Editor's Note: This month, the journal features a group of articles that tell important stories about the significant impact of Title VII programs on generalist training and the generalist workforce in the United States. Dr. P. Preston Reynolds served as guest editor for these articles and wrote this month's column discussing them. I thank her for that and also for her extensive efforts in working with the authors and with Anne Farmakidis and her colleagues at the journal to develop and organize the articles so that they offer valuable insights about the legacy and potential of the Title VII Training in Primary Care Medicine and Dentistry program and the Title VII diversity programs. - —Steven L. Kanter, MD
Generalist medicine and dentistry have had their ups and downs over the past 30 years with the coming and going of health reform and managed care and the expansion and contraction of national programs launched by the Robert Wood Johnson Foundation and the Association of American Medical Colleges in its generalist physician initiatives. While much attention has been given to these efforts, little notice has been paid to the role of federal policy and the Title VII, Section 747 programs on the production of the nation's generalist clinician workforce. And yet, when carefully studying, for example, the history of the Title VII Training in Primary Care Medicine and Dentistry grant program, there is little doubt the impact has been significant on both professions. If for no other reason, from 1972 to 2008, this federal program poured nearly $3.9 billion (adjusted to 2008 dollars) into the health professions educational system for one explicit purpose: to produce well-trained family physicians, general internists, general pediatricians, physician assistants (PAs), and general dentists.
The Office of Management and Budget (OMB) evaluated Title VII by aggregating over 40 separate programs, all authorized under this one piece of legislation, and most with different goals and objectives, into one comprehensive assessment. In doing so, the OMB determined that the Title VII programs did not demonstrate specific outcomes and effectiveness. The OMB's methodology was challenged directly in late 2005 by the Advisory Committee on Training in Primary Care Medicine and Dentistry in its fifth report, Evaluating the Impact of Title VII Section 747 Programs.1 In their report, the advisory committee highlighted seven key objectives of the Section 747 training programs:
1. Improve the quality of education and training of the nation's primary care workforce.
2. Improve the capacity for education and training of the nation's primary care workforce, with special emphasis on individuals from disadvantaged backgrounds and underrepresented minorities.
3. Improve primary care education and training curricula.
4. Improve primary care faculty development.
5. Identify, develop, and disseminate primary care education and training innovations and best practices among programs, accrediting bodies, and other constituents.
6. Improve the preparation of faculty, residents, and students (or learners) to work with medically and dentally underserved populations and build linkages to communities.
7. Improve the diversity and number of primary care faculty and students (or learners), with special emphasis on individuals from disadvantaged backgrounds and underrepresented minorities.
Building on the advisory committee's report, the articles in this issue of Academic Medicine describe the significant success of the Title VII, Section 747 programs in achieving these seven objectives.
This theme issue is also intended to illustrate the impact of these grant programs on (1) the establishment and/or growth of the primary care medical disciplines of family medicine, general pediatrics, general internal medicine, and physician assistants, and on general dentistry, (2) residency and fellowship training in primary care, (3) training for the care of vulnerable populations, (4) educational innovation and ambulatory care, and (5) diversity in the medical and dental health professions. The theme issue is designed also to show how federal contracts, most often to national organizations, served as an effective strategy to stimulate change in medical education at all levels of training.
The disciplines most affected by the Training in Primary Care Medicine and Dentistry grant program have been family medicine, physician assistants, and general dentistry. In their article, Newton and Arndt argue effectively that Title VII funds “were instrumental in establishing family medicine in nearly all medical schools and in supporting the educational underpinnings of the field.” Within competitive academic health centers, these grants “helped enhance the social capital of the discipline” as it strove to prove its financial and academic viability among basic science and clinical departments. Additionally, it helped create the past and current leaders of family medicine, many of these individuals having been grantees during the 1970s, 1980s, and 1990s.
Cawley looks at how Title VII funding significantly shaped the curricula of the early PA training programs beginning with their origins in the 1970s into the 1990s, with nearly all programs emphasizing the knowledge and clinical skill base of primary care. The federal policy goal was to achieve greater productivity of generalist physicians who were declining in number with each decade. The strategy was training PAs who could work effectively with family physicians, general internists, and pediatricians, most often in office-based practices in urban and rural settings. The policy goals aligned well with an emerging profession keen to secure federal funds to help expand its infrastructure and curricular offerings. What is rarely appreciated is the impact PA training programs have had on diversifying the workforce of the health professions, since they are able to recruit minority and disadvantaged students directly from high school and college into college-level and masters-level training programs.
