1109
THE OBJECTIVES OF PRIMARY-CARE EDUCATIONAL PROGRAMS* KENNETH G. JOHNSON, M.D. Professor, Department of Community Medicine The Mount Sinai School of Medicine of the City University of New York New York, N.Y.
IT is difficult to single out groups of physicians who do not provide primary care to some patients at some time. Family practitioners, internists, and pediatricians do so 80 to 100% of the time; obstetriciansgynecologists function as primary care physicians for many women of child-bearing age. Primary care is being given, but the system of providing it is difficult to identify; gaining entry into the system presents problems for patients; and, being hidden, the present system does not emerge as an entity which one can describe with clarity. Nor does this system provide a clear template for the reproduction of primary-care practitioners; only within the past few years has it been possible for a medical student attracted to primary care to find a postgraduate program which offers training in primary care as a major focus. I do not find education to prepare physicians to provide primary care a simple issue. There are problems and contradictions which find expression in the difficulties of seeing a physician when you need one-access and availability being the desiderata-and, concurrently, institution of a malpractice litigation because you suffered from some other physician's lack of skill. Meeting the national need for primary care involves the simultaneous attainment of two objectives: 1) providing easy access to such care and 2) training physicians who can provide technologically correct solutions. Further, in order to avoid repetition of the failure of the general practitioner in the 1940s and 1950s, the provision of such care should be sufficiently rewarding to both the physician and the patient. "He is only a *Presented in a panel, Education to Provide Primary Medical Care, as part of the Fourth Annual Symposium on Medical Education, Prospective Medical Manpower Requirements-How Are They To Be Met? held by the Committee on Medical Education of the New York Academy of Medicine October 9, 1975.
Vol. 52, No. 9, November 1976
1110 1110
K. G. JOHNSON
general practitioner" is an expression which persists in our society. Within medicine, the description of a generalist as a physician who greets all visitors to the office, treats minor illnesses, and refers patients with potentially serious illness to specialists is not likely to attract the sustained interest of some of the brightest young men and women in our country. The contradiction of the expectations of easy access and a high level of technologic expertness is one which those in medical education must strive to describe and to state as more apparent than real. Such statements in medical education eventually are manifested as major programs or departments. These usually bear the medical school's imprimatur and have related bodies of faculty, residents, and students; time in the curriculum; supporting staff and facilities; and, at some point, recognition-usually bqard certification-of the program's graduates. In reference to primary care, the process has already begun. Familypractice residencies have increased from 25 in 1969 to 219 in 1975 and the majority of the nation's 114 medical schools now have divisions or departments of family medicine or primary care. However, in 1974 the combined number of first-year residencies in family medicine was 1,313. Corresponding first-year residencies in 1974 were 3,700 for internal medicine and 1,000 for pediatrics. Considering the 15,000 men and women who will be graduating from United State medical schools in 1976, the August 1974 statement of the American Board of Internal Medicine, which Dr. Richard J. Reitemeier will discuss, is an enormous step forward in recognizing the importance of preparing greater numbers of physicians to provide primary care. Pediatrics is a specialty which has always been deeply involved in primary care. Thus, there is a pluralism of models for primary care, delimited only by the age groups of patients to be served. But pluralism and competition are the hallmarks of American society and, I believe, are welcome to an area which has attracted little attention in the past several decades. In the family-medicine model the faculty are real or converted general practitioners, agumented by pediatricians and psychiatrists, working in a department or unit of family medicine. The other model, often referred to as primary care, operates within traditional clinical departments, chiefly internal medicine and pediatrics. In the primary-care model there is likely to be little representation of family practitioners on the faculty of a medical school. The objectives of each type of program, where stated, are almost Bull. N. Y. Acad. Med.
