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Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings (1989)

Chapter: Appendix A: Workshop Program and Proceedings

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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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Suggested Citation:"Appendix A: Workshop Program and Proceedings." Institute of Medicine. 1989. Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings. Washington, DC: The National Academies Press. doi: 10.17226/1487.
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APPENDIX A PROGRAM AND PROCEEDINGS OF A WORKSHOP Held By The Committee to Study Strategies for Supporting Graduate Medical Education for Primary Care Physicians In Ambulatory Settings Institute of Medicine April 17 and is, 1989 65

PROGRAM April 17, 1988 S:30 am WELCOME AND INTRODUCTION Samuel 0. Thier, M.D., President, Institute of Medicine Daniel D. Federman, M.D., Chairman, Committee to Study Strategies for Supporting Graduate Medical Education in Primary Care 9:00 am CHARACTERISTICS OF PRIMARY CARE GRADUATE MEDICAL EDUCATION IN THE AMBULATORY SETTING Evan Charney, M.D., Professor & Chairman, Department of - Pediatrics, University of Massachusetts Medical School Jack M. ColwitI, M.D., Professor & Chairman, Department of Family & Community Medicine, University of Missouri-Columbia Jordan Cohen, M.D., President APDIM, Dean, School of Medicine, SUNY at Stony Brook Fred Tinning, Ph.D., President, Kirksville College of Osteopathic Medicine & Chairman, Board of Governors, Association of Colleges of Osteopathic Medicine Moderator: Richard E. Rieselbach, M.D., Associate Dean, University of Wisconsin Medical School 10:30 am COST AND REVENUES FOR GRADUATE MEDICAL EDUCATION Judith R. Lave' Ph.D., Professor of Health Economics, Universitr of Pittsburgh Ruth S. Hanft, M.A, Research Professor and Health Policy Consultant, George Washington University Robert Derzon, M.B.A., Lewin/ICF, Inc. Moderator: Sheldon S. King, President, Stanford University Hospital 66

11:30 am LESSONS FROM PROGRAM DIRECTORS Larry ~ Green, M.D., Professor & Chairman, Department of Family Medicine, University of Colorado Health Sciences Center doe! A. Alpert, M.D., Professor & Chairman, Department of Pediatrics, Boston University School of Medicine, Chief of Pediatrics, Boston City Hospital Steven ~ Wartman, M.D., Ph.D., Director of the Division of General Internal Medicine, Brown University Moderator: Henry W. Foster, cr., M.D., Professor and Chairman, Department of Obstetrics & Gynecology, Meharry Medical College 2:00 pm ALLOCATION OF RESOURCES AT THE INSTITUTIONAL LEVEL Sheldon S. King, President, Stanford University Hospital Norman G. Levinsky, M.D., Professor & Chairman, Department of Medicine, Boston University Medical School John d. Collins, cr., M.D., Vice President for Professional and Physician Services, Mercy Health Services Harry N. Beaty, M.D., Dean, Northwestern Medical School Moderator: Daniel D. Federman, M.D., Dean for Students and Alumni Professor of Medicine, Harvard Medical School 3:00 pm BREAK 3:30 pm POLICY OPTIONS Sandra C. Peinado, M.D., Fellow, General Internal Medicine, University of Pennsylvania John Eisenberg, M.D., M.B.A, So] Katz Professor of General Internal Medicine, University of Pennsylvania Moderator: Daniel D. Federman, M.D., Dean for Students and Alumni Professor of Medicine Harvard Medical School 5:00 pm ADJOURN 67

April 18, 1989 8:30 am POLICY OPTIONS, Continued Peter Bouxsein, d.D., House Subcommittee on Health and the Environment John K. Ki~redge, Former Executive Vice President, The Prudential Insurance Company of America C. Ross Anthony, Ph.D., Associate Administrator for Program Development, Health Care Financing Administration Arthur M. Fournier, M.D., Associate Dean for Community Health Affairs, University of Miami Medical School 12:00 pm ADJOURN 68

Introduction _ 1_ ~ 1 ~:1 ~1 There is a growing consensus that changes in the way in which health services are provided require that residency programs for primary care physicians increase their emphasis on ambulatory care experiences in order to prepare physicians for the real world of primary care practice. There is also a growing sense that new strategies are needed to enable these programs to overcome the financial disadvantage at which they operate, compared with other medical specialties. The Institute of Medicine, with support from the Josiah Macy Jr. Foundation and the Health Resources and Services and Administration of the Department of Health and Human Services, appointed a committee to plan a workshop and recommend strategies for surmounting the fiscal constraints that bind primary care training programs. By bringing together experts from primary care education and practice, health care institutions, federal agencies, insurance and health care financing and others, the workshop was to be both a useful event for the participants and provide the basis for the committee's deliberations. The workshop was held in Washington, D.C., April, 1988. Summaries of presentations and discussion at the workshop follow. 69

CHARACTERISTICS OF PRIMARY CARE GRADUATE MEDICAL EDUCATION IN THE AMBULATORY CARE SETTING Primary Care Residency Training in Pediatrics: Current Status, Current Issues, Suggested Solutions Evan Charney, M.D. Professor and Chairman Department of Pediatrics University of Massachusetts Medical School Demographics of Pediatric Training and Practice There are currently 230 fully approved three-year pediatric residency programs in the United States with just over 6,000 residents in training. Approximately half of these programs are in University hospitals and half in community hospital settings (with varying degrees of university affiliation). Of the 35,000 pediatricians in the United States (physicians who limit their practice to children and adolescents) 80 per cent are in off~ce-based primary care practice; one-fifth of those physicians devote a portion of their time to subspecialty as well as general pediatrics. Fifteen per cent of pediatricians are in full-time subspecialty practice and, except for the age specific areas of neonatology and adolescent medicine, are in areas comparable to internal medicine (e.g. organ system specialties, infectious disease, immunology). The remaining five per cent of pediatricians are in public health and administrative positions. The Setting of Residency Training The hospital setting in which pediatric residency is based presents certain problems for primary care education: On hospital inpatient services, children have illnesses more complex and more severe than in the past. Attending physicians are increasingly specialized, and children are often segregated by disease category to more efficiently pronde that care (separate intensive care units for neonates and older children with full-time attending supervision, inpatient units divided by subspecialties, emergency departments staffed by specialists rather than generalists). The technology appropriate to such care becomes correspondingly more complex as well. Moreover, the 70

shortened inpatient length of stay further reduces the time available to absorb (much less metabolize) the available learning. 2. Patients in most general pediatric clinics are disproportionately drawn from poor or socially disorganized families. Those children cared for in the emergency department tend to have more acute problems than do most patients in practice, and usually are unknown to the physician providing care. Those in subspecialty clinics have more complex or unusual conditions. In fact the management sale with patients with the same clinical condition often varies between office practice and hospital practice. For example, the emergency department physician commonly orders far more extensive laboratory investigation for a well-appearing but febrile one year old than does the office-based physician who knows the child and family. While each st3rIe is probably appropriate to its own setting, trainees may get mixed messages about what is optimal or correct. 3. The community-based practitioner is less visible (perhaps less welcome) within the hospital and emergency service than in the past. The average practicing pediatrician hospitalizes fewer children now and, therefore, spend less time in the hospital, except for full-term newborn care. As a result, when a child is hospitalized, pediatricians are less able to direct that care without consultant help than they were ten or twenty years ago. The common denominator of these changes is that in 1989 the average pediatric resident is less likely to observe the average primary clinician functioning knowledgeably and comfortably in the hospital setting than was true in the past. Medical Education as an Apprenticeship Model Graduate medical education is based on an apprenticeship model, as opposed to the classroom/seminar approach typical of law and engineering schools, for example. The core philosophy of this education is to expose trainees to appropriate patients, in appropriate settings, taught by role-model faculty. This has worked well, by and large, for the trainee who will go on to become a consultant pediatrician, and appears to provide a reasonable foundation for further subspecialty training. I believe it has worked less well for general pediatric education for the reasons stated above. While general or ambulatory pediatric divisions have been established within 71

most teaching programs, The problems of a hospital environment remain. As noted, the patients in hospital ambulatory settings are often poor, with complex social and psychological problems that would tax the most skilled practitioner. Moreover, the "continuity practice" they are enrolled in is an artificial construct, an educational device that has little resemblance to most practice settings. In contrast, we do not place residents in artificial intensive care or emergency room settings for their education and expect that they will learn principles to apply later in ''real' practice: we place them in functional care systems practicing alongside skilled clinicians. The point here is that primary care practice within the hospital may not resemble community-based primary care practice either in setting' patient mix, or facula. The Residency Review Committee The Special Requirements for pediatric residency programs have been modified (revised in 1985 and 1990) with the goal of making standards more explicit and more stringent in several areas. Primary care training must now include one half- day per week in a continuity practice in all three years of training, a more clearly defined experience in child development, behavior and adolescent medicine, and a minimum of six months in general ambulatory settings. With the added continuity clinic time the mandated minimum general ambulatory time now comprises 27 per cent of the three-year residency. However, other changes in the Special Requirements will have an impact on general pediatric training; there is an explicit requirement for more subspecialty faculty available at the parent institution, and the hospital inpatient setting is more clearly defined as a tertiary referral center for children with severe~and diverse illness. The result will be that smaller programs (with fewer subspecialists and less complex inpatient services) may have difficulty meeting standards, which will lead to an increase in the proportion of pediatric residents trained in large tertiary care hospitals. What will be the effect of these changes on primacy care education? Although it is not valid to assume that high quality primary care education is always characteristic of small training programs, it is clear that a general pediatric orientation is not easy to cultivate in the climate of a tertiary care center. Moreover, pediatric department chairs are subspecialists for the most part. Although they have a strong commitment to pediatricians providing primary care for children, the demands of running a service, teaching, and conducting research in a tertiary care environment make issues of primary care education seem less immediate and compelling. Challenges of Primal Care Education Our challenge is to develop education settings and curricula (in the continuity practice and in the community) to accomplish for primary care what has been achieved for subspecialty education. Simply stated, trainees need to observe 72

successful practice by skilled clinician-teachers in a variety of situations applicable to practice. In office practice: residency programs need either to establish (potentially under hospital auspices) or affiliate with real-life, functional pediatric practices. There are a variety of such settings which can be utilized, depending on where the residency program is located. These include urban group practice with indigent or mixed social class patients; suburban group practice with predominantly middle class patients, rural practices, which in addition to primary care, may involve a consultative role with family practitioners, and a major role with hospitalized children. Such teaching practices should be able to demonstrate the pediatrician's role with children and adolescents with chronic medical conditions, with behavioral and developmental problems, as well as with parent and child preventive health education. The role of allied health professionals and office staff, organization of practice, medical records, consultation and referral decisions to both medical and psychosocial resources are all proper subjects for learning. In community settings: Primary care practitioners (optimally) play important roles as consultants in community settings outside of their office and trainees should have the opportunity to observe and learn these roles. These occur, for example, in day care facilities, schools (elementary through college level), settings for children with chronic handicapping conditions, and detention facilities for juvenile offenders. The role of the generalist in a community hospital without housestaff is a very different one from the practicing physicians whose principal hospital is a regional tertiary center, with available residents and subspecialists. Although some of these skills can be learned in short block rotations in office practice, there is considerable value to learning how skilled primary care physicians manage problems over time, and that is best achieved by a longitudinal, several year experience (particularly for the primary care practice). This strategy requires identifying promising clinician/teachers within the community, and providing them a structured (and ongoing) educational program to grow as teachers. They need to be compensated for the time they spend teaching and not practicing. I believe it is more logical to place residents in "educationally prepared" community settings than to bring practitioner-teachers into tertiary settings to observe and teach residents in hospital clinics. These comments are not meant to ignore the role of subspecialists. They are vital to graduate education for primary care and, in general, I think subspecialty teaching is of high quality. At present, subspecialists play a vital role in conveying to pediatric residents a body of knowledge about disease and up-to-date diagnostic, technical and management skills in dealing with children with complex illness. However, if trainees only observe neurologists caring for children with seizures, 73

