The future of primary care

The New England Journal published a sounding board piece on the future of primary care in the United States. The authors suggest that one paradoxical reason is the increased exposure to primary care in residency training:

But an additional possibility, albeit an apparently paradoxical one, is that the decline is due in part to the successful efforts by medical schools to increase students’ exposure to primary care practice. How can this be? And if it is true, what might be done about it?

To understand this dynamic, it is important to recognize what students observe about primary care practice during medical school. In most schools, students spend some time during their first two years in the offices of community-based primary care practitioners, where they observe the reality of this type of practice and gain insight into the challenge of caring for patients with a wide range of conditions, including serious chronic diseases. . .

However, during the actual medicine clerkship, the majority of training is spent on an inpatient venue – essentially what students are seeing is the failure of outpatient medicine:

During these clerkships, they once again observe patients with chronic diseases, many of whom have been hospitalized because of inadequate or inappropriate treatment of their underlying diseases. And although students may see how the episodic conditions that precipitate hospitalization are managed, they cannot help but notice how little attention the attending physicians and residents devote to considering how hospitalization might have been avoided through better outpatient management.

It is this constant exposure to “outpatient failures” that causes hesitation to a career in primary care:

As a consequence, we believe that the clerkships discourage many students from pursuing residency training in a primary care specialty, because they are concerned that they will not be adequately prepared to meet the responsibilities of such a practice.

This is certainly a valid point. It has taken me the greater part of two years to comfortably make the transition from residency to primary care. To this day, I continue to feel more comfortable taking care of an acute MI than I do a rash.

Solutions? The authors suggest redesigning primary care residency programs to further focus on the skills needed for ambulatory care – and not treat it like an afterthought. The alternative is a grim scenario:

Unless these changes are made — and made soon — the practice of primary care medicine seems destined to become the province of nurses and other nonphysician health care professionals.

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