Similarly, Ng et al show that not only did Title VII directly result in more general dental residency programs, but these federal funds in more recent years helped diversify the dental profession and train more pediatric dentists. At the same time, these authors make a cogent argument that changes should be made in the Title VII, Section 747 program to allow dentistry to compete for training grants at the predoctoral (dental student) level in order to influence and shape dental school curricula to more explicitly teach skills in the care of disadvantaged and vulnerable populations.
The articles by Lipkin et al, Green et al, Voss et al, and Altshuler et al together illustrate how Title VII funding served as the cornerstone for the design of innovative residency programs and curricula that evolved as new priorities emerged for health professions training. Rarely can an author speak directly to the impact of 23 years of federal funding. The article by Lipkin et al, however, does just that, demonstrating not only how Title VII funds were instrumental in changing the institutional culture of New York University's Bellevue Hospital to embrace the positive value of continuity primary care to its patient population, but also how the general internal medicine primary care residency resulted in greater productivity and better patient outcomes and satisfaction, improved the quality of residency education beyond the primary care program, and contributed significantly to the future direction of graduate medical education nationally.
The more focused articles by Green et al, Voss et al, and Altshuler et al illustrate how Title VII's grant guidance—with the inclusion of cultural competency, quality improvement and patient safety, and genetics as areas of innovation—has moved residency training programs both locally and nationally to institute new curricula and evaluations that resulted in higher levels of competency in areas of national priority. What is remarkable is that the authors show how Title VII funding, when available over several cycles and in several different funding categories, could lead to more comprehensive and robust programs for residents as well as faculty and, thereby, contribute again to institutional change advocated by the Institute of Medicine and others.2–5
The impact of Title VII funding on generalist fellowship training and faculty development has been no less dramatic, as captured in the articles written by DeWitt and Cheng, Beck et al, Davis et al, and Glicken. While DeWitt and Cheng focus their analysis on pediatric fellowships and academic general pediatrics, the same story could be told for family medicine and general internal medicine. And just as Title VII funds, through contracts to professional organizations, brought together the generalist medical disciplines in collaborative and innovative faculty development initiatives (as illustrated in the article by Davis et al), these dollars similarly affected the physician assistant profession and its faculty (as captured by Glicken in her article on contracts to the Physician Assistant Education Association).
As I describe in my own article on the legislative history of federal funding for health professions training in medicine and dentistry, the third period of funding, from 1992 to the present, is characterized by Title VII's emphasis on training to care for vulnerable and disadvantaged populations. The article by Hedgecock and Steyer highlights how contracts to the American Medical Student Association acted synergistically with an organization's mission and goals to leverage greater change in medical schools for students and faculty across the country and to launch new collaborative initiatives between medicine and dentistry. The article by Shannon provides a more in-depth look at how Title VII funding under at least two major programs led to an institutional commitment to broad-based competency education and preparation of clinicians for Maine's rural communities.
The article by Beck et al on faculty development for care of vulnerable and disadvantaged populations addresses recommendations of the Advisory Committee on Training in Primary Care Medicine and Dentistry in its sixth report.6 It also signals a future direction for the program, if reauthorized as an essential element in America's safety net. My article on Title VII innovations in medical and dental education, and all of the other articles in this collection, reinforce the fact that all of the grantees, regardless of discipline or program, are meeting the objective of implementing curricula and evaluation strategies to improve clinicians' competence in the care of the poor, disadvantaged, and vulnerable.
This theme issue was titled originally “Federal Support for Primary Care Medicine and Dentistry: Is It Time for an Overhaul?” The facts are clear: generalists are leaving clinical practice, whereas specialists are staying; students are choosing careers as hospitalists, specialists, and proceduralists, not as generalists; and federal funds for health professions training in primary care medicine and dentistry have been cut, perhaps beyond recovery. And yet, at the same time, patients with primary care physicians have lower health care expenditures, and primary care is correlated with better health status, lower overall mortality, and longer life expectancy. Is it time for an overhaul? Or, instead, is it time to celebrate and recommit to reinvigorating and refunding the Title VII, Section 747 program at the necessary level to prepare the medical and dental professionals of the future to care for an increasingly diverse and sophisticated American public?
In closing, this issue on the history and impact of the Title VII, Section 747 health professions training programs could never have existed without the leadership of Senator Edward Kennedy. He has led every effort to reauthorize the legislation over the past 30-plus years, and to reshape the programs to meet current and future national health priorities. This issue is dedicated to him individually and also to all of the staff of the Health Resources and Services Administration who have remained committed to administering these funds with the highest degree of integrity and professionalism. The American public, and medical and dental educators dedicated to primary care, thank you.
P. Preston Reynolds, MD, PhD
Dr. Reynolds is professor of medicine, Division of General Medicine, Geriatrics, and Palliative Care, Department of Medicine, Center for Biomedical Ethics and Humanities, University of Virginia, Charlottesville, Virginia.