“Can the disciplines of family practice, general internal medicine, and general pediatrics work cooperatively rather than competitively in an academic setting?” Facing the prospect of primary care integration, a family practice department chair posted this question on a listserv of department chairs in family practice. The dominant sentiment was negative: “Been there, done that, doesn't work!” The cultures of these specialties and the departmental relationships in medical schools seem to work against cooperation.
Yet the competitive health care marketplace is moving toward functional multispecialty groups. A divisive group of physicians is ill suited to compete successfully with other clinical systems, and they are likely to miss opportunities for productive collaboration in education and research. In short, integration may be the most important strategy for the primary care disciplines today.
Interdisciplinary collaboration in academic generalism is not a new concept. For decades, educators have recommended integrating primary care teaching, research, and clinical practice.1,2 On one end of the spectrum, some authors have advocated for primary care disciplines to merge into a single comprehensive specialty.3,4 Others have proposed less complete forms of integration, such as multidisciplinary generalist curricula in certain courses or rotations,5,6 a perspective reflected in the joint statement on collaborative generalist training issued by the American Boards of Internal Medicine and Family Practice in 1995.7
The literature on interspecialty integration documents formidable challenges.8–10 These include traditional medical hierarchies, poor communication, lack of knowledge about other specialties, economic barriers, and lack of trust in the collaborative process itself. As Reynolds and colleagues10 state, interdisciplinary collaboration requires unique efforts; it does not occur automatically within multidisciplinary groups, but necessitates working together to achieve both mutual and individual goals, maximizing the participation of all involved. Wartman et al.11 learned this lesson in undertaking the national Interdisciplinary Generalist Curriculum (IGC) Project at ten U.S. medical schools. Collaboration on this project was time consuming and required meticulous communication and goal setting, even when broad-based institutional support was present.
Yet when interdisciplinary collaboration succeeds, the literature suggests it can yield tremendous benefits for all involved, including increased clinical efficiency,12 better training for primary care learners,13 and the enhanced research productivity that appears to be linked with strong professional networks.14
In this article we describe a medical school environment where the department family practice and the divisions of general internal medicine and general pediatrics cooperate extensively in education, research, and patient care. This cooperation did not happen overnight; rather, it evolved gradually over many years. No change was made to the academic structure; all three disciplines remain in separate departments. However, cooperation in the primary care education of medical students and residents, a unified health policy research unit, and a unified primary care medical group reflect the depth of cooperation and integration. Recently, the university recruited an associate dean for primary care (JES) to reinforce this integration and to represent primary care in the governing structure of the medical school. We now use the title the University of California Irvine Primary Care Coalition to reflect and promote this interspecialty cooperation.
The Primary Care Coalition is not intended to be a step in the direction of a generic primary care specialty.3,4 Special identities and departmental structures have been preserved. However, we believe primary care is strengthened through both our diversity and our cooperation. Also, in working cooperatively, we are able to share educational resources, the research infrastructure, and clinical systems, thus avoiding duplicative use of valuable resources.
How and why did this cooperation among primary care disciplines come about at the University of California, Irvine (UCI)? It was not mandated from on high, nor was it forced by any departmental changes. It may reflect the particular attitudes and styles of the leaders in the three primary care specialties. Below, we describe the three major areas in which the specialties collaborate—education, research, and patient care—and how this collaboration was initiated, in the hope that our experiences will be helpful to colleagues in other institutions.
THREE AREAS OF COLLABORATION
Education
The cooperative effort in medical education grew from a knowledge of our strengths and a frank assessment of our weaknesses. As in the other two areas of cooperation, in education we were driven by the dual recognition that individually we had much to offer and collectively we had much to gain. This knowledge did not come as an epiphany; rather, it came gradually as a result of early efforts to work together.
The efforts of the senior associate dean for educational affairs to create a multidisciplinary, multiyear course on doctoring skills served as an initial stimulus for cooperation. This course spans all four years of the medical curriculum. The second-year component is the largest course in that year, including nearly 300 contact hours. It covers physical diagnosis and communication skills as well as such content areas as epidemiology, informatics, nutrition, human sexuality, medical economics, and ethics; it depends heavily on standardized patients for both instruction and evaluation. Obviously, no single department could run this curriculum independently. In the process of learning to work together to develop and teach this course, the primary care faculty discovered previously unrecognized advantages to bringing their collective skills to bear on curriculum development, course administration, evaluation, research, and clinical teaching.