PRIMARY-CARE EDUCATIONAL PROGRAMS
1111
identical. The care of the ambulatory patient is given high priority; the management of common illness-respiratory, emotional, skin, digestive, musculoskeletal, and gynecologic-is stressed, as are the psychosocial factors contributing to health and disease and the utility of preventive measures. The family-medicine program includes the acquisition of skills in pediatric and sometimes in obstetrical care; the primary care model assumes that a general internist will be working with a general pediatrician if all members of the family are to be cared for, and that obstetrics will be left for the obstetrician. It would be misleading to conclude that because models of primary care have been established in medical centers that permanent relief lies just beyond the horizon. The allocation of physician manpower related to primary care is not likely to change significantly within the next five years. The predominance of residents now in training are committed to other specialties, and the educational and training programs which have produced specialists for the past several decades, although perhaps not prosperous, are numerous and substantial. Family practitioners, internists, and pediatricians in the United States for the next five years will constitute less than 40% of the total number of physicians. 1 It also would be misleading to feel assured that a curriculum for primary care at the undergraduate and graduate levels has been developed which sets forth a list of objectives which are unique to primary care. Progress has been made in the objectives relating to the diagnosis and management of the common illnesses and conditions which a physician encounters in providing ambulatory care. That common illnesses should receive special attention is real progress and certainly is essential to the training of a
primary-care physician. If the expertness of the primary-care physician is confined to the management of common illness in individual patients, I see little challenge or attractiveness in the job, not because such activities are inappropriate, but because they lock the physician into a role which can be carried out as well, in large measure under his supervision, by assistants. With this limited set of objectives I believe that we would be programming a future march back into the subspecialties. There are two other sets of objectives which must be listed in the primary-care curriculum in order to allow primary care to develop as a separate entity. One relates to producing, at a high level of consciousness, for those students inclined toward primary care, what Walsh McDermott Vol. 52, No. 9, November 1976
1112
1112
K. G. JOHNSON
K. G.
JOHNSON~~~~~~~~~~~~~~~~~~~~~~~~
has called "samaritanism;"2 the term was chosen as the best available antonym to a technological orientation. To be a Samaritan is to be ready and generous in helping those in distress and to treat illness as opposed to disease-to add compassion and human support to science and technology. This goal is translated into a set of objectives which can be met by the use of the medical school's resources in sociology and psychiatry; these can be used in the study of the perception of illness by individuals and families and its impact on them. Compassion for groups of people-the stillborn, infants who die or are injured at birth, "expendable" American workers, etc.-is best taught as community medicine. Primary care is as Samaritan as it is technological and the failure to include related educational objectives can be but an omission. The last set of objectives may prove difficult for many to understand or accept; at least, such has been my experience over the past five years, although there are indications that the idea is taking hold now. This set of objectives relates to training a primary-care physician to be an adequate manager of the resources and facilities over which he can exercise control. It is not appreciated widely that an individual practitioner directs the spending of large sums of money on health care. Hospitalizing four patients a week could account for an annual expenditure in excess of $600,000. Under present conditions the dollar flow in private practice, except for professional fees, largely is the concern of the patient or a third party. When setting limits on financial resources becomes common, as will happen with capitation reimbursement under national health insurance, the physician's stewardship of resources will assume new and greater importance. How well he allocates finite resources will correlate closely with the extent and quality of the services given. Thus, skill in management be joined with clinical excellence and samaritanism as an important paradigm of success. Management skills are not confined to getting the best bargain in supplies for the office. Rather, they relate to the practitioner's ability to assess the performance of his practice-ultimately in meeting the needs of people, but proximally in matters of efficiency, availability, efficacy, productivity, acceptability, and costs of services. What is the quality of his services? Are his services directed to the appropriate populations? Do they make a difference? A typical question would be, "What value is the yearly check-up?" One group of experts in the prevention of disease suggests that in the absence of symptoms such examinations be done every 10 years
Bull. N. Y. Acad. Med.
PRIMARY-CARE EDUCATIONAL PROGRAMS
1113
