with which the students work in medical schools serve as extremely important models in influencing medical students toward their choices of careers. Since university medical centers are principally institutions with highly sophisticated and specialized facilities whose distinction is marked by their abilities in investigation and research, the educational programs developed in such institutions are believed to place excessive emphasis on research problems and on unusual illnesses. Whether, in fact, the character of medical school faculties has been such an important influence is open.to debate. However, it * Presented in a panel, Sources of the Problem, as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976.
Bull. N.Y. Acad. Med.
TRAINING AND EDUCATION OF PHYSICIANS
41
is now generally accepted among medical educators that a directed effort should be made toward the development of educational and training programs which will result specifically in the provision of more generalist physicians for the entire population. While the content of undergraduate medical education may appear to be directing students' career plans away from generalist primary care, in fact its major purpose has been to develop a pattern of critical analysis which would be applicable to any type of clinical practice, whether in primary care or in more complicated realms. I contend that it is during residency training, and not in the undergraduate phase of medical school, that the behavior of the physician is most significantly determined. However, as a consequence of the view that it is the undergraduate curriculum as well that influences the future behavior of the students, medical schools have been asked to modify curricula and to provide educational programs in community hospitals, physicians' offices, and neighborhood clinics. In the past several years, especially since the Millis Committee Report in 1966,1 medical schools have done exactly what has been called for, and have established undergraduate educational programs within the practicing community. One might call this the centrifugal response on the part of the medical schools for increased primary-care experience for medical students. In addition, medical schools have also established within their own campuses programs which specifically attempt to attract patients who present primarycare problems. These patients usually are persons living near the medical center. Medical schools have established model practices within the medical center proper in which to demonstrate to the student body all the characteristics of a primary-care physician: continuity of care, immediacy of response, and personal acquaintance between physician and patients. This addition to the nature of the clinical practices within medical centers might be called the centripetal response on the part of medical schools to the need for more primary-care education. But it is the residency-training program that has the most powerful influence on the specific interests and emphases which a young physician is likely to incorporate into his personal style of practice. Many observers have believed that the interest and concerns of attending physicians and of supervisors of residents are the most important determinants of the physician's eventual activity in practice. Since, as was stated above, university medical centers have recruited staffs composed primarily of biomedical scientists with highly specialized interests, the training programs in these major university estabVol. 53, No. 1, January-February 1977
42
M.D. BOGDONOFF
42~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
M..BGDNF
lishments have been said to focus too narrowly upon the complex facets of clinical problems which are best cared for by such specialty physicians. Although not all observers have agreed that these traditional programs have failed to produce generalist physicians,2 in the past few years there has been a determined effort upon the parts of the departments of internal medicine and of pediatrics to modify the residency-training programs in such a way as to emphasize primary care. Many university medical centers have developed divisions of general medicine within their departments of internal medicine and have attempted to recruit to their faculty rosters numbers of young physicians who wish specifically to provide models of generalist care.3 These efforts have been well received throughout American medicine. In addition to modifying the traditional programs, many medical centers have established residencies in family medicine and have also extended their graduate training programs to community hospitals. These programs in family medicine have been popular among medical students. I am cautious about the consequences of all this. The first note of caution has to do with the expectations of our society as to the rate of change within the practicing community that will occur as a consequence of the modifications and additions in the program. The net effect will be relatively slow to occur. The reasons for this are simply that the total pool of practicing physicians now in place in our nation has a half-life of about 20 years; hence, even if all new graduates of medical schools, starting this very year, were to enter only into generalist primary-care medicine, it would take a number of years before there would be a major increase in the total fraction of all physicians engaging in such practice. But no one, not even the most enthusiastic, has requested that more than 50 to 60% of all medical graduates become generalist physicians. Therefore we can expect only a moderate rate of change during the next decade in the general over-all character of our practicing physicians. Of course, new federal legislation which directly determined geographic location and specialty function quotas for various areas of the country would bring about change much more immediately, but such a legislative step would be
revolutionary. Further, in order to enact the changes in curricula and in residency training programs that have been described, there must be a sufficient number of faculty members to direct and participate in these programs. At present, in academic medical centers there is a major shortage of faculty in general primary-care medicine, and the number of candidates qualified to teach in these programs is limited. It is not often possible to simply choose from the community a well-established, effective practicing physician who promptly Bull. N.Y. Acad. Med.