endocrinologists caring for diabetics, and psychologists caring for children with behavioral disturbances, a powerful message is communicated to the trainee about who provides optimal care. Our education needs to occur, at least in part, where excellent generalist teachers are seen to play a central and satisfying role with such children and their families. Funding Constraints Funding constraints present a realistic barrier to implementing the changes in primary care education outlined above. In hospital inpatient and ambulator settings patient care reimbursement provides a significant portion of resident and faculty salaries. If residents spend time outside of the hospital in community settings alternate payment mechanisms need to be devised for resident (and faculty - supervision) time. Hospital services will continue to require staff time, and either more residents need to be recruited (but there are a limited number of American medical school graduates available) or new allied health manpower (physician assistant, nurse clinician) need to be trained. Moreover, community-based primary care, child development and behavioral services tend to be poorly reimbursed, without considering the additional educational expenses required to teach n those settings. Current Title VII funding for primary care residency training has allowed for the funding of these activities (apart from usual hospital sources) and can provide valuable data on the costs of such education. In summary, pediatrics retains its strong commitment to primary care: the majority of pediatricians are engaged in that activity. Changes in the Residency Review Committee Guidelines for pediatrics should enhance primary care education, but may tend to concentrate residency training in larger tertiary care centers where such educational experiences must compete with the service demands of complex patient care. A variety of curricular innovations are needed to strengthen primary . . . · ~ e , e care education In pectlatrlcs, and the flexibility to develop and assess these curricula is highly desirable. Funding support to place trainees in functioning primary care settings in the community (and prepare the appropriate faculty) is required, which will necessitate some restructuring of present reimbursement mechanisms. 74

BIBLIOGRAPHY Bryke C, Tunnessen W. Scully T. Oski F. Pediatric residencies between 1959/60 and 1984/85. Pediatrics 82:752, 1988. : Differences Mathieu O. Alpert d. Residency training in general pediatrics: The role of federal funding. Am ~ Dis Child 141:754, 1987. Reuben D, McCue ], Gerbert B. The residency-practice training mismatch. Arch Int Med 148:914, 1988. Sargent it, Ashley M. Comparison of patient populations seen by pediatric residents and by practicing community pediatricians. Med Ed 61:610, 1986. 75

Graduate Education in Family Medicine - Its Ambulatory Emphasis Tack M. Colwill Professor and Chairman Department of Family and Community Medicine University of Missour~-Columbia Two decades have passed since the American Board of Family Practice was established. This new specialty of family practice developed as a result of a national consensus that the nation faced a shortage of primary physicians and of rural physicians. With state and federal support, the number of residents increased almost exponentially throughout the 1970's.i (Figure I) Now, during the 1980's, the number of residents has plateaued at 12% of all first-year residents. Despite the impact of these residency programs, the total number of family physicians in the U.S. is not increasing significantly because of the high retirement rate of aging general practitioners. The Council on Graduate Medical Education, COGME, indicates that we continue to have a shortage of family physicians and probably of other primary physicians. Despite this shortage, family practice residency programs are not expanding. In this setting ~ suspect that the greatest concerns of family practice educators are for the declining interest among medical school graduates in primary care careers and the fiscal vulnerability of current family practice residency programs. In the following, I shall describe some of the characteristics of family practice residency programs and shall reflect upon the concerns that I have outlined above. The three-year residency curriculum in family practice is designed to mirror the practice of a primacy physician who renders patient care services to patients and families of all ages. Kerr White's classic 1961 paper, "The Ecology of Medical Care," demonstrated that in a given month 750 of any 1,000 patients will have an illness.2 (Figure 2) Of this group, 250 will seek a physician, 9 will be admitted to a hospital, 5 will receive consultation, and only 1 admitted to a University Medical Center. The clinical practice of a primary physician deals with the primary care encounters, the primary care admissions, and the secondary level consultations. Consequently, educational programs in family practice are designed to emphasize these areas. Conceptualized another way, the box in Figure 3 encompasses the content information of medicine. The vertical lines separate the boundaries of the traditional clinical disciplines. The area above the horizontal line reflects what is known about disease, and that below the line that which is known about health. Common problems fall closer to the horizontal line. These problems constitute the 76

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vast majority of patients seen by a primary physician. Further, the problems seen by the primary physician bridge many of the classical disciplines. ^ ~ Consequently' the practice ot a family physician scnemat~catty can ne represented by the dark area in Figure 3. Likewise, educational programs in family practice are designed to provide competence in the more common ambulatory and secondary level problems. The three-year residency curriculum in family practice is demonstrated in Figure 4. The unique core of the residency lies in each resident's continuity practice in the practice center, which constitutes approximately 30% of scheduled daytime activities. Each resident provides longitudinal care for a panel of families over the 1 ~ rnree years of residency training. The proportion of time within the continuity practice increases each year, so in the fourth year it typically totals at least 40% of daytime activity. In addition, while programs vary markedly, in a typical residency approximately 40% of scheduled time is based on inpatient services in specialties such as internal medicine. pediatrics. surgery. obstetrics. and family ~ practice. The remaining 30% is based in ambulatory specialties including dermatology, orthopedics, ENT, gynecology emergency medicine, etc. Characteristics of problems seen in the primary care ambulatory setting differ in major ways from those seen in the inpatient setting. Problems tend to be common, early, subtle, and to fall within the domain of many clinical disciplines. Psychosocial problems constitute a significant part of the practice as do chronic problems and health maintenance. The emphasis of education in the continuity practice is on the care of the patient in the context of the family and its social and economic environment. The role of the primary physician is that of primary provider, coordinator of medical services, and increasingly the financial manager of care. Faculty supervision in the practice center is highly labor intensive in comparison with a typical inpatient service. Residency review requirements in family practice mandate that a faculty member without other responsibilities be available full-time to supervise residents in the ambulatory setting. The guidelines of the Residency Assistance Program, (RAP), sponsored jointly by the family practice organizations stipulate that in a quality program faculty members should supervise no more than four residents at a time. This can be contrasted with an inpatient service where a faculty member may supervise a large busy inpatient service 80

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with multiple residents and students and typically spend only two to three hours a day in the attending role. The typical family practice residency program is relatively small, adding sin residents annually to a three-year program. Although residencies in most specialties are based in large teaching hospitals, most residencies in family medicine are located in community hospitals. (Figure 5) In half of these community hospitals, family practice represents the only residency program. Even so, most programs are associated with medical schools. In 198S, 33% were operated directly by a medical school and an additional 55% were affiliated with one. Fifteen programs were based in the armed services. One characteristic of family practice residency programs is the fiscal vulnerability of these residencies. This probably is a major explanation for the plateauing of residency positions in family practice in the 1980's. Family practice residencies vary greatly in their costs and sources of revenue. However, several studies suggest that a typical program divides its expenditures almost equally between the cost of faculty and administration, the cost of residents, and the cost of operating the family practice center.3 (Figure 6) Sources of revenue vary markedly from program to program. For a typical program, revenue is approximately equally divided between hospital support, state and federal governmental support, and patient care income from the family practice population. (Figure 7) Federal training grants have been a small but nevertheless tribal component of residency funding. Residency program costs in family practice are probably less than those in many other specialties. Certainly, faculty salaries are less. Further, the cost of the family practice center is not great compared with the cost of an operating room, which is essential for other residencies. The difference is that the family practice center may not be essential to the operation of the hospital while the OR is highly essential for patient care. Overhead costs for the family practice center exceed those of private practice, but probably are comparable to the costs of teaching clinics in other specialties. The well-known added "teaching" costs consist of the increased administrative, medical records, and patient care staffing costs common to all educational ambulatory settings. The dilemmas for financing family practice residencies lie primarily on the income-generating side. Each of the three major sources of revenue, patient care, hospital support, and governmental support will be addressed. 82

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Patient care income for professional services to the family practice population is limited by a number of factors. In order to be competitive, charges typically minor customary charges in the community. Charges are primarily for cognitive services. The patient mix includes individuals without health insurance and higher Dronortions of patients funded bY Medicaid. As a result of the above, the overall ~ ~ - - . ~ collection rate was only 60% of gross charges for 10 programs sampled by the author for this presentation. Thus, in comparison with a physician in private practice, the nonprofessional overhead cost per patient visit is higher and the percentage of gross charges collected is marketedly less than in private practice. It is not at all surprising that on average the income from patient care services of a family practice residency program only approximates the nonprofessional overhead cost of operating the practice center. The residency programs serve populations of all ages. Consequently, the proportion of services rendered to Medicare patients is relatively low. In the survey of 10 residency programs, I found that Medicare provided an average of only 13% of practice income. Further, the gross collection rate from services to Medicare patients after Medicare adjustments was less than for the practice as a whole in seven out of ten programs, ~ ~ ~ collection rate for Medicaid was only 40% of gross charges. averaging only 55% of gross charges. The average Typically, the hospital provides the largest single source of revenue for family practice residency programs. In turn, the hospital is reimbursed for its direct and indirect educational costs. Congress has now capped direct educational costs at an institution specific rate per resident and is now strongly considering further reductions in the indirect educational reimbursement. As this occurs, graduate medical education will progressively become a "loss leader" for the hospital. Hospitals will in all likelihood seek to reduce their financial commitments to graduate medical education. For the hospital, reductions in family medicine and other primary care residency support would be financially preferable to reductions in residencies which function in high revenue-generating areas of the hospital. Family practice programs have been blessed with state and federal training support to a greater degree than primary care programs in internal medicine and pediatrics. Conversely, family practice residency programs have not had available to them the financial resources of the VA and the potential for internal shifting of patient care revenues from procedurally-oriented subspecialties. Approximately two-thirds of family practice residency programs do receive federal training grants andior state support. This governmental support, both federal and state, has plateaued and indeed has decreased significantly when inflationary increases are taken into account. Further, inasmuch as training grants are competitive, they co not provide the stability of funding necessary to maintain programs over time. 86 . · . · . -