from ages 25 to 35, every five years from ages 36 to 64, and every two years thereafter. After several decades of advising people to be examined each year, serious questions are now being raised about the benefit of doing so. I introduce the issue, not for detailed discussion, but as an example of the questions which should be addressed to the provision of primary care. The spacing of examinations related to the prevention or detection of illness is important because the complete history and physical examination represents a substantial expenditure of time, effort, and money within the health-care system. The need of the primary-care practitioner for skills in management is based on projections of the mode and style of health-care practice in the next several decades. The projections assume the absence of the solo practitioner, except possibly in the most rural areas. Where he does survive, he will probably have the aid of nurse-practitioners and physician's assistants. Physicians will practice in groups and, within a defined budget, will provide services to defined populations. I hope that an enlightened public policy will emerge which will reward those groups of physicians who are the most skillful stewards of resources and who offer a high quality of care. Fortunately, the attainment of the three sets of educational objectivesprimary clinical skills, samaritanism, and management abilities-is within the reach of most medical schools. It is a matter of such things as timing in the curriculum, making room for a clerkship in ambulatory care for medical students, and enriching the residency for family practice or primary care. In addition, a long-overdue reform of ambulatory services will be required in most institutions. The largely unexploited skills of private practitioners must be given a prominent place in a program of primary care. To cite briefly a program for primary care in one medical school,3'4 in the first month of medical school students are engaged-through visits to primary-care practitioners, readings, and seminars-in the issues of primary care. Courses in medical sociology, ethics, sexuality, personality development, and alcoholism follow. The compassionate element of the samaritan objectives are approached in the second year, along with courses in epidemiology and systems of health care. A required clerkship in ambulatory care-done in the clinical years in ambulatory care practices in several communities-defines the range of clinical skills. A postgraduate residency program-appropriately (and not accidentally) called the physi-
Vol. 52, No. 9, November 1976
1114
K. G. JOHNSON
cian-manager program-has been set up for the training of internists and pediatricians in primary care. The ultimate success of any program in primary care, however, depends on the attractiveness of the program to young men and women and the willingness of medical educators to accept that primary care is a peer to other medical disciplines. The federal government should offer special assistance for the training of primary physicians as well as incentives for physicians to go where they are needed. Further, diminishing federal support for the training of subspecialists whose numbers need thinning is pro bono. Even as an advocate of primary care, I interpret, as a new and unwelcome federal regulation of medical education, legislation which links general support for medical education, e.g., capitation grants, to the proviso that a school be coerced into teaching primary care. The odds are great that primary care will emerge as a farce under such coercion. However, I would be less than honest if I did not ascribe to federal threats a renewed interest in primary care in the medical school. Given proper support within the medical school, primary-care programs, divisions, units, or departments can emerge as the equals of other units in teaching, research, and service, and the primary-care practitioner will be accepted as equal to other specialists. Whether primary care proceeds in one institution under the banner of family practice or in another progresses within the traditional departments of medicine and pediatrics is not important, provided there is freedom for the discipline to develop with vitality and a capacity for innovation. The renaissance of primary care as major medicine must surface for a society in which a rational system of primary care remains elusive. REFERENCES 1. The Supply of Health Manpower-1970 3. Johnson, K. G. and Haughton, P. B. T.: Profiles and Projections to 1990. DHEW An outreach program for a rural medical Publication No. (HRA) 75-38. Washingschool. J. Med. Educ. 50:38-45, 1975. ton, D.C., Govt. Print. Off., 1975, p. 4. Taylor, J. M. and Johnson, K. G.: A 78. residency program in primary medical 2. McDermott, W.: General medical carecare: The physician as provider-manager. Identification and analysis of alternative J. Med. Educ. 48:654-60, 1973. approaches. Johns Hopkins Med. J. 135:292-321, 1974.
Bull. N. Y. Acad. Med.
THE OBJECTIVES OF PRIMARY-CARE EDUCATIONAL PROGRAMS* KENNETH G. JOHNSON, M.D. Professor, Department of Community Medicine The Mount Sinai School of Medicine of the City University of New York New York, N.Y.
IT is difficult to single out groups of physicians who do not provide primary care to some patients at some time. Family practitioners, internists, and pediatricians do so 80 to 100% of the time; obstetriciansgynecologists function as primary care physicians for many women of child-bearing age. Primary care is being given, but the system of providing it is difficult to identify; gaining entry into the system presents problems for patients; and, being hidden, the present system does not emerge as an entity which one can describe with clarity. Nor does this system provide a clear template for the reproduction of primary-care practitioners; only within the past few years has it been possible for a medical student attracted to primary care to find a postgraduate program which offers training in primary care as a major focus. I do not find education to prepare physicians to provide primary care a simple issue. There are problems and contradictions which find expression in the difficulties of seeing a physician when you need one-access and availability being the desiderata-and, concurrently, institution of a malpractice litigation because you suffered from some other physician's lack of skill. Meeting the national need for primary care involves the simultaneous attainment of two objectives: 1) providing easy access to such care and 2) training physicians who can provide technologically correct solutions. Further, in order to avoid repetition of the failure of the general practitioner in the 1940s and 1950s, the provision of such care should be sufficiently rewarding to both the physician and the patient. "He is only a *Presented in a panel, Education to Provide Primary Medical Care, as part of the Fourth Annual Symposium on Medical Education, Prospective Medical Manpower Requirements-How Are They To Be Met? held by the Committee on Medical Education of the New York Academy of Medicine October 9, 1975.