TRAINING AND EDUCATION OF PHYSICIANS
43
can become an effective and disciplined teacher. It takes much time to develop distinguished and productive teachers; and for the field of generalist medicine there is need to create a large number of such individuals if the proposed programs are to be developed successfully. Finally, I am aware of an over-reaction to the post-World War II emphasis upon biomedical science. It is crucial that the medical profession and other educators be on guard against antiscientific bias as we go about making changes in undergraduate and graduate education in order to produce more generalist primary-care physicians. We must be extremely careful not to abandon or to dismantle the fundamental basis of excellent medical care in a zealous endeavor to improve the availability of medical care for all the people of our country. REFERENCES 1. The Graduate Education of Physicians: The Report of The Citizens Commission on Graduate Medical Education. Chicago, American Medical Association, 1966. 2. Reitemeier, R.J., Spittel, Jr., J.A., Weeks, R. E., Daugherty, G.W.,
Vol. 53, No. 1, January-February 1977
Nobrega, F.T., and Fleming, R.W.: Participation by internists in primary care. Arch. Intern. Med. 135:255-57, 1975. 3. Bogdonoff, M.D.: On divisions of general medicine in departments of internal medicine. Arch. Intern. Med. 135:112728, 1975.
TRAINING AND EDUCATION OF PHYSICI ANS * MORTON D. BOGDONOFF, M.D. Executive Associate Dean Cornell University Medical College New York, N.Y.
T HE characteristics of the practicing physician and of the system of patient care which may be most effective in fulfilling the widely held expectations for medical care for our society have been discussed here by Dr. David E. Rogers. He has also described the problems of the geographic maldistribution of physicians and of the unusual emphasis by practicing physicians upon subspecialty disciplines. The title of this presentation, chosen by the designers of the present conference, suggests that during the past several years the physician's education and training have been among the sources of the problem. It is a widely held opinion that the dramatic change in the facilities and curricula of medical schools which occurred after World War II has had an important effect upon the location and character of the practicing physicians of our country. The last 25 years have seen an extraordinary expansion in biomedical research, and the major part of that research has been conducted by the faculties of university medical centers. These faculties, with their intense interest in the development of new knowledge in highly specialized fields, have been perceived as not being sufficiently concerned with the details of primary general medical care. It has been generally believed that the geographic and subspecialty maldistribution of physicians derives primarily from the curricular content of undergraduate education and that the faculty with which the students work in medical schools serve as extremely important models in influencing medical students toward their choices of careers. Since university medical centers are principally institutions with highly sophisticated and specialized facilities whose distinction is marked by their abilities in investigation and research, the educational programs developed in such institutions are believed to place excessive emphasis on research problems and on unusual illnesses. Whether, in fact, the character of medical school faculties has been such an important influence is open.to debate. However, it * Presented in a panel, Sources of the Problem, as part of the 1976 Annual Health Conference of the New York Academy of Medicine, Issues in Primary Care, held April 22 and 23, 1976.
Bull. N.Y. Acad. Med.