Thus, from the above it is easy to see that family practice programs have struggled simply to maintain the status quo. In the current fiscal situation, significant further expansion of these programs seems unlikely. The declining interest in primary care careers is another area of great concern to all in primary care. The NRMP results for the past three years demonstrate that the total number of U.S. medical school graduates matching in primary care specialties has dropped by 970 graduates with a decline of 111 in pediatrics, 212 in family practice, and 647 in internal medicine categorical and primary care tracks. (Table 1) Further, the AAMC's Graduation Questionnaire suggests a declining interest in primary care careers among those entering internal medicine and pediatrics, which is associated with an increasing interest in the medical and pediatric subspecialties. (Tables 2 & 3) Thus, between 1982 and 1988, the interest in general internal medicine dropped from 14% to 8% of graduating medical students. That in pediatrics declined from 6 to 5% of graduating students, and interest in family practice dropped from 15.5 to 11.2. Total interest in primary care specialties dropped one-third so that only 24% of 1988 graduates planned primary care careers. Even more distressing trends are apparent in family medicine. Utilizing data from the MCAT Questionnaire interest by entering medical students in family medicine dropped from 37% to 16% between 1978 and 1986. (Table 4) This fall is especially distressing in as much as Babbott's study of the 1987 cohort of U.S. medical school graduates demonstrated that 46% of those entering family medicine had planned to enter family medicine when they took the MOAT test.4 Utilizing the above trends in family practice, Babbott's data, and data from the AAMC Graduation Questionnaires for general internal medicine and pediatrics from 1982 and 1988, I project that interest on the part of senior medical students in the three primary care specialties will drop from 36% of graduating students in 1982 to only 17.1% of students graduating in 1992. (Table 5) This projection anticipates a continuing rate of decline in each of the three specialties as reflected in the figures above. Hopefully, current trends will not continue and higher percentages of students will decide upon primary care careers during their medical school experience. This data is relevant to the discussions of this conference. Obviously, the causes of the decline in interest in primary care careers are multi-factoral and will require multi-factoral solutions. One component of the solution appropriately would be to increase education of both medical students and of residents in internal medicine and pediatrics in primary care. Such an expansion has major fiscal implications, which are appropriately addressed in this conference. 87

Table ~ NRMP Positions Matched by U.S. Graduates 1986 1989 Percent Decline Internal Medicme. 4067 3420 16 Family Practice 1680 1468 13 Pediatrics 1367 1256 ~ ~ Includes Categorical, Medical Pediatrics, Primary Care. Source: NRMP 1989 Results. National Resident Matching Program: Evanston, Illinois. March 1989. Table 2 Specialty Preference U.S. Graduates (% Graduates) Percent 1982 1988 Change Family Practice 15.6 11.2 - 28 General Eternal Medicine 14.3 8.1 - 43 General Pediat;rice 6.2 5.3 - 15 Total Primal Care 36.0 24.6 - 32 Source: Association of American Medico Colleges. Medical Student Graduation Questionnaire. 1982 and 1988. Washington, D.C. 88

Table 3 Preference for Medical Subspecialties (% Graduates) Percent 1982 1988 Change Internal Medicme 7.6 Subs Pediatrics Subspecialty 1.8 11.6 2.9 + 53 + 61 Source: Association of American Medical Colleges. Medical Students Graduation Questionnaire. 1982 and 1988. Washington, D.C. Table 4 Specialty Choice - Medical School Matriculants 1978 1983 1987 Family Medicine 37% 24% 16% Source: Association of American Medical Colleges. Medical College Admimions Test Questionnaires. 1978, 1983 and 1987. Washington, D.C. 89

Table 6 Projection Specialty Preference 1992 1982 1988 1992 Family Practice 15.5 11.2 B.2 General Internal Medicine 4.3 8.1 5.1 General Pediatrics 6.2 5.3 4.8 Percent Pruna~y Care 36.0 24.6 17.1 90

BIBLIOGRAPHY 1. American Academy of Family Physicians, Accredited Family Practice Residencies, July 1988. Reprint Series 160, American Academy of Family Practice Residency Census, 1988. White, K.L., William, T.F., and Greenbery, B.G. "The Ecology of Medical Care" New England Journal of Medicine, 1961, 265:885-892. 3. Colwill, J.M. "Financing Graduate Medical Education in Family Medicine", Academic Medicine, 1989, (March):164-158. 4. Babbott, D., Baldwin, D.C., Killian, C.D., Weaver, S.O. "Trends in Evolution of Specialty Choice: Comparison of U.S. Medical School Graduates in 1983 and 1987", Journal of the American Medical Association, 261(16):2367-2373. 91

The Case for Increasing the Education of General Internists in Ambulatory Settings Jordan J. Cohen, M.D. President, APDIM School of Medicine Health Sciences SUNY at Stony Brook Before considering why tomorrow's general internists should receive more education in the ambulatory setting, let's review our overall goals. Our aim is to educate general internists who can: 1. Establish strong, durable ties with patients and their families. 2. Deal definitively, competently, and confidently with most of the non- surg~cal conditions of adults. 3. Manage complex as well as simple problems in the ambulatory setting. 4. Orchestrate cost effective utilization of allied health personnel, laboratory tests, community resources and, when necessary, consultants (i.e., function as "team captains. 5. Understand and incorporate into practice modern strategies for health promotion/disease prevention. We have recognized for some time that these goals will be increasingly difficult to attain if we continue to depend on the inpatient setting as the primary educational venue. As we all know, wrenching changes have occurred in hospitals over the past decade or two and these changes have rendered hospitals incapable of providing an adequate classroom for primary care education. Examples of such changes are: i. Pre-admission screening and effective utilization review resulted in a marked shift in the inpatient population towards much greater acuity. Many important conditions that fall within the traditional domain of internal medicine are simply no longer seen, or seen only rarely in the inpatient setting. 2. Pre-admission evaluation aimed at controlling hospital costs has resulted in a marked reduction in the number of diagnostic problems and in the number of decisions remaining to be made by trainees. Increasingly, patients are admitted to the hospital with well-defined problems and with diagnostic and treatment plans already established by the attending physician prior to admission. Such patients leave the trainee with little opportunity to hone their own professional skills. 92

3. Early discharge from the hospital in an effort to reduce length of stay has had the effect of impeding the trainee's ability to establish professional relationships with patients and families, hindering the development of their crucial skills. 4. Primary care attendings spend much less time in the hospital (because their patients are increasingly ambulatory) resulting in reduced contact with trainees and, hence, in reduced opportunities for role modeling and for teaching primary-care attitudes and skills. Clearly, the remedy is to shift more of the burden for educating primary care physicians to outpatients sites. Some of the advantages and some of the difficulties in doing so are evident from an examination of the following table which notes many of the differences that exist between the inpatient and outpatient setting with respect to the educational mission: On balance, the advantages of shifting more of general internal medicine training to the ambulatory setting are obvious, but such a shift will incur considerable cost. Among the cost implications are the following: 1. On inpatient wards, the third-year medical student, the fourth-year student, the intern, and the senior resident can all interact with the same patient and gain educational benefits appropriate to their level of training. The efficiencies inherent in this scheme are not achievable in the outpatient setting. As a rule, only one primary-care trainee can be involved directly in the management of a given ambulatory patient, a cost arrangement. 2. Efficient use of attending time is also maximized in the inpatient set-setting and is significantly attenuated in the ambulatory setting. One teaching attending is generally sufficient to address the educational needs of several residents at each level of training on inpatient services; the ratio of residents to teaching attendings in the ambulatory setting is much lower. Moreover, virtually immediate availability of inpatients for "unscheduled" visits by trainees and attendings contributes further to the efficiency of the learning process, but is a luxury that is unobtainable in the ambulatory clinic. 3. Space constraints pose a serious problem for ambulatory teaching. Most standard examination room, designed to accommodate a patient and one physician, are not of a size sufficient to accommodate the preceptor, the trainee, the patient, a family member, and others, as often required to conduct an ideal teaching exercise. Moreover, the additional time required for teaching, and the fact that relatively inexperienced trainees are less efficient, means that more examination rooms are needed for a given patient load. Most ambulatory settings also do not currently contain adequate conference room space for the teaching missing. 93

4. Increasing ambulatory teaching time not only incurs additional costs in the ambulatory setting but does so in the inpatient setting as well. Pressure to reduce residents working hours is already increasing the cost of inpatient care because "cheap" services provided by house staff will, of necessity, be shifted to other providers (e.g., attendings, nurses, allied health personnel). Shifting available resident time more to the outpatient setting will, of course, aggravate this problem. How would the shift towards ambulatory training effect the attractiveness of internal medicine as a career option for medical students? Evidence that internal medicine is losing its attractiveness is undeniable. Over the last four years, the number of U.S. graduates seeking three-year internal medicine programs has fallen by more than 800. As a result, less than 60 percent of the available positions in three-year internal medicine training programs were filled by US graduates in the 1989 Residency Match. This figure is down from a high of about 77 percent ten years ago. The reasons for this declining interest in internal medicine (a decline paralleled by the experience of Family Medicine and Pediatrics) are multiple and still largely speculative. They almost certainly include higher income expectations in other fields, heavy indebtedness, life style issues, and the positive attractions of the technology and new capabilities of other specialties. Just as certainly, however, many students who might naturally be inclined to careers in general internal medicine are being driven away by the way in which we introduce them to our specialty. The vast majority of medical students are exposed to the practice of internal medicine for the first time during the third-year clerkship, an experience that occurs predominantly and often exclusively on busy inpatient services. As a result, we reveal to the student only a small and often discouraging segment of the internal medicine spectrum. Moreover, those individuals on the medical ward with whom students identify most closely--the interns and residents- -are overly stressed, often disgruntled and, because of limited ambulatory experience, unable to communicate the sense of gratification inherent in the traditional, non-hospital portion of internal medicine practice. Unfortunately, it is precisely at this time--in the third-year of medical school--when most students make their final career choice. It is reasonable to assert, therefore, that a shift towards education in the ambulatory setting--motivated by sound didactic considerations--will also have the desirable secondary benefit of enhancing the attractiveness of the field to medical students and of augmenting the nation's dwindling supply of primaly care specialists. 94

!'t~rti~l`'llt, l''tllIC:It,.iOll;ll 1~t,0 ;lLi(.lll ~tit,, .i..ll1, .~tillr N;)tur(. of '):~tiel)~; n) h1:'rl;~`ll,, a) 'I'rltc rcllectioll Or ~;ke~v~ `! lA,` ;trt' i'3~r't.~l '',~3 ici'`e's .'c''tcly `,r do'''.'i'~; cl~ro'~ic, r''~in.~lly ill. FOSS i'~tcusc conditions; l,) Ofic', no'`- spectru~n include con,~u'~ic.~tiVc. prc-~ospital, ~,ost hospital and ',o'~- c) i'rigl'Lcned, l~ospihl care. stressed. l,) Gcncrally commun~cat~vc c) Ethically relaxed; able to rciatc. Duration of rciationship Epically only a Rev days Indefinite Conhet between a) One of sc~cral a) One octane trainee and patient trainees b) Broadly focused b) Highly focused on the whole on immediate patient problem Resemblance to primary care practice Use of Community Resources Opportunities to learn health promotion! disease prevention E~cienc~ for educational purposes Scant Nil Sited High: Each patient available to several trainees; multiple work-ups Extensive; identical Routine Unlimited EoW: Each patient available to only one trainee Availability of patients for ~espy to Deduce a) hard to schedule teaching teaching teaching exe acmes exercises b) mternapted by Gained (24- interaction over hr.) intcmetion months to years over ~ [cw days e) outpatients arc e) inpatients are immersed in "capti~rc. activities Or daily lift; rmist~capti`rity. 95