Vol. 52, No. 9, November 1976
1110 1110
K. G. JOHNSON
general practitioner" is an expression which persists in our society. Within medicine, the description of a generalist as a physician who greets all visitors to the office, treats minor illnesses, and refers patients with potentially serious illness to specialists is not likely to attract the sustained interest of some of the brightest young men and women in our country. The contradiction of the expectations of easy access and a high level of technologic expertness is one which those in medical education must strive to describe and to state as more apparent than real. Such statements in medical education eventually are manifested as major programs or departments. These usually bear the medical school's imprimatur and have related bodies of faculty, residents, and students; time in the curriculum; supporting staff and facilities; and, at some point, recognition-usually bqard certification-of the program's graduates. In reference to primary care, the process has already begun. Familypractice residencies have increased from 25 in 1969 to 219 in 1975 and the majority of the nation's 114 medical schools now have divisions or departments of family medicine or primary care. However, in 1974 the combined number of first-year residencies in family medicine was 1,313. Corresponding first-year residencies in 1974 were 3,700 for internal medicine and 1,000 for pediatrics. Considering the 15,000 men and women who will be graduating from United State medical schools in 1976, the August 1974 statement of the American Board of Internal Medicine, which Dr. Richard J. Reitemeier will discuss, is an enormous step forward in recognizing the importance of preparing greater numbers of physicians to provide primary care. Pediatrics is a specialty which has always been deeply involved in primary care. Thus, there is a pluralism of models for primary care, delimited only by the age groups of patients to be served. But pluralism and competition are the hallmarks of American society and, I believe, are welcome to an area which has attracted little attention in the past several decades. In the family-medicine model the faculty are real or converted general practitioners, agumented by pediatricians and psychiatrists, working in a department or unit of family medicine. The other model, often referred to as primary care, operates within traditional clinical departments, chiefly internal medicine and pediatrics. In the primary-care model there is likely to be little representation of family practitioners on the faculty of a medical school. The objectives of each type of program, where stated, are almost Bull. N. Y. Acad. Med.
PRIMARY-CARE EDUCATIONAL PROGRAMS
1111
identical. The care of the ambulatory patient is given high priority; the management of common illness-respiratory, emotional, skin, digestive, musculoskeletal, and gynecologic-is stressed, as are the psychosocial factors contributing to health and disease and the utility of preventive measures. The family-medicine program includes the acquisition of skills in pediatric and sometimes in obstetrical care; the primary care model assumes that a general internist will be working with a general pediatrician if all members of the family are to be cared for, and that obstetrics will be left for the obstetrician. It would be misleading to conclude that because models of primary care have been established in medical centers that permanent relief lies just beyond the horizon. The allocation of physician manpower related to primary care is not likely to change significantly within the next five years. The predominance of residents now in training are committed to other specialties, and the educational and training programs which have produced specialists for the past several decades, although perhaps not prosperous, are numerous and substantial. Family practitioners, internists, and pediatricians in the United States for the next five years will constitute less than 40% of the total number of physicians. 1 It also would be misleading to feel assured that a curriculum for primary care at the undergraduate and graduate levels has been developed which sets forth a list of objectives which are unique to primary care. Progress has been made in the objectives relating to the diagnosis and management of the common illnesses and conditions which a physician encounters in providing ambulatory care. That common illnesses should receive special attention is real progress and certainly is essential to the training of a
primary-care physician. If the expertness of the primary-care physician is confined to the management of common illness in individual patients, I see little challenge or attractiveness in the job, not because such activities are inappropriate, but because they lock the physician into a role which can be carried out as well, in large measure under his supervision, by assistants. With this limited set of objectives I believe that we would be programming a future march back into the subspecialties. There are two other sets of objectives which must be listed in the primary-care curriculum in order to allow primary care to develop as a separate entity. One relates to producing, at a high level of consciousness, for those students inclined toward primary care, what Walsh McDermott Vol. 52, No. 9, November 1976
1112
1112
K. G. JOHNSON
K. G.
JOHNSON~~~~~~~~~~~~~~~~~~~~~~~~
has called "samaritanism;"2 the term was chosen as the best available antonym to a technological orientation. To be a Samaritan is to be ready and generous in helping those in distress and to treat illness as opposed to disease-to add compassion and human support to science and technology. This goal is translated into a set of objectives which can be met by the use of the medical school's resources in sociology and psychiatry; these can be used in the study of the perception of illness by individuals and families and its impact on them. Compassion for groups of people-the stillborn, infants who die or are injured at birth, "expendable" American workers, etc.-is best taught as community medicine. Primary care is as Samaritan as it is technological and the failure to include related educational objectives can be but an omission. The last set of objectives may prove difficult for many to understand or accept; at least, such has been my experience over the past five years, although there are indications that the idea is taking hold now. This set of objectives relates to training a primary-care physician to be an adequate manager of the resources and facilities over which he can exercise control. It is not appreciated widely that an individual practitioner directs the spending of large sums of money on health care. Hospitalizing four patients a week could account for an annual expenditure in excess of $600,000. Under present conditions the dollar flow in private practice, except for professional fees, largely is the concern of the patient or a third party. When setting limits on financial resources becomes common, as will happen with capitation reimbursement under national health insurance, the physician's stewardship of resources will assume new and greater importance. How well he allocates finite resources will correlate closely with the extent and quality of the services given. Thus, skill in management be joined with clinical excellence and samaritanism as an important paradigm of success. Management skills are not confined to getting the best bargain in supplies for the office. Rather, they relate to the practitioner's ability to assess the performance of his practice-ultimately in meeting the needs of people, but proximally in matters of efficiency, availability, efficacy, productivity, acceptability, and costs of services. What is the quality of his services? Are his services directed to the appropriate populations? Do they make a difference? A typical question would be, "What value is the yearly check-up?" One group of experts in the prevention of disease suggests that in the absence of symptoms such examinations be done every 10 years
Bull. N. Y. Acad. Med.