The physical diagnosis component of the second-year course illustrates the benefits of this cooperative approach. Previously, this training had been led by internal medicine faculty and had been hospital based. With the advent of our cooperative approach, we began to bring patients with specific organ-system findings into our learning center as a programmed means of focused teaching. We invited family medicine and internal medicine faculty to train together as preceptors. Through faculty development and teaching together, the preceptors came to see themselves as a group of primary care physicians committed to teaching physical diagnosis. We developed curricula and core knowledge in subject areas that were independent of our own specialties. Students have given high ratings to the physical-diagnosis preceptors regardless of specialty, and they have done well on standardized tests of their skills. This same opportunity for shared expertise came through implementing faculty task forces to develop integrated, longitudinal curricula in medical economics, communication skills, evidence-based medicine, geriatrics, and palliative care.
Our experiences with medical students brought us to the realization that we might fruitfully work together to develop residency curricula. Certainly, the residency review committees' requirements for the individual primary care disciplines contain considerable overlap in such content areas as cross-cultural medicine, medical economics, medical informatics, evidence-based medicine, managed care education, and communication skills. In the past, each program's faculty felt responsible for developing their own curriculum for each of these areas, requiring considerable resources and expertise that was not always available in all programs.
We were convinced that we could achieve our independent goals and maximize our limited resources by working cooperatively together. We found that some of the residency programs already had considerable expertise in unique areas that complemented that of other programs. We divided up the tasks and shared the products. As we worked together we had to make certain compromises in program structures. We needed to make sure that what one program developed, another could import. We also needed to ensure that the necessary audiovisual and computer resources were available to all programs. To a certain extent, we had to share budgets. But the experience of working together has made cooperation and interdependence preferable to going on our own.
Our communication skills course for primary care residents is an excellent example of the way in which collaboration can work. We adopted a training method in communication skills based upon the methods of the Bayer Institute for Health Care Communication. This approach requires trained faculty facilitators from family medicine, internal medicine, and pediatrics. When we present the course, we integrate residents from each of these disciplines and make the training available to all residency programs, including the surgical specialties. Residents and faculty are thereby encouraged to develop collegial working relationships and a larger pool of facilitators is made available.
Cooperation in educational affairs cannot be mandated. Faculty must see the advantage of working together. At UCI, we had to overcome our own particular departmental orientations and our traditional biases about what certain disciplines could or could not do. Broad curricula with interdisciplinary objectives provide an ideal environment for collegial growth and learning. Eventually, it becomes obvious that working together not only makes sense educationally, but also saves crucial amounts of time and resources. Cooperation also serves as a model of professionalism for our students as they prepare to work in practice environments that emphasize teamwork.
Research
Research collaboration among the primary care disciplines began at UCI in 1991 with a proposal to establish a health policy research center. At that time, relatively few faculty members in general internal medicine, general pediatrics, and family medicine conducted research. This was not surprising, since UCI fostered these disciplines to meet the need for better primary care teaching and patient care, not to address research issues. Therefore, those faculty members who were involved in research faced several obstacles to competing in the larger research arena. Two problems were particularly evident: first, the lack of an effective research infrastructure within these disciplines, and, second, limited opportunities for collaboration with investigators from other fields. The latter issue was of particular concern, because the focus of most of the research-oriented faculty was health policy research, an area in which multidisciplinary collaboration is particularly important.
To overcome these barriers, several faculty members from the primary care disciplines, along with additional investigators from the social sciences and health economics, developed a proposal for a multidisciplinary research unit that would focus on health policy issues. The unit would provide an infrastructure for collaborative research, including space and administrative staff with expertise in contract and grant development and administration. The proposal included a request for only a limited amount of funding, with the expectation that most resources would come from extramural sources. Because several of the proposal's authors had large federally funded grants at the time, this did not seem to be a false hope.
In 1993, after extensive evaluation by the appropriate deans, the Committee on Research, the vice chancellor for research, and an extramural advisory committee, the Irvine Research Unit in Health Policy and Research (HPR) became officially established at UCI. Initially, the unit included a director (FAH), eight faculty members, and a small administrative staff. The faculty members were from the College of Medicine, the School of Social Ecology, the School of Social Sciences, and the Graduate School of Management.
As HPR gained a reputation for its work in health policy research, additional faculty members joined the unit. In 1999, HPR had 21 members—the majority of whom were from the primary care disciplines of the College of Medicine. Their areas of expertise included anthropology, biostatistics, community health, epidemiology, family medicine, general internal medicine, geriatrics, marketing, medical economics, medical education, medical ethics, sociology, pediatrics, and public health. Interaction among the members has resulted in numerous innovative multidisciplinary research projects that have received funding from federal, state, and local agencies.