A final word underscoring the urgency of developing an effective strategy for teaching primary care medicine in the ambulatory setting relates to the Resident Review Committee in Internal Medicine. In the fall of 1988, the RRC-IM put forward a new set of Special Requirements for training in internal medicine which, among other needed reforms, mandates that a minimum of 25 percent of the three-year training program be spent in ambulatory settings. This change was strongly endorsed by the Association of Program Directors in Internal Medicine (APDIM) as well as the American Board of Internal Medicine (ABIM) and the American College of Physicians (ACP). The Accreditation Council on Graduate Medical Education (ACGME) accepted the proposals and agreed to an implementation date of October 1989. Unfortunately, as the logistics and cost implications of complying with this new standard are becoming more widely appreciated, the ACGME is under pressure to back off from, or at least to delay, implementation of this "25 percent rule". Thus, despite universal acknowledgement that more ambulatory training is an educational imperative for the 1990's, the inadequacy of current mechanisms supporting graduate medical education in internal medicine to accommodate this change threatens to prevent it from occurring. We need help. 96

Characteristics of Primal Care Osteopathic Graduate Medical Education In The Ambulatory Setting Fred C. Tinning, Ph.D., President Kirksville College of Osteopathic Medicine Overview Before I speak briefly to you today about two osteopathic primary care graduate medical education programs in the ambulatory setting--one at my college, the Kirksville College of Osteopathic Medicine (KCOM), and the other one at Michigan State University- College of Osteopathic Medicine (MSU-COM)--I would like to give you some background regarding the osteopathic profession and KCOM. The osteopathic profession has over 23,000 practicing physicians. Just three years ago, we had 200 hospitals; we now have 178. We have over 50 million patient visits per year. A recent study completed by Ron DeGarmo, fourth-year student at KCOM and a research assistant in the office of institutional research and development, found that 58.8 percent of the 1975-1985 KCOM graduates identified primary care as their regular practice.] In northeast Missouri, KCOM serves a catchment area of 23 counties with a population of 350,000. Our sister institution, the University of Missouri-Columbia, is about 90 miles away. In those 23 counties there are seven small hospitals, a rural referral center (which is our teaching hospital), and a mental health facility (which is also ours). We have an 80,000 square foot ambulatory clinic, which has 60,000 patient visits per year, and for 40 years, we have had eight rural clinics which are located in very small communities (populations under 2,000). Forty-four percent of the people are underinsured; 22 percent are totally uninsured. Forty-two percent are 150 percent below the poverty level; 23 percent are over 63 years of age. A significant number of them are in extended care facilities. Our institution has provided support for the physicians in small communities by having some of our specialists and subspecialists hold clinics in preceptor or health department offices in the local communities. For example, the chairperson of our department of obstetrics and gynecology works with three general practitioners who provide obstetrical care for underserved areas of northeast Missouri. In addition, our students go to Missouri Department of Health clinics and provide clinical services. An intern is always with them, and two clerks go with the physician. Indemnification obviously is a problem, but we are working on that with the state of Missouri. It seems that in reviewing our osteopathic programs, what goes around comes around. The osteopathic profession is approximately 100 years old. Our bread and 97

butter has been family health care, especially in communities of 60,000 or less. Of course, we went to the major cities as the years passed, but up until about 40 years ago, you never heard of a specialist in the osteopathic profession. Then came the advent of training in internal medicine and OB and then in pediatrics. Before that time, our general practice physician did it all wherever he was. In planning solutions for the problem of an inadequate number of primary health care providers, one must understand the decisions that brought about the present dilemma. In the past decade, osteopathic medical schools moved in part away from their traditional osteopathic clinical education programs, based upon junior/senior year rotating preceptorships, externships, and rotating internships in physicians' offices, hospitals, and ambulatory clinics, to a greater hospital/specialty-based education program. This is the primary reason for the observed decrease in primary care providers. A secondary reason, which was fueled by the first, was the increasing pressure placed upon osteopathic students to receive specialty training because of costs associated with education and the need for greater income in order to practice (e.g., malpractice, technology in office, etc.). Now we have gone full circle. In an effort to increase the numbers of primary care providers to their former levels, schools of osteopathic medicine are returning to and/or strengthening their traditional ambulatory-based intern and residency education programs. MSU-COM's ambulatory-based pediatric residency program and primary care specialty residency training programs and KCOM's growth from the rotating senior clerkship and rotating internship to the family medicine residency and internal medicine residency programs being conducted in extended care facilities, rural clinics, the Gutensohn Osteopathic Health and Wellness Clinic, and smaller, rural hospitals3 are examples of this trend. The Michigan State University College of Osteopathic Medicine Models MSU-COM, under the leadership of their dean, M. S. Magen, D.O., believes it is time for significant change in medical education to address the issues brought about by the societal context of medicine, the university value system, clinical specialization, and the changing face of health care delivery in America. MSU-COM will use the following precepts to guide implementation of ambulatory-based, primary care, postgraduate education programs. 1. Develop an ambulatory-trained, primary care physician with high levels of competence in the areas of general practice, general internal medicine, pediatrics, and obstetrics and gynecology. 98

2. Increase exposure of the undergraduate and graduate osteopathic medical students to ambulatory care in a structured environment with no diminution of didactics and with opportunity for exposure to other health care professions. 3. Combine undergraduate exposure to primary care with the first two years of graduate medical education in the same discipline under the control of the medical schools with a hospital(s) and ambulatory clinic(s). The third year of medical school would be coupled with GME1 and GME2.5 The control would rest with the medical school but would consist of organized hospitals and ambulatory clinics.6 4. Include non-medical aspects of practice such as health policy, health economics, geographic distribution, etc., in students' educational exposure. We have neglected the relationship between medicine and the medical professions and the nation and the public--access to care, physician productivity, managed care, supply of physicians, geographic distribution, and essentials of health policy at both the federal and state levels. Other issues include the ethics of care, the business and economic aspects of practice, relationships to third-party payers, and responsibilities to patients and the profession. We have neglected health and wellness, prevention, and care for the total family by promoting the importance of high-tech medicine. 5. Expose students to the problems of populations within community-based medical education. Coordination with schools of public health and departments of community health/preventive medicine would be of value. It is time to move to the "community-based medical school" concept to train the students in communities, community hospitals, and ambulatory clinics to develop physicians capable and sensitive to practice primary care at this level. The Kirksville College of Osteopathic Medicine Model Historically, undergraduate clinical education at KCOM has been based upon ambulatory experiences involving the school's Gutensohn Osteopathic Health and Wellness Clinic, eight rural clinics located in a 60-mile radius of Kirksville, the Twin Pines extended care facility, and private osteopathic physicians acting as preceptors. Ambulatory clinics can provide the facility for appropriate instructional input of undergraduate students, as well as postgraduate students. To accomplish this, six areas of consideration must be emphasized: 1) program educational objectives, 2) objectives for the ambulatory training centers, 3) types of ambulatory training centers, 4) location of facility' 5) management and supervision' and 6) selection and evaluation.7 99

Undergraduate education programs conducted in ambulatory settings have been judged successful by graduates of this type of program. Graduates surveyed stated that their education in ambulatory settings provided primary care exposure, opportunity to follow patients over time, and an opportunity to improve doctor/patient relationships.8 Each of these results coincides with the expected results of postgraduate programs conducted in similar ambulatory settings. KCOM's success with providing undergraduate clinical education in its rural clinics, extended care facilities, and private physicians' (preceptors) offices during the junior/senior year clinical education clerkships is supported by the research literature which reports positive results. From these well-developed educational programs, the basic foundation is provided upon which to build a viable, postgraduate ambulato~y-based education program. Postgraduate programs at KCOM have been revised to conform with the new AOA postgraduate education regulations adopted in March 1989 and with specialty colleges, such as the American College of Osteopathic Internists (ACOI), that mandate that at least 25 percent of the resident's education time must be in an ambulatory continuity health care setting. Because the model is intact from the undergraduate program, the accessibility for graduate education is made simpler. Both the postgraduate intern year, PGY-l, and the residency years, PGY-2 and PGY-3, etc., are modeled after KCOM's successful undergraduate ambulatory-based rural clinics and private physician preceptor educational program.9 The internship year will follow the traditional rotation model with the one-month block of general practice being replaced by weekly experiences in ambulatory primary care settings. Course work that builds skill in doctor/patient relationships, practice management, patient management, and personnel management presented in an ambulatory setting has been made a part of the internship education program. Primary care resident programs based on ambulator clinical education experience have been developed in general practice/family medicine and general internal medicine. A three-year grant was awarded to the College by the U. S. Department of Health and Human Services to revise the College's general practice residency program.'° The general practice residency is an outpatient program in which the resident develops primary care skills in the ambulatory clinics operated by the College and in the offices of private physicians who are performing as preceptors. The private physician preceptor program was developed through a three-year grant from the U. S. Department of Health and Human Services. The grant provided funds to identify and train private physicians to serve as preceptors, and additional funds were provided to develop the instructional processes and curriculum for the preceptors to utilize with the students. loo

Program Description of General Practice Residency12 This education program develops cognitive skills that are patient-oriented through quality clinical experiences in ambulatory primary care settings. The program is designed to achieve the following goals: ~Vow r~ 4~1_y In a; Ot;~111~. 1. Provide training directed toward ambulatory care for all patients, regardless of age or sex. This is a basic responsibility of the general practice physician. 2. Provide training that is programmed for ambulatory care and continuity of care experiences with emphasis on health maintenance and illness prevention. 3. Provide the resident with the psychosocial skills necessary to establish a trusting and therapeutically beneficial relationship with his/her patients. 4. Enhance the ability of the general practice physician to practice comprehensive health care. 5. Produce a residency-trained, general practice physician who is cost effective in patient management, both ambulatory and in-hospital. 6. Increase the number of residency-trained osteopathic general practice/family medicine physicians who may choose to practice in small towns and rural areas, including underserved rural areas. SUMMARY It has been pointed out in the literature that a need exists for additional primary care physicians. Many reasons have been identified by the declining numbers of primary care Droviders over the past two decades. The major solution ~ ~_d ~C__ 14 _ _ _ 1 ~. . _ _ to this problem most often FUR lUl-~11 lay unose ~owleageaole about this subject is to change the primary care postgraduate program from an inpatient model to an ambulatory education model. So, for us, we have come full cycle, realizing that at one time 90 percent of our physicians were serving in primary care, general practice medicine. In the seventies, the percentage decreased, and only 50 percent were replacing the physicians who were retiring. We are now back to about 58 percent of our physicians who are practicing in the primary care area. 10