PRIMARY-CARE EDUCATIONAL PROGRAMS
1113
from ages 25 to 35, every five years from ages 36 to 64, and every two years thereafter. After several decades of advising people to be examined each year, serious questions are now being raised about the benefit of doing so. I introduce the issue, not for detailed discussion, but as an example of the questions which should be addressed to the provision of primary care. The spacing of examinations related to the prevention or detection of illness is important because the complete history and physical examination represents a substantial expenditure of time, effort, and money within the health-care system. The need of the primary-care practitioner for skills in management is based on projections of the mode and style of health-care practice in the next several decades. The projections assume the absence of the solo practitioner, except possibly in the most rural areas. Where he does survive, he will probably have the aid of nurse-practitioners and physician's assistants. Physicians will practice in groups and, within a defined budget, will provide services to defined populations. I hope that an enlightened public policy will emerge which will reward those groups of physicians who are the most skillful stewards of resources and who offer a high quality of care. Fortunately, the attainment of the three sets of educational objectivesprimary clinical skills, samaritanism, and management abilities-is within the reach of most medical schools. It is a matter of such things as timing in the curriculum, making room for a clerkship in ambulatory care for medical students, and enriching the residency for family practice or primary care. In addition, a long-overdue reform of ambulatory services will be required in most institutions. The largely unexploited skills of private practitioners must be given a prominent place in a program of primary care. To cite briefly a program for primary care in one medical school,3'4 in the first month of medical school students are engaged-through visits to primary-care practitioners, readings, and seminars-in the issues of primary care. Courses in medical sociology, ethics, sexuality, personality development, and alcoholism follow. The compassionate element of the samaritan objectives are approached in the second year, along with courses in epidemiology and systems of health care. A required clerkship in ambulatory care-done in the clinical years in ambulatory care practices in several communities-defines the range of clinical skills. A postgraduate residency program-appropriately (and not accidentally) called the physi-
Vol. 52, No. 9, November 1976
1114
K. G. JOHNSON
cian-manager program-has been set up for the training of internists and pediatricians in primary care. The ultimate success of any program in primary care, however, depends on the attractiveness of the program to young men and women and the willingness of medical educators to accept that primary care is a peer to other medical disciplines. The federal government should offer special assistance for the training of primary physicians as well as incentives for physicians to go where they are needed. Further, diminishing federal support for the training of subspecialists whose numbers need thinning is pro bono. Even as an advocate of primary care, I interpret, as a new and unwelcome federal regulation of medical education, legislation which links general support for medical education, e.g., capitation grants, to the proviso that a school be coerced into teaching primary care. The odds are great that primary care will emerge as a farce under such coercion. However, I would be less than honest if I did not ascribe to federal threats a renewed interest in primary care in the medical school. Given proper support within the medical school, primary-care programs, divisions, units, or departments can emerge as the equals of other units in teaching, research, and service, and the primary-care practitioner will be accepted as equal to other specialists. Whether primary care proceeds in one institution under the banner of family practice or in another progresses within the traditional departments of medicine and pediatrics is not important, provided there is freedom for the discipline to develop with vitality and a capacity for innovation. The renaissance of primary care as major medicine must surface for a society in which a rational system of primary care remains elusive. REFERENCES 1. The Supply of Health Manpower-1970 3. Johnson, K. G. and Haughton, P. B. T.: Profiles and Projections to 1990. DHEW An outreach program for a rural medical Publication No. (HRA) 75-38. Washingschool. J. Med. Educ. 50:38-45, 1975. ton, D.C., Govt. Print. Off., 1975, p. 4. Taylor, J. M. and Johnson, K. G.: A 78. residency program in primary medical 2. McDermott, W.: General medical carecare: The physician as provider-manager. Identification and analysis of alternative J. Med. Educ. 48:654-60, 1973. approaches. Johns Hopkins Med. J. 135:292-321, 1974.
Bull. N. Y. Acad. Med.
