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Training Residents for a New System of Primary Care

Dow, Alan MD, MSHA; Li, Su-Ting T. MD, MPH; Srinivasan, Malathi MD

doi: 10.1097/ACM.0000000000000476
Responses to the 2014 Question of the Year
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Dr. Dow is associate professor of medicine and assistant vice president of health sciences for interprofessional education and collaborative care, Virginia Commonwealth University, Richmond, Virginia.

Dr. Li is associate professor, program director, and vice chair of pediatrics, University of California Davis School of Medicine, Sacramento, California.

Dr. Srinivasan is associate professor of medicine and director of practice based learning and improvement, University of California Davis School of Medicine, Sacramento, California.

Funding/Support: Dr. Dow is funded by the Department of Health and Human Services (HHS), the Health Resources and Services Administration (UD7HP26044), and the Donald W. Reynolds Foundation. The contents of this essay are solely the responsibility of the authors and do not necessarily represent official views of HHS or the Donald W. Reynolds Foundation.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Dr. Dow, PO Box 980102, 1301 E. Marshall St., Richmond, VA 23298-0102; telephone: (804) 828-0180; e-mail: awdow@vcu.edu.

The days of traditional primary care are over.

In the old system of care, primary care physicians were the Jacks (and Jills) of all trades. They managed chronic disease, provided urgent care, and ensured preventive care. Over the past several decades, society has changed. While the population has aged, the physician workforce has not grown proportionally, and costs have risen. Meanwhile, nonphysician providers, guided by sound algorithms, have been shown to deliver straightforward chronic disease management and urgent care that is similar or better in quality and cost than that provided by physicians.1 Time-limited physician outpatient visits are now dominated by pressing acute care issues that overshadow preventive care. Facing increasing demands and decreasing payment, a new system of primary care is emerging, one grounded in interprofessional practice and population management. How, then, should the physician workforce adapt to provide primary care to an aging, ailing, and expanding population in this new system?

One possibility is that physicians could refocus their efforts on providing outpatient care to only the most medically complex individuals. Across many populations, a small percentage of patients with multiple, interacting diseases drive health care costs.2 These individuals require the expertise of physicians for complex decision making. Physicians, thinking beyond condition-specific treatment algorithms, tailor care to the unique needs of patients and families and then, through coordination with an interprofessional team, optimize health and provide cost-effective care.

Yet, focusing physicians’ efforts on this population segment alone is shortsighted. Concentrating on patients already afflicted with a significant disease burden removes physicians from the important work of preventing or mitigating chronic disease progression. Physicians, as the most trained members of the health care workforce, are critical to creating and studying systems of care that avert disease development and progression. In addition, this model disrupts continuity of care, an important aspect to improve the quality of and satisfaction with primary care.3

The alternative is to train physicians with the expertise in interprofessional practice and population management to engage in this new system, a system in which all professionals practice at the top of their license. How, then, should graduate medical education (GME) prepare residents for this new role? We offer four principles to guide training in this transforming primary care environment.

1. Physician training in primary care should focus on population management rather than panel size.

  • Residents should have responsibility for a population larger than current ambulatory panels.
  • Residents should work with an interprofessional team to provide care across this population.
  • Residents should be responsible for the outcomes of the population.
  • Health systems and training programs should provide support, such as team members from other health professions, that allows residents to work at the top of their expertise and license.

2. Primary care training should include competency in leadership and collaboration.

  • While residents should be responsible for population outcomes, they also should learn that shared leadership is critical to reach optimal results.
  • Residents should be taught how to lead, to collaborate, to supervise, and to delegate.
  • Residents should be taught population health management principles, including financial analysis, community health, and advocacy.
  • Training should be graduated with appropriate milestones.

3. Competency in primary care should be judged by the outcomes of the population and the contributions of the resident to improving population health.

  • Metrics of team effectiveness should include patient, population, supervisory, and system quality outcomes. Many of these metrics are currently being tracked but not fed back to residents.
  • Deficiencies should result in resident-led quality improvement efforts, framing learning around implementation science and change management.

4. Funding for GME should be tied to team effectiveness.

  • Aligning GME funding with current incentive-based system goals will improve quality and prepare residents to be paid based on outcomes or by an accountable care organization.
  • Gains in quality might justify the premium paid for resident-led care as part of indirect medical education funding.4

Faced with a new system of care, physicians could become increasingly specialized and distant from the community at large. The leadership void for population health then would be filled by others, perhaps insurers and administrators, perpetuating our current plight—short-term cost savings leading to greater long-term expenses with multiplying undiagnosed and undertreated chronic diseases. This future is untenable for our profession and our society.

Alternatively, physicians can lead the emergence of a new model for primary care. By understanding populations and working with an interprofessional team, physicians can target the appropriate care to each patient and family. Through restructuring GME, we can reorient primary care training towards the interprofessional, population-focused approach needed to produce the primary care leaders of the future.

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References

1. Laurant M, Harmsen M, Wollersheim H, Grol R, Faber M, Sibbald B. The impact of nonphysician clinicians: do they improve the quality and cost-effectiveness of health care services? Med Care Res Rev. 2009;66(6 Suppl):36S–89S
2. Dow AW, Bohannon A, Garland S, Mazmanian PE, Retchin SM. The effects of expanding primary care access for the uninsured: implications for the health care workforce under health reform. Acad Med. 2013;88:1855–1861
3. Wasson JH, Sauvigne AE, Mogielnicki RP, Frey WG, Sox CH, Gaudette C, et al. Continuity of outpatient medical care in elderly men. A randomized trial. JAMA. 1984;252:2413–2417
4. Rich EC, Liebow M, Srinivasan M, Parish D, Wolliscroft JO, Fein O, et al. Medicare financing of graduate medical education. J Gen Intern Med. 2002;17:283–292
© 2014 by the Association of American Medical Colleges