We have had to ensure in our own institution the replacement of our physicians by providing some unique reimbursement programs for our students. KCOM's tuition is about $15,000 per year. That is very high. Thus, we developed the Institute of Rural Health, which was made possible through an endowment of approximately $2 million from benefactors of the College. From the earnings, we provide our third- and fourth- year students the opportunity to have their tuition reimbursed if they agree to practice in a rural area as a primary care physician for a predetermined number of years. In summary, the residency ambulatory programs presented herein address the problems and the changing paradigm of American medical practice. To reach a resolution for these problems, the combined resources of osteopathic hospitals, ambulatory clinics, and the colleges of osteopathic medicine have been marshalled to develop and operate a residency program that will: l. Attract an increased number of osteopathic graduates interested in broad-based, · · ~ pr~marSr care met Scone; 2. Prepare residents to practice competently well into the next century; 3. Pronde a continuum of education from the undergraduate to the graduate level and an opportunity for continuing osteopathic medical education; 4. Raise the quality of trainees by incorporating contemporary scholars and study groups' recommendations for strengthening primary care residency training; and 5. Increase the breadth and variety of learning experiences through shared faculty and resources of several osteopathic and allopathic medical disciplines. Note: The full report is available through the President's Office at the Kirksnlle College of Osteopathic Medicine, 800 West Jefferson, Kirksville, MO 63501. i02

REFERENCES (1) Ron DeGarmo, Senior D.O. Student, "Unpublished Study--Practice Patterns of KCOM Graduates 1975-1985," Kirksville College of Osteopathic Medicine, KirksnIle, Missouri, March 1989. (2) Bernard M. Kay, D.O., et al., Detailed Description of Pediatric Residency Training Program: Overview of Proposed Training at Michigan State University College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, 1988. (3) Lloyd Cleaver, D.O., et al., Department of General Practice Five-Year Plan, Kirksville College of Osteopathic Medicine, Kirksville, Missouri, 1987. (4) Myron S. Magen, D.O., Medical Education--A Dean's Perspective, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, 1988. (5) Ebert, Robert H. and Eli Ginzberg, The Reform of Medical Education. Health Affairs. 7~21:5-38, 1988. (6) Hanft, Ruth. Thoughts on Medical Education Reform. Letter. Health Affairs. 7(4):187, 1988. (7) Fred C. Tinning, Ph.D., Proposal for Organization of Ambulatorv Patient Care Training Programs, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, 1973. (8) Michael Glasser, Ph.D., and Judith Grevdal, M.D., "Graduates Assessments of Undergraduate Training in Ambulatory Primary Care Education," Journal of Medical Education, Vol. 62, 1987, pp. 385-393. (9) Carmella D'Addezio, D.O., "Report on KCOM Postgraduate Education, Unpublished, Kirksville College of Osteopathic Medicine, Kirksville, Missouri, April 5, 1989. (10) B. Charles Leonard, Ed.D., Lloyd Cleaver, D.O., et al., Proposal for the Expansion of an Osteopathic General Practice Residency Program Emphasizing Primary Care Family Medicine, Kirksville College of Osteopathic Medicine, Kirksville, Missouri, September 1987. ~03

References (cons) (11) Marlene A. Wager, D.O., B. Charles Leonard, Ed.D., et al., Predoctoral Training in Family Medicine, Kirksville College of Osteopathic Medicine KirksnIle, Missouri, November 1987. (12) Howard Hunt, D.O., et al., Training Program for Residency in Genera] Practice, KirksnIle College of Osteopathic Medicine, Kirksville, Missouri, June 1988. i04

Discussion Responding to the concern expressed about the level of interest in careers in primary care specialties, discussants considered the extent to which different factors influence physician career choice. Noting that data suggest that experiences during the clerkship have relatively little influence on specialty choice, and that data collected by the Association of American Medical Colleges indicate that the amount of debt accrued by the end of medical school does not appear to be a determinant of specialty choice, discussants suggested that other factors are important. Namely, the sense that cost containment pressures and an emphasis on the efficacy of care are changing primary care practice styles; and that income and prestige is lower in primary care than in most specialties. A related matter was raised: is the quality of entrants into primary care specialties declining, and are top medical school graduates choosing primary care specialties less frequently? While n~rl~ir.ins~ntc: expressed a belief that some deterioration in the quality of entrants has occurred, no hard evidence exists. An attempt to examine changes in the quality of entrants into various specialties might provide assistance to policy-makers concerned with the specialty distribution of physicians. ~ ~ ~ ^ via The question of the quality of patient care and the quality of training in ambulatory residencies was also addressed. At issue is whether the patient population of continuity clinics, particularly in urban areas, is sufficiently representative of the general population to provide an adequate training experience; whether practitioners and faculty, who have not been specially prepared to teach in ambulatory settings, can provide an adequate quality of teaching; and whether low- income patients who attend continuity clinics are well served by being cared for by residents. It was suggested that there is an absence of knowledge about how best to provide ambulatory primary care for low-income populations, and that faculty development funds are needed to upgrade the teaching of ambulatory care. 105

COST AND REVENUES FOR GRADUATE MEDICAL EDUCATION Financing of Medical and Graduate Medical Education: Issues in Primary Care Education Support Ruth Hanft, Ph.D. Research Professor and Health Policy Consultant Department of Health Administration George Washington University (This paper summarizes the paper that can be found in Appendix B) Introduction The financing of graduate medical education is complex and evolved pragmatically with the historic development of teaching hospitals and patient care financing. For almost all of this century, medical and graduate medical education clinical instruction has been concentrated in the hospital setting. Graduate and undergraduate medical education and financing are intertwined because of the jointness of clinical activities of faculty/residents and M.D. student. While there are data on the sources of revenue that support medical schools and their faculty, and sources of data on support of hospitals, there are no comprehensive data on the funding streams for medical and graduate medical education that: allow disaggregation by discipline/specialty; separate the funds flow between undergraduate and graduate medical education; and separate inpatient and ambulatory care financing. Many of the funding sources are fusible and their specific use is departmental or hospital specific. History of Support Until the development of a variety of federal programs that indirectly and directly support medical education, didactic and clinical undergraduate medical education was supported similarly to other higher education through state appropriations for public institutions, tuition and endowments. Prior to World War Il. medical schools relied on a small full-time faculty, mainly in the basic sciences. ~as ~. en · . ~ ~ ~· to ~ ~1 - · 1 ~1 1 ~· ~ and a volunteer-- or geographic full-t~me clinical tacuity Waco received no compensation or modest stipends from the school and/or hospital with the quid pro quo being the prestige of the affiliation with a medical school and/or teaching hospital and admission privileges for private patients at a teaching hospital. Residents and interns were provided with meals, housing and sometimes small stipends. i06

World War II marked a turning point in medical education with substantial federal investment in biomedical research funding, developing after the war. This funding became a major source of indirect support for medical schools and their faculties. The National Institutes of Health and other grants awarded for the conduct of research and research training include funds for salaries of faculty who conduct research and also spent time in teaching. These funds enabled the schools to expand the numbers of full-time faculty. By 1956, one third-of medical school revenues were derived from research grants and contracts. Direct federal support for education did not emerge until the 1960s. Federal direct support for schools and undergraduate medical education began in 1963. This support was relatively brief. Patient care funding began to increase with the growth of private health insurance in two ways. Hospitals incorporated education costs into their charges, and for a growing number of middle class patients insurance covered physicians' fees. Today support for graduate and undergraduate medical education comes from a multiplicity of sources. These sources for graduate medical education include: - State appropriations to schools and their hospitals - Federal support of VA and military hospital residencies - Private and public third-party payments, including Medicare, to hospitals and fees to teaching physicians. - Indirect faculty and fellow support from research. Patient Care Support Patient care activities are an integral part of the educational process. The support of GME takes two forms: (1) direct support from hospitals for salaries, fringes and other direct costs of residents and supervisory teaching physicians, and (2) fee support for patient care services to individuals covered by public or private insurance. Fees are billed by faculty for services rendered. Medicare also adds an indirect education adjustment designed for multiple purposes in addition to education. Faculty have organized "practice plans" for collection and disbursement of the fees. This source of income has grown rapidly since the early 1970s. The amount of revenue generated from faculty practice plans varies widely among institutions, depending on many factors, including the payment sources for patients' care, and the structure of the practice plans. The plans now account for more than 19.4 percent of the gross revenue of public schools and almost 22.5 percent of i07

private schools' revenue. Hospital payments to medical schools in addition, amount to 7.S percent and 21.2 percent respectively, mainly for payment of the teaching . . P ~yslclans. With the increased flow of third parlor payments for graduate medical education in the 1970s, issues relating to both geographic location and types of specialty training began to arise, as well as issues of the "fairness" of financing. Specifically, for the purpose of this discussion, reimbursement from third-party payers for inpatient services has financed a greater proportion of the costs and charges than for outpatient services. Role of the States The states have played a major role in support of undergraduate and graduate medical education and have been primarily responsible for the expansion of the number of medical schools and for increased enrollment, as well as for the support of primary care residencies. The states vat defy in how they support graduate medical education, their teaching hospitals, and the degree of control they maintain over the number of residency positions in their own state university hospitals which are a major training base for residents. State university hospitals provide approximately 15 percent of all of the graduate medical education positions. Primacy Care Residencies and Ambulatory Care Training Historically, support of graduate medical education has come from hospital financing. Traditionally, hospitals incorporated education costs in their cost base and these costs were recognized during the implementation of Medicare. The federal government made an early decision to pay the direct costs of residents, supervising faculty and other direct costs associated with graduate medical education as part of Medicare Part A. Blue Cross cost based plans also recognized these costs and hospitals incorporated these costs in charges to charge payers. The evolution of the family medicine residency and the development of the community based medical schools in the 1960s and 1970s stimulated the initial interest in a change in focus of residencies from the traditional large teaching hospital to community based hospitals and ambulatory care settings. The advent of competition in the late 1970s and prospective payment, stimulated changes in the nature of the hospital and the delivery of health care services and has led to increased pressures to expand education sites to ambulatory care settings. While doe

most pronounced in the primary care specialties, ambulatory care training is an increasing need in specialties like ophthalmology, radiology, and general surgery. The financing of graduate medical education however, has not changed accordingly, except for the recent Medicare change which recognizes the direct cost the hospitals pays when the resident is in an outpatient setting, including outpatient settings outside the hospital if the hospital is willing to support these costs. There are no national data on financing of graduate medical education in ambulatory care settings. Family medicine residencies are structured differently than other residencies. In general, the first year of education is based in a hospital with the financing from the hospital. In subsequent years the education takes place in an ambulatory care group setting with support from grants and fees for service generated by faculty and residents. Residents who are licensed can have their services billed for in these settings, although not in the hospital setting. On average, about 30 percent of the revenues come from fees from patient care. There are several generic problems in financing primary care residencies outside of the hospital setting. The problems are summarized as follows: - In the hospital setting the resident and supervisory physician are paid salaries from hospital revenues with education costs separately recognized by Medicare and Medicaid and historically included in hospital charges. If a personal and identifiable service is provided by the teaching physician, a fee can be charged to the patient or Insurer. - In the outpatient setting not linked to a hospital (for Medicare) and for private third-party payment in outpatient settings, the resident's salary and a supervisory salary for the faculty must be generated from fees to the patient/third- party or from grants from government and/or philanthropy. In the primary care specialties, the fee levels are substantially lower than for procedure oriented specialties. While there are two sources of patient care support for hospital based or hospital outpatient linked training there is only one in the non hospital ambulatory care setting. In addition, there is no Medicare indirect education adjustment in the outpatient setting. - The development of faculty practice plans has been on a departmental/specialty basis with the procedural specialties able to generate substantially higher revenues than primary care specialties, because of the Medicare and private insurance charge structure. The revenues of these plan flow to the department with some small percentage flowing to the institution. The organization of medical schools on a departmental basis and graduate medical education on a specialty/program basis combined with the departmental flow of hospital and practice 109

plan revenues leave the medical school as an institution with a paucity of flexible funds. Institutions that do not receive public appropriations, have little ability to cross subsidize and specific specialties retain the majority of their practice earnings for departmental and even division rather than institution wide goals. Supporting education through charge based reimbursement to physicians is feasible. There are, however, both institutional and structural constraints that limit the viability of relying on charge payments to fully support ambulatory based programs summarized as followed: - The charge and reimbursement structure that rewards procedural activities at much higher rates than cognitive services. - Potential reduced productivity in ambulatory care education and higher costs, in contrast to hospital based education. - The volume of no pay or low pay patients and Medicaid patients. Who Should Support GME? The question of who benefits and who should pay for graduate medical education has been a subject of debate for many years. From the studies that have been conducted, patients are major beneficiaries of house officer activities. Residents spend the majority of their time providing patient care services' with and without supervision. A large proportion of training takes place in public and large teaching hospitals and their outpatient departments that provide care for the indigent. Residents have traditionally provided, and continue to provide, indigent care. In some states, the family practice residency clinics are major providers of care to Medicaid and uninsured patients. Medical schools also benefit from the teaching activities of house staff. The activity analysis studies show a significant teaching contribution by the residents to the education of medical students. Yet no payment is made by the schools to the teaching sites for these activities. Faculty also benefit significantly. The resident provides an "extra" hand and coverage for the teaching physicians, as well as contributing substantially to the services that the teaching physician bills for. These fees flow to the medical school department and faculty in addition to the hospital payment for supervision by faculty. 110

Hospital benefits accrue from the availability of round-the-clock physician staffing by residents at a lower cost than if provided by community physicians. Teaching programs are also regarded as a qualitative asset for hospitals. The residents also benefit, receiving the advanced training that provides the skills to practice a high earning profession. There are multiple beneficiaries. However, current practice places the majority of financing burden on patient care funds. A case could be made for multiple sources of financing from the multiple beneficiaries if there could be quantification of the benefits that accrue to each. These sources of financing could include: - Tuition paid by the resident for education - Salary support from health professions schools to account for teaching activities of the resident. - Salary support from the hospital for standby/coverage ~ - OI services. - Fees or salary support from patients/third-parties for the provision of services. - Salary support or fee sharing from faculty Moving to increased fee support for primary care training in the outpatient setting raises the following problems, and probably is not feasible unless the financing of practice plans on a departmental basis is changed to institution wide plans. The barriers to increased fee based support in summary include: - Incentives to support residencies in the high fee/high earning specialties and inability of the primary care specialties to generate sufficient funds to cover education costs. - The concentration of GME in settings with a large number of indigent, both Medicaid and uncompensated care, patients. - Increased regressivit3r of financing.

Large amounts of dollars, not including faculty fees, estimated at $~-$10 billion ($4 billion of Medicare funds), flow for the support of graduate medical education. The issue is not the amount of revenues but the distribution of the revenues in support of graduate medical education priorities. ~2

The Cost Of Graduate Medical Education In Outpatient Settings Judith R. Lave, Ph.D. Professor of Health Economics University of Pittsburgh (This presentation summarizes the paper that can be found in Appendix B) In considering the cost of training programs in the ambulatory sector, the appropriate question to be raised is: what additional resources are needed to accomplish this task or what is the increased monetary cost of adding this activity? These questions are different from an equally important one: will the implementation of this program generate net positive revenues? To the sponsoring institution or administrator of the training program, the impact on net revenues may be the more important question. The cost of the training program will depend on its nature. Training programs can range from the development of a residency program in family practice in a nonhospital setting, the introduction of an ambulatory based primary care component in an internal medicine residency program, or the implementation of a clerkship for medical students in an HMO or family practitioner's office for 4 weeks during the summer. Since the programs differ, so too will their costs. The question that has attracted the most attention in the literature is the following: is it more costly to provide medical care in ambulatory settings in which residents are both being trained and are providing services than it is to provide such care by fully trained physicians? If costs are higher, the "net costs" of training will be positive; if lower, then the net costs of training will be lower. I consider this issue here in some depth. In the ambulatory setting, as in all settings, residents acquire skills while "learning by doing'. However, while they are practicing, they receive faculty input through direct supervision, case conferences, chart review and consultations. The nonphysician cost component may be higher when residents provide care because they may order more tests, require more nursing time per visit or use examining rooms less efficiently than experienced physicians. In addition, to accommodate the training activity, the space configuration may be different and more expensive than when only experienced physicians practice. To focus attention on the most important factors determining the net costs of training, assume that only physician services are needed to produce patient visits. Figures One and Two are used to motivate the discussion. Figure One indicates that a Fully Trained (FT) physician provides OJ visits per unit time, while the number of visits provided by a resident varies with the year of training 113

Patients Per flour - Cost Per Visit J o S o Faculty lo) Input Per Resident Vis t) Output o \, 12 24 Month of Traintug FIGURE ONE: Resident Year of Training FIGURE "0 114 ><is / Resident / Output Faculty it) Input - 36 Fully Trained M1) T

as indicated by the curve CD. The amount of faculty input needed per average visit provided by a resident decreases as residents become more experienced as shown by EF. In Figure 2, OS indicates the average cost of a visit provided by a FT physician. RT indicates the average cost of a visit provided by a resident. At first the cost per visit provided by the resident is higher than that provided by a FT physician, however, as faculty input decreases and resident productivity increases with the level of training, the cost per resident visit approaches that of a FT physician's and then falls below it. The curve RT increases towards the end of the training period because resident salaries increase while the number of hours worked decrease, leading to an increase in the cost per hour. Although the general shapes of Figures One and Two should hold in all settings, the details will vary from site to site. For example, the position of CD in Figure One will depend upon the flow of patients through the clinic, the efficiency with which the practice is operated and the pace at which residents practice. The position of EF will vary with the amount of training and feedback the residents actually receive. Finally the relative positions of OS and RT will depend upon the hourly cost of residents and the faculty. Thus, the net cost of training will depend upon the amount of faculty input into the training process, the relative income of the faculty residents and the flow of patient visits. It will also depend upon the mix of residents. There are four different approaches to estimating the net cost of graduate medical education in the ambulatory sector: time and motion studies, replacement cost studies, before and after studies and relative cost studies. In time and motion, the investigators directly observe how physicians spend their time. Although these studies sometimes have methodological problems (particularly when physicians are doing a number of tasks simultaneously), they provide much useful information. For example, in a recent study of 15 practices, Kossecoff and associates found that for follow up visits when the second year resident was the primary provider, the attendings spent less than a minute with the patient in 9 practices, between 1 and 6 minutes in 4, and over 6 minutes in 2 of them. In replacement cost studies, the following question is asked: if outpatient clinics continued to serve the same number and mix of patients, what would be the cost of closing the teaching programs and using full time practicing physicians to provide the services that were previously provided by the residents? In before and after studies, analysts examine the effect of introducing residents and medical students into practice settings by estimating the level of costs and output at both points of time. In comparative cost studies, analysts compare the costs of care across settings which have different levels of involvement in graduate medical education. ~5

Since most of these studies are based on single sites, they often come to greatly different conclusions. For example, two replacement costs studies have just been published. Both studies used comparable methods of analysis - yet they reached diametrically opposite conclusions because their estimated hourly costs for residents and fully trained physicians were quite different. However, there is some consistency in the findings and the following conclusions can be reached: 1. The introduction of medical students into the ambulatory practice setting leads to an increase in patient care costs while second and third year residents lead to a decrease in patient care costs. 2. The nonphysician inputs are higher in those settings in which training is taking place. Controlling for case my, residents order more tests than fully trained physicians. 3. The amount of "teaching" provided by attending physicians varies widely across programs and sites. 4. In the ambulatory sector, most of the training is done by faculty physicians. This is quite different from the practice that prevails in the inpatient setting where the interns teach the medical students and the senior residents teach the junior residents. Some of the difference is due to the fact that the patient is only in the setting for a brief period of time. The above discussion addressed a narrow question: will the cost of adding residents to the ambulatory clinical setting lead to an increase ~ the costs of patient care provided in that setting. There are other important questions. One such question is: what is the effect of a training program on primary care on the financial status of the overall institutions. To address this question we need to look at a broader range of costs and revenues. The costs of a training program are the additional costs which are incurred as a result of the program. In this case, the costs of the program can be classified into three groups: the costs of providing the services which are generated in the clinical setting in which the training in primary care is taking place, the administrative costs of running the training program and the costs which are incurred when the primary care residents rotate through the other services. The revenues from the program include practice revenues, other program revenues (such as government grants) and other hospital revenues such as the Medicare payments for the cost of direct education and revenues associated with increased outpatient testing and hospital admissions associated with the ambulatory programs. 116

No study has ever studied the full range of costs and revenues. Most studies examine whether clinic revenues cover clinic costs (including the prorated resident and faculty costs), or whether clinic revenues cover the full costs of the training program as seen from the perspective of the training program rather than the perspective of the sponsoring institution. The general findings are that in most cases clinic revenues do cover the costs of operating the clinics (if only the prorated cost of the faculty and residents is included in the cost of the clinic) but that they do not cover the full cost of the training programs. Some studies find that the clinics are not operated very efficiently and that occasionally there is a "shortage" of patients. Many analysts, particularly those who have studied family practice clinics, believe that it should be possible to increase clinic revenues by increasing the volume of patients without jeopardizing either the quality of patient care or the quality of the training. However, most do not believe that it would be possible to raise revenues by increasing fees both because of the limited insurance coverage for ambulatory services and increased competition with the community physicians. Before concluding, there is a final cost issue that should be addressed; and that is what are the costs of reallocating residents time from the inpatient to the ambulatory setting. There are no published studies as yet which have examined this issue. In concluding, I would like to return to the training process per se. Training in the ambulatory setting is probably more costly than it is in the inpatient setting. As noted above, not only is more training done by attendings rather than residents, but also there appears to be a higher attending/resident ratio. In the studies that were examined, there was considerable variation in the amount of faculty time that was provided to the resident in the clinic setting. Since faculty time is very expensive, research on the training process per se would seem to be called for. Discussion Robert Derzon, Vice President, Lewin/ICF Inc. was the discussant for the presentations by Ruth Hanft and Judith Lave. Discussion noted that available evidence indicates that there are both net and gross costs to residency training in primary care ambulatory settings. It was emphasized that there are important limitations to all the studies on which this conclusion is based. In particular, the variability among training sites (HMOs, model family practices, hospital based clinics, etc.), variability in inputs such as faculty time, variability in the organization of teaching, variability in the insurance status of patients, and the large differences in support of state and private schools, make it difficult to come 117