The HPR unit has also provided an educational environment for undergraduate and graduate students to learn how to conduct health policy research. Once exposed to the research environment, many of the students have chosen to participate in other projects in the unit. Most of the students are enrolled in the School of Social Ecology, the School of Social Sciences, or the Graduate School of Management. However, some of our medical students and residents have also found the time to participate in HPR research programs.
The HPR unit fosters research on a variety of health policy issues. Initially, most of the research addressed problems that affect medically disadvantaged populations, including the poor, minorities, children, and the elderly. For example, the research program in pediatric injury prevention and control has addressed the epidemiology and prevention of childhood injuries, with particular emphasis on Latino children. The research findings have led to changes in laws regarding the use of seat belts and riding in the beds of pickup trucks. Another example is the program in cancer prevention and control. Faculty members have worked together on a variety of studies aimed at identifying and addressing the cancer-control needs of Latinos, Asian Americans, Native Americans, and American Samoans in Southern California and evaluating culturally sensitive programs to improve cancer prevention in these special populations. As HPR has evolved it has developed research programs in other important health policy arenas, such as health care delivery systems, the cost of medical care, and medical education.
The challenges associated with running a multidisciplinary research unit such as HPR are complex. Funding depends largely on extramural support and consequently the number of administrative staff varies according to funding levels. In addition, collaboration among faculty members from different disciplines doesn't always go smoothly. Furthermore, space requirements sometimes exceed the unit's capacity to provide an adequate working environment for everyone.
Despite these challenges, HPR has been a success by most measures. It has provided a research infrastructure and has facilitated collaboration among health policy researchers. Moreover, it has led to increases in both the number of primary care physicians involved in research and the number of funded projects. These successes could not have been accomplished without collaboration among the primary care disciplines of the College of Medicine.
Patient Care
The process of organizing and managing a faculty medical practice offers an ideal opportunity for fostering cooperation and improving integration among academic primary care faculty, as leaders in other health systems have found.15 The highly competitive Southern California health care market provided UCI's departments of family medicine, internal medicine, and pediatrics with the impetus to develop an innovative interdisciplinary practice organization, the UCI Primary Care Medical Group (PCMG). This organization has allowed UCI (1) to compete more effectively with local medical groups; (2) to expand its pool of clinician—educators; and (3) to elevate the stature of the primary care disciplines within the larger UCI Health System and College of Medicine.
Before the mid-1980s, UCI's primary care faculty practices were organized along traditional departmental lines. The small faculties of family medicine, general internal medicine, and general pediatrics devoted less than 20% of their individual and collective efforts to patient care. Because clinical faculty practiced at what had formerly been the county hospital, the majority of their patients were either underinsured or uninsured and were cared for in the medical center's multispecialty and community teaching clinics.
In order to attract commercially insured patients to UCI, all clinical departments were encouraged to expand their faculty practice commitment and to recruit more clinically oriented faculty. To support the growth of its primary care patient base, the university entered into its first fully capitated managed care contract in 1984 with the enrollment of some 800 university employees. One of us (RWC) was chosen as the medical director of the faculty practice's managed care component, and he quickly became aware of the shortcomings of our departmentally structured primary care practice. These included an inadequate number of faculty clinicians, a lack of adequate incentives, a low valuation of patient care relative to education and research, an insufficient practice infrastructure, and the physicians' lack of practice-management expertise. Patients were not satisfied with many aspects of the existing practice structure and functioning. They expressed dissatisfaction with physician availability, urgent care access, phone and messaging systems, confusing billing systems, and cumbersome utilization-review procedures. Many faculty, particularly those with strong clinical orientations, were unhappy with the practice environment, and several key faculty had resigned out of frustration.
In 1985, we initiated a series of informal meetings of internists and family physicians in an attempt to improve relationships among primary care colleagues who had previously had littel interaction and to identify areas of mutual concern. A joint utilization committee began to meet. This committee included key clinical leaders of both departments and it served as the main forum for fostering cooperative problem solving. In 1986, a leading family physician was selected as the assistant medical director, further strengthening the developing trust among the two disciplines.
Although this informal working relationship did improve some aspects of the practice environment and infrastructure for primary care faculty, many problems persisted. Lack of an integrated practice organization hampered our ability to address key issues: capitation, faculty recruitment, practice staffing, and physician availability and scheduling. Our resulting inability to negotiate with the hospital and the dean's office placed the primary care disciplines at a significant disadvantage in competing with specialty colleagues for resources. Instead, we found ourselves competing, usually ineffectively, against one another for the investments we felt were necessary to develop our departmentally based primary care practices.
In searching for a more effective primary care delivery system for UCI, we began to look to the larger community, where managed care had fostered the development of several large primary and multispecialty group practices. With the support of the chairs of both family medicine and internal medicine, we created an extradepartmental practice organization to take responsibility for managing the faculty medical practice of the two primary care departments. With support of the dean and the hospital director, we hired a practice-management consultant, and a subcommittee of general internists and family physicians worked for four months to create a practice model and business plan. Ultimately, the plan was endorsed by the key leadership of the university and the PCMG began operation in 1992.
Key elements of the new practice organization included:
- The designation and empowerment of a PCMG president to be responsible for overseeing all aspects of primary care faculty practice
- The establishment of PCMG as a separate business unit reporting to the dean of the College of Medicine
- The creation of a PCMG governing board consisting of key leaders from the primary care departments, the medical center, and the health system
- Joint faculty recruitment by the PCMG and the academic departments, with salary support provided by the individual entities proportional to their clinical and academic responsibilities
- The development of an equitable incentive-based compensation system applied uniformly across all participating primary care departments
- The creation of a practice management subcommittee consisting of practice medical directors and key medical center personnel as a forum to improve practice infrastructure
- The implementation of a regular set of practice-site meetings and membership forums to ensure open communication, solidify group identity, and direct team building
- Commitment by each member of the PCMG to a minimum of 10% time to their departmental teaching responsibilities
Our experience with the integrated primary care group practice has been very favorable. Our number of capitated patients has grown to nearly 35,000 enrollees, of whom 13,000 are commercially insured; the remainder are part of the capitated Medicaid program. In addition, we have attracted many other patients with Medicare and private insurance. Patient satisfaction has improved dramatically, and our practice infrastructure has greatly improved. The group has been able to recruit and retain exceptionally trained clinician educators and currently has over 50 full- and part-time clinicians, including three nurse practitioners. The general pediatrics faculty joined the group in 1996, further strengthening the ability of the PCMG to negotiate with the medical center and health system. Two new ambulatory care sites have been added, while older sites have benefited from major remodeling and facelifts. The PCMG has also been able to secure improved support for faculty involved in supervising residents and students at all of our university teaching clinics.
In spite of these successes, the UCI PCMG is confronted by a number of ongoing challenges. These include:
- Dependence upon the medical center and health system to cover the regular budgetary shortfalls that result from low capitation allocation and a high proportion of indigent patients.
- Attraction of the sickest and most costly capitated patients to our specialists; many of these patients are then transferred into our primary care group. This results in the group's treating a disproportionate share of high-acuity capitated patients, which in turn exposes the group to losses on capitated contracts.
- Faculty providers' relatively high use of technology and high-cost drugs in patient care, resulting in utilization rates that exceed capitated budgetary allowances.
- Low faculty productivity compared with community-based counterparts. Because the group receives health system budgetary support, the productivity of its clinical faculty is under close scrutiny, and changes in the compensation plan are being considered to help address this concern.
- Educational needs competing with clinical time. The college and departments are continually soliciting the PCMG faculty to expand their involvement in student and resident educational activities. Although rewarding for the clinical faculty, these activities do not generate professional fees and may adversely affect patient access and satisfaction. The PCMG struggles constantly to ensure an appropriate balance of academic and patient care activities.
In spite of these problems, we believe the UCI model of integrated faculty practice has been extraordinarily successful. Despite changes in leadership in the dean's office and new department chairs, this integrated practice model continues to receive support throughout the institution. In fact, the cooperation and integration of UCI's primary care physicians has become a model for interdisciplinary practice development in both medical and surgical areas at UCI.
CONCLUSION
At the University of California, Irvine, cooperative efforts among primary care departments in education, research, and patient care began separately but simultaneously. We believe there are two reasons for their linked successes. First, all three disciplines were in strong but not dominating departments. If one department had been dominant, then that department would have had little reason to cooperate and integrate with the others. Second, all three primary care disciplines benefited by cooperating in all three spheres; in other words, we all had something to gain. Since each department had its own strengths and corresponding interests, and since each department was willing to share what it had, we were all able to see that cooperation would ultimately strengthen each discipline. The integrated activities of the office of medical education, the health policy research unit, and the primary care medical group all grew out of that cooperative spirit.
Every medical school has its own history and balance of power among departments. In today's environment of decreasing academic resources and managed competition among organized clinical delivery systems, survival and ultimate success require interdisciplinary cooperation and, is possible, integration. We hope that our positive experience serves as an incentive for other medical schools to move toward greater cooperation among the primary care disciplines.
