OCR Text |
Show frequently have a strong interest in and talent for writing. Primary care typically is little emphasized during medical school; in fact, several of the most prestigious medical schools in the country (Harvard, Yale, and Johns Hopkins) do not even have a department of family practice (Page, 1992a). To counter this trend, the AMA's Liaison Committee on Medical Education is considering a change from the current requirement that all medical students complete core clerkships in internal medicine, obstetrics-gynecology, pediatrics, psychiatry, and surgery to one which recommends these five fields plus family practice. Many ideas have been presented as possible solutions to the problems of medical training, and specifically how to encourage more future physicians to choose primary care. Primary care training programs are suffering from declining financial support. Costs of graduate medical education are paid primarily from patient care income, and thus funding available for any specific residency program is based on the income that residency can generate. Since reimbursement is the highest for inpatient, procedure-oriented care, surgery, and specialty care get the lion's share of the income, while outpatient-oriented, preventive-care focused family practice gets only a small portion of the funding (McKegney, 1989). This means that residency positions in family practice are disappearing at the same time that the government is trying to encourage more residents to choose family practice as a career. At the same time that the number of primary care residency positions is declining, the number of applicants is also declining. From 1982 to 1987, the percentage of medical students choosing family medicine declined by 5%, those choosing general internal medicine declined by 40%, and those choosing general pediatrics declined by 8% (Colwill, 1988). Even at the point of entry into medical school, when the maximum number of students would be expected to express a preference for primary care, 37% selected family medicine as their preferred field in 1978, but only 16% chose it in 1987 (based on MCAT data). And of those selecting family medicine on entry to medical school, 75% changed to another specialty prior to graduation (Colwill, 1988). Colwill (1988) suggests that to remedy this situation, students should be selected for medical school based on characteristics which are associated with selection of primary care: "people-oriented", social concern, demonstrated intellectual interests outside of science, and a preexisting interest in primary care. He also recommends providing primary care role models during medical training, and providing a community-oriented primary care experience rather than the exclusively tertiary-care subspecialists that most medical schools provide. His final recommendation is to offer monetary rewards for choosing primary care, such as debt forgiveness and modification of the reimbursement system to provide more payment for cognitive functions. In contrast to these "carrot" incentives for choosing primary care, one lawmaker proposes using the "stick" approach instead. A Kansas legislator has sponsored a bill requiring the University of Kansas School of Medicine to increase the proportion of its graduates who choose primary care by 5% per year to a goal of 60%. Failure to achieve the goal would result in a 10% decrease in funding (Page, 1992c). Several programs have been developed with the specific goal of providing more rural primary care physicians (Bloom, Vatavuk, & Kalaszewski, 1988; Gessert, Blossom, Sommers, Canfield, & Jones, 1989; Houser, 1971; Williams, 1990). These typically involve selection of candidates who express interest in rural primary care or have family ties to rural areas, thus increasing the likelihood that they will choose to go to rural areas after graduation. They are given the opportunity to work in ambulatory and inpatient settings in rural areas throughout their training. Many of the programs are integrated pre-med/medical school/ Utah's Health: An Annual Review 1993 99 |