to firm, generalizable conclusions about costs. Because of this variability it is unrealistic to expect to find a single solution to financing problems. An important factor in determining costs and revenues is the efficiency with which the residency medical practice is run. Because there is a dearth of knowledge about how to run an efficient teaching clinic, and faculty reward systems do not encourage individuals to devote time and resources to developing managerial skills, there is a need for incentives that will draw attention to improving the efficiency of training sites. There are a number of areas for which the information base is inadequate for policy-making, or in which further study would help primary care residency programs establish effective ambulatory training sites. Questions to be answered include: Where is outpatient training conducted today? What are the characteristics of the settings, the patients, and the sources of payment? o o In what settings and geographical locations does the health care system depend on residents to provide access to care? In what settings would it be best to extend outpatient training? This ~ . ~ . · · ~ ~ · ~ ~ ~ 1 -] ~ 1 ~ 1 · · question encompasses conslaerallons OI one quall~r OI one training, the financial support available, and the extent to which residents add important services to the local care health system. What are the replacement costs that a hospital will incur if the inpatient service time of residents is reduced? Developing some possible solutions to the financing problems of primary care ambulatory residencies, note was made of the differential in faculty practice plan income between the primary care specialties and some of the more highly paid areas of medicine. While this differential suggests that some redistribution of faculty practice plan income from the higher paid groups to the less well paid groups could alleviate financing problems, this would be difficult to implement. If ~ . e- . e ~ ~ ~ ~ ~ ~ this redistribution were made, there would ne a risk of driving the high earners out of academe. Another approach would allocate money to ambulatory settings by funding residents through a voucher system, thereby ensuring that a portion of house staff financing would move to the outpatient setting with the resident.

LESSONS FROM THE EXPERIENCES OF PROGRAM DIRECTORS Larry A. Green M.D. Woodward-Chisholm Chairman of Family Medicine University of Colorado Health Sciences Center Introduction When ~ was seeking graduate training to be a family physician, the number of family medicine residencies in the United States was increasing from 21 to 46. Since then the number of family medicine residencies has plateaued short of 400 and I have had the opportunity to be a family medicine resident in a University- related residency with a home base in a community hospital and practice in an underserved area where there was a family medicine residency in the local AHEC (area health education center). I also have had the opportunity to direct a universi~-based family medicine residency, direct a community-based family medicine residency with no university affiliation, and chair a university department of family medicine with its own and six affiliated family medicine residencies. These experiences provide the principle basis for my current views about graduate education in primary care. In the last three months I invited the leadership of Colorado's family medicine residencies to share with me their views of graduate medical education, I unsystematically discussed current affairs with various faculty members at the American Academy of Family Physician's 1989 Residency Advisory Program Workshop in Kansas City, and then I identified four "lessons" to present here today. After a description of each of them, including a few examples, I will end with two simple, perhaps self-evident, conclusions. Lesson One The Clinical Phenomena Of Primary Care Are Important, They Differ From Hospital Phenomena And They Have Intrinsic Value. This is not news. The ecology of our medical care has been elucidated for some 30 years quantifying the larger burden of suffering that never arrives at hospital or consultant's officer The articulation of the nature of primary care has made clear the important differences between ambulatory care and primary care.2 Clinical practice and experience with teaching primary care have established the great importance of social sciences in primal care. Yet, we persist with the mistranslation of knowledge from health science centers into primary care practice, trap our residents in hospitals where the patients are not, simply relocate hospital services to ambulatory treatment centers and misname it primary care, and find social services and behavioral sciences expendable to primary care ~9

training programs. There is a well recognized academic disdain captured in many quarters by the phrase, "go down to the clinic." In fact, "the clinic" is the challenging interface between medicine and the rest of the world, a place where people who should come to know each other negotiate the identification and response to various ills, a place where prognosis may be more important than diagnosis -- a place about which we are dangerously ignorant. For example: 1. We live in an infertility epidemic. Pelvic inflammatory disease (PID) appears to be a major contributor to female infertility. Early detection and aggressive treatment of PID seems to preserve fertility and reduce morbidity. Yet we now know that even though at least 43 percent of women thought to have PID seen in a primary care research network met current recommendations for hospitalization, only 9 percent were admitted.3 We also know from the National Ambulatory Medicare Care Survey that randomly selected physicians working in their offices only admit 5 percent to 7 percent of the patients they diagnose with PID.4 Is this neglect or prudent management? Is this misdiagnosis or a different way of clinical thinking? 2. Miscarriage occurs much more frequently than previously realized, partly because of "the tip of the iceberg' selections biases of our teaching centers.5 We doctors emphasize in our papers, texts and teaching, the hemodynamic and infectious complications. Our texts advise prompt operative intervention. Yet, primary care clinicians notice that miscarriage as they see it has great psychological morbidity, infrequent hemodynamic and infectious morbidity, and is subject to discriminating non-operative management.6 The first lesson from those who aspire to teach doctors to do primacy care is that the clinical phenomena of primary care are important, they differ from hospital phenomena, and they have intrinsic importance in and of themselves. Lesson Two The Strategies For Teaching In The Primary Care Setting Must Adapt To The Nature Of Primary Care, Specifically The Service Of Free-Living People. In primary care, patients can and should come and go as they please, making choices they judge to be in their own best interests. Patient preferences, convenience, and effective time management are high priorities, and when addressed, contribute to satisfied, loyal patients who in turn present the precious opportunities available only in continuing relationships, e.g. sustained prevention strategies based on behavior change and uninterrupted treatment plans for chronic disease. However, when appointments are not available, not kept, too long or too short, delayed to maintain continuity with a resident -- frustrations can emerge. ~20

The critical phenomena, episodes of illness, play themselves out over hours, days and years with teachable moments appearing from time-to-time, at various places. The patients' stories evolve with chapters that the residents will probably miss entirely, since only a small fraction of their training time is spent with their own patients in the primary care setting. One program director wrote: "An inefficient inpatient setting will still provide set teaching time. In fact, it may provide easily maintained teaching time since direct patient care needs do not have to be met immediately in an inefficient system. This is very much the opposite to the primary care setting where there is a brief period of time for teaching." Somewhat paradoxically the healthier patients require immediate attention. This, of course, is a principle explanation for why primary care education requires different strategies and why it is expensive. The doctor, the patient, and the illness converge for a brief visit, perhaps in a small room; and the process of learning must accompany the resolution of the patient's problem, preferably now. We have begun to learn about the special requirements of teaching in the primary care setting; we have much more to learn. Lesson Three The Relationship Between Primary Care Residencies and Their Sponsoring Hospitals is a Strained and Tentative Relationship. There are fantasies that good primary care is easy and cheap and that primary care education can be a free by-product. On one hand, the primary care residency's practice represents a revenue-generating cost center, a source of downstream revenues from its own admissions and referrals to medical staff physicians, a solution to indigent care problems, and a steady stream of new medical staff members. On the other hand, the same residency practice represents a major source of uncompensated care, a cost center that always exceeds its accounted revenues, a supplier of physicians for the competition, and subsidized competition that offends other medical staff members -- especially other primary care physicians. One hospital CEO responded, "Since we depend very heavily upon the participation of the private practitioners in the education of the residents, it would be self-defeating to pursue ambulatory care growth beyond that which is necessary for the purpose of the program." Yet we know in Colorado that throughout the 1980's it consistently has cost us $70,000 to $80,000 per year, per resident to provide family medicine training as we now understand it.7 About one-third of this amount was spent on resident stipends, one-third on the cost of the primary care practice site, and one-third on 121

faculty and staff salaries. Despite efficient management outpatient revenung to pursue ambulatory care growth beyond that which is necessary for the purpose of the program." Yet we know in Colorado that throughout the 1980's it consistently has cost us $70,000 to $80,000 per year, per resident to pronde family medicine training as we now understand it.7 About one-third of this amount was spent on resident stipends, one-third on the cost of the primary care practice site, and one-third on faculty and staff salaries. Despite efficient management outpatient revenu essential to the economic viability of family medicine residencies. Having breakfast last month with a group of family medicine residency directors from both coasts, ~ asked what advice they would offer a program director concerning their sponsoring hospital and in the next 30 seconds the comments ricocheted from -- "Never trust a hospital administrator", to "Never believe the numbers they give you", to "Never forget you are making money for them". These comments were not personal attacks but a candid reflection of conflicts between primary care residencies and their associated hospitals. Perverse incentives abound in the current arrangements. For example, the patient's need may be well-addressed by management in the office without any hospital-based ancillary services, but the hospital's reimbursement may entice referral; and the hospital's budget, and thus, the residency's budget, may best be served by treatment in the emergency room, ambulatory surgery suite, or radiology unit. The resident's educational needs may best be met at the state health department, the occupational medicine health station, the consultant's office, or with the resident's very own patients. The hospital, however, needs in- house, 24 per day hour coverage, particularly for its intensive care units where the primary care residency's graduates will soon find themselves perhaps unwelcomed. The chief executives of our sponsoring hospitals write: "With the bottom line shrinking in all hospitals, the limited funds are going to be sought after by everyone in many community hospitals. (Our) patient care priorities will win out over education. This may be true even with the academic center." "While trustee boards are supportive of the quality that a residency brings to an institution, revenue margins of only ~ percent to 2 percent cannot sustain an institution over a five year period...Direct funding of teaching programs, especially those that favor ambulatory care over inpatient care by state or federal agencies is clearly essential if our country is to replenish its primary physician contingent". The relationship between primary care residencies and their sponsoring hospitals is not a particularly health relationship. What is good for one may not be good for the other. 122

Lesson Four Data Management is Essential in Primary Care Training, not a Luxury. There has been progress with primal care taxonomy, and there are now reasonable classifications for use in primary care. There are information systems that can manage both clinical and business data. These new information tools provide unprecedented opportunities to define what is going on in primary care and contribute to medicine's "tree of knowledge", yielding a more complete picture of human suffering. The same systems can contribute to the monitoring and evaluation strategies essential to assuring residents of an appropriate educational experience. They can help to define episodes of illness, track patients over time, remind doctors to respond, warn doctors of danger, link the patient and the doctor to help that is needed, audit performance of a practice, provide fiscal accountability, define subsets of patients needing special attention, and more. In short, the primary care environment is an unusually complex environment, and effective information management is not peripheral but central to effective patient care, teaching, and relevant research. The fourth lesson is that the costs of information management are a legitimate part of the cost of primary care education. Conclusion The simple, self-evident conclusions are that it is important to fund primary care education and it is important to fund it directly. In the first instance, it is important to fund primary care education because it is of such great value to people, focusing on improving the services rendered in behalf of the greatest portion of the burden of suffering. It is not a free by-product of the better- established medical enterprises. In the second instance, it is important to directly fund primary care education because it announces and establishes the intrinsic value of primacy care to our society, relieves conflicting and counter productive incentives inherent in current financial arrangements, and assures the investment is actually made in primary care education. Furthermore, it can stimulate the fuller development of primary care with improved accountability and create incentives for the primary care disciplines to respond directly to public requirements. ~23