TRAINING AND EDUCATION OF PHYSICIANS
41
is now generally accepted among medical educators that a directed effort should be made toward the development of educational and training programs which will result specifically in the provision of more generalist physicians for the entire population. While the content of undergraduate medical education may appear to be directing students' career plans away from generalist primary care, in fact its major purpose has been to develop a pattern of critical analysis which would be applicable to any type of clinical practice, whether in primary care or in more complicated realms. I contend that it is during residency training, and not in the undergraduate phase of medical school, that the behavior of the physician is most significantly determined. However, as a consequence of the view that it is the undergraduate curriculum as well that influences the future behavior of the students, medical schools have been asked to modify curricula and to provide educational programs in community hospitals, physicians' offices, and neighborhood clinics. In the past several years, especially since the Millis Committee Report in 1966,1 medical schools have done exactly what has been called for, and have established undergraduate educational programs within the practicing community. One might call this the centrifugal response on the part of the medical schools for increased primary-care experience for medical students. In addition, medical schools have also established within their own campuses programs which specifically attempt to attract patients who present primarycare problems. These patients usually are persons living near the medical center. Medical schools have established model practices within the medical center proper in which to demonstrate to the student body all the characteristics of a primary-care physician: continuity of care, immediacy of response, and personal acquaintance between physician and patients. This addition to the nature of the clinical practices within medical centers might be called the centripetal response on the part of medical schools to the need for more primary-care education. But it is the residency-training program that has the most powerful influence on the specific interests and emphases which a young physician is likely to incorporate into his personal style of practice. Many observers have believed that the interest and concerns of attending physicians and of supervisors of residents are the most important determinants of the physician's eventual activity in practice. Since, as was stated above, university medical centers have recruited staffs composed primarily of biomedical scientists with highly specialized interests, the training programs in these major university estabVol. 53, No. 1, January-February 1977
42
M.D. BOGDONOFF
42~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
M..BGDNF
lishments have been said to focus too narrowly upon the complex facets of clinical problems which are best cared for by such specialty physicians. Although not all observers have agreed that these traditional programs have failed to produce generalist physicians,2 in the past few years there has been a determined effort upon the parts of the departments of internal medicine and of pediatrics to modify the residency-training programs in such a way as to emphasize primary care. Many university medical centers have developed divisions of general medicine within their departments of internal medicine and have attempted to recruit to their faculty rosters numbers of young physicians who wish specifically to provide models of generalist care.3 These efforts have been well received throughout American medicine. In addition to modifying the traditional programs, many medical centers have established residencies in family medicine and have also extended their graduate training programs to community hospitals. These programs in family medicine have been popular among medical students. I am cautious about the consequences of all this. The first note of caution has to do with the expectations of our society as to the rate of change within the practicing community that will occur as a consequence of the modifications and additions in the program. The net effect will be relatively slow to occur. The reasons for this are simply that the total pool of practicing physicians now in place in our nation has a half-life of about 20 years; hence, even if all new graduates of medical schools, starting this very year, were to enter only into generalist primary-care medicine, it would take a number of years before there would be a major increase in the total fraction of all physicians engaging in such practice. But no one, not even the most enthusiastic, has requested that more than 50 to 60% of all medical graduates become generalist physicians. Therefore we can expect only a moderate rate of change during the next decade in the general over-all character of our practicing physicians. Of course, new federal legislation which directly determined geographic location and specialty function quotas for various areas of the country would bring about change much more immediately, but such a legislative step would be
revolutionary. Further, in order to enact the changes in curricula and in residency training programs that have been described, there must be a sufficient number of faculty members to direct and participate in these programs. At present, in academic medical centers there is a major shortage of faculty in general primary-care medicine, and the number of candidates qualified to teach in these programs is limited. It is not often possible to simply choose from the community a well-established, effective practicing physician who promptly Bull. N.Y. Acad. Med.
TRAINING AND EDUCATION OF PHYSICIANS
43
can become an effective and disciplined teacher. It takes much time to develop distinguished and productive teachers; and for the field of generalist medicine there is need to create a large number of such individuals if the proposed programs are to be developed successfully. Finally, I am aware of an over-reaction to the post-World War II emphasis upon biomedical science. It is crucial that the medical profession and other educators be on guard against antiscientific bias as we go about making changes in undergraduate and graduate education in order to produce more generalist primary-care physicians. We must be extremely careful not to abandon or to dismantle the fundamental basis of excellent medical care in a zealous endeavor to improve the availability of medical care for all the people of our country. REFERENCES 1. The Graduate Education of Physicians: The Report of The Citizens Commission on Graduate Medical Education. Chicago, American Medical Association, 1966. 2. Reitemeier, R.J., Spittel, Jr., J.A., Weeks, R. E., Daugherty, G.W.,
Vol. 53, No. 1, January-February 1977
Nobrega, F.T., and Fleming, R.W.: Participation by internists in primary care. Arch. Intern. Med. 135:255-57, 1975. 3. Bogdonoff, M.D.: On divisions of general medicine in departments of internal medicine. Arch. Intern. Med. 135:112728, 1975.