REFERENCES I. White, K.~., William, T.E. Greenberg, B.G. 1961. Ecology of Medical Care. NEdM, 265:885-892.. 2. Millis, d.S. 1966. The Graduate Education of Physicians. Report of the Citizens Commission on Graduate Medical Education. Chicago. American Medical Association. 3. Freeman, W.L., Green, L.A., Becker, L.A. 1988. Pelvic Inflammatory Disease in Primary Care. Family Medicine, 20:192-196. 4. National Center for Health Statistics. Pattern of Ambulatory Care in Obstetrics and Gynecology: The National Ambulatory Medical Care Survey, United States. 1980-1981. Vital and Health Statistics, Series 13, No. 76. Washington, D.C., Government Printing Office. 1984. DHHS Publ. No. (PHS) 84-1737. (Aggregate data from 1979-1981 obtained by personal request from NAMCS). Last, d.M. 1963. The Iceberg "Completing the Clinical Picture" in General Practice. The Lancet. July 6. pp 28-31. 6. ASPN. Spontaneous Abortion in Primary Care. 1988. A Report from ASPN. The Journal of American Board of Family Practice. i:15-23. 7. Annual Reports of the Colorado Addison Commission on Family Medicine (obtained upon request from the Colorado Advisory Commission on Family Medicine. 303/863-77771. ~ 24

Lessons From A Pediatric Program Director Joel d. Alpert, M.D. Professor and Chairman Department of Pediatrics Boston University School of Medicine Director of Pediatrics, Boston City Hospital The pediatric residency at Boston City Hospital and Boston University School of Medicine stresses primary care pediatrics. The program emphasizes continuity in training experience, has developed a psychosocial curriculum, includes the practice of preventive pediatrics and provides pediatric residents with the opportunity to care for inner city children at risk. Training occurs in ambulatory and out-of-hospital care settings, and a special program strength has been the use of neighborhood health centers in the Boston community as teaching sites. Continuity teaching also occurs in the hospital's primary care and adolescent centers. We have followed graduates' career choices over a ten-year period. Almost 80% have chosen primary care careers with many practicing in inner city settings, and the vast majority have demonstrated, at least to date, impressive career stability. What issues have emerged in our program? ~ will comment briefly on our commitment, funding, recruitment of residents, teaching space, changing patient needs and scholarship. We made a major departmental commitment and our educational goals have matched our service responsibilities. Our faculty has been recruited because of broadly-based interests in general pediatrics. There has been significant involvement of the department chairman in the program, and this has contributed to our reputation as a primely care program. Funding is a second major issue. Our health centers require extramural funding, especially since training in these settings and the hospital represents increased costs, including faculty for whom either no or inadequate reimbursements exist. We have remained dependent on targeted support such as that provided by Title VII, and pursue other funding sources such as linking our teaching with programs for schools, the homeless and AIDS. Curriculum has been an issue. While we have developed a comprehensive curriculum which addresses the current morbidity affecting children, emphasizing high-prevalence psychosocial events, we must meet the essentials of the Pediatric Residency Review Committee (RRC). The RRC has mandated changes in pediatric subspecialty training requiring rotations largely in sub-boards of the American Board of Pediatrics. We modified our program to meet these requirements despite 125

the fact that our judgment was that a different set of specialties might better meet future needs. In the most recent revisions of the pediatric essentials by the RRC, some increased emphasis has been put upon continuity of care, but the essentials still reflect the tensions within pediatrics regarding the role of a pediatrician as a generalist or as a consultant. As of this year, we are sending approximately 40% of our residents to neighborhood health center sites. We should be sending 100%. We have sought to expand the neighborhood health center teaching experience for our residents because it gives them direct community experience that is lacking in usual medical-center based activities. But we need to strengthen faculty coordination in teaching by bringing the faculty together as a group. This is not easy. Moreover, with the increased emphasis on shorter work weeks for residents (80 hours specifically and 24 hour shifts), we see difficulty in maintaining, let alone enlarging, continuity time. Ambulatory and continuity time may be cut back, especially if shifts are rigidly enforced. Previously, I mentioned our reliance on Title VII. One of the Title VII requirements is that residents have continuity in sites which meet specific grant criteria. In pediatrics, there are some 40 potential sites outside of the hospital (including courts, schools, day care centers, prisons, shelters, migrant vans, neighborhood health centers, physicians' offices), all of which are important in the experience of pediatric residents in training, but do not meet the strict federal criteria. Just as there is not enough time to educate for all of the specialties, so there is not enough time to have experience in all of these settings, particularly if one is locked into an arbitrary definition of a primary care site. Recruiting minorities has been an important part of our program, and we are having difficulty despite a special program which the Boston City Hospital House Officers Association, with funds from the Department of Health and Hospitals, has implemented, offering a subsidized elective program for senior medical students. We have been completely up front in ranking minority applicants as high as possible to insure their successful match at Boston City Hospital. We have achieved through the last decade anywhere between 11% and 24% but have found in the last few years that it is harder to have minority men and women match in pediatrics at Boston City Hospital. Nationally, the number of U.S. seniors entering pediatrics has decreased now to about 61% and many programs did not match (and of those that did an increasing number filled with other than US seniors). Programs specifically identified as primary care did even worse (about 50%). I cannot tell you whether pediatrics fell short because of increased student debts, because of AIDS, because of competition with other disciplines, or because of decreasing interest in primary care, but recruitment is a very real issue for pediatric programs. Students say, 'yes, you're great at primary care, but how do you teach the subspecialties?" That 126

attitude is a symptom of the movement away from primary care which has been fostered by the emphasis on tertiary care in medical school clerkships. Adequate teaching space has been another issue. It is not easy in the ambulatory environment directed toward service to find the space that we require for conferencing and lecturing, especially in the out-of-hospital settings. Identifying a special teaching day, clinic or time helps, but we must remember that this causes disruptions since continuity for the resident and program is in fact discontinuity for the service site when a special teaching day is set aside. Changing patient need is also an issue. The increase in acuity of illness, particularly around children with AIDS and the relationship to drug abuse has placed another burden on the teaching of general pediatrics. We are attempting to include HIV-positive patients in the panels of pediatric residents and present a curriculum so that they may gain an understanding of the generalist's role in caring for this disease with its devastating impact on inner-city families. Our program has an active research component, and our scholarship has been successful as measured by the publications and research programs supported by federal, state, municipal and private sources which relate to general pediatrics and/or primary care. Our research seminars and the emphasis on health services research have given us an important scholarly component in our program but much of this remains invisible to the resident staff. Our scholarship is important because it keeps us competitive, but that has not protected us from interruptions in funding. In summary, it is logical for a public hospital to emphasize training in general pediatrics, since we are not a tertiary referral center. Clearly, the educational goals of primary care match the service needs of patients who come to the municipal hospital for care. Without an emphasis on general pediatrics, ~ believe that training at the municipal hospital would be in conflict with its service mission. But the issues identified in educating for general pediatrics are not confined to the public hospital, but have application to a broad range of pediatric training programs, including tertiary care hospitals devoted exclusively to the care of children as well as to any academic, public, general, or community hospital where children receive care and residents are educated.

Primary Care Programs: Then (1980) and Now (1990) Steven A. Wartman, M.D., Ph.D., Director Division of Internal Medicine Rhode Island Hospital ~ plan to contrast what it took to build a general internal medicine program from scratch in 1980 with what ~ think it would take in 1990. 1980 In 1980, my highest priority was in educating department chairs, administrators, and hospital directors about the value, meaning, and reasons for the need for primary care programs. My themes were the importance of continuity of care and the need to develop a better balance between inpatient and outpatient training. This effort occupied an inordinate amount of my time but was absolutely vital in 1980. Federal support was absolutely necessary to get a general internal medicine program going. Competitive federal funding provided much needed credibility. It gave us the sanction to go ahead and build a program that was experimental. It provided the luxury of buying some additional faculty support and resources to build the program. It helped to support some of our residents' time in the ambulatory setting as well. Resident support was essential because we needed to increase the total number of residents training in internal medicine at our institution in order to cover existing inpatient service requirements. We couldn't simply convert a categorical resident's slot to a primary care slot because that left a deficit in inpatient coverage since primary care residents spend less time on the wards. This is not a strategy that ~ would recommend for 1990. We developed our own particular program based on the block-type format for education in primary care settings. The theory behind the Block system is that in order to educate residents properly in the ambulatory setting, one had to remove them entirely from the inpatient environment for "blocks" of time. It was essential that ambulatory medicine not be treated as an "add on" to inpatient care. During ambulatory block, residents spent about half their time in continuity of care, a quarter in ambulatory specialties (e.g. GYN., dermatology), and a quarter in behavioral sciences, seminars and journal club. When not on block, residents spend one-half day/week in the outpatient clinic. ~ 2 ~

We needed to upgrade our existing medical clinic. We needed to increase staff, hire nurse practitioners, and to develop a system to promote continuity of care for our patients. We developed a 24-hour, 7-day-a-week on-call system for the medical clinic. The role of nurse practitioners underwent considerable discussion. We finally concluded that they would best serve in the role of "continuity-gap providers", caring for residents' patients on their team when the residents were not available. We also needed to train physician faculty, as clinic preceptors, and to develop an ambulatory care core curriculum. During this period it was critical to assemble and maintain a quality teaching faculty. Faculty development, therefore, was accorded a high priority. It took us 3 or 4 years to get a faculty on board with the teaching program, to get them publishing some papers, and to make them feel that they are part of a unit. I didn't want to lose faculty through failure to be promoted. Fortunately, Brown has two main promotion tracks: research scholar and teaching scholar. These tracks are not distinguished by different names or different titles. The criteria are different, however. Both require publications and national and international recognition at various levels. Many faculty in general internal medicine are natural teaching scholars. As of this academic year, we have had three of our faculty promoted (two associate professors and one full professor). The period up to the present time has been one of continued growth and development. One of my major efforts has been to increase the visibility and recruitment efforts of our program. This has included published articles, presentations at national meetings, and a detailed structuring of the applicants' interview day. We have had continued federal grant support each year since 1979. I have gradually converted these monies to the support of non-clinical faculty in the areas of behavioral science, medical ethics, and communications skill. These were the major efforts during our first few years as we tried to get the program off the ground. Frankly, I felt at that point very vulnerable. If our efforts should fail or if we didn't match well with applicants, I was concerned that the entire program might be scrubbed. It was a vein scaly feeling. As the program became more well known and successful, it eventually surpassed the existing categorical program at our institution in popularity and in the "quality" of applicants. As a result, we began to gradually covert existing categorical slots to primary care slots so there are today approximately equal number of residents in each track. ~ 29

1990 I would now like to turn to the subject of what it might take to develop a similar program in 1990. First of all, ~ am veer grateful that the issue of credibility is not as big as it was in 1980. ~ don't think there is as much of a battle to fight, and it has been very gratifying to see the tide turn in favor of the kinds of things that we were pioneering 1980. One major issue for 1990 concerns the so-called "service/education conflict" in residency training. It is a topic of a paper that we are presenting at the 1989 Society of General Internal Medicine's National Matting in Washington. What we endeavor to do in this paper is to "separate" training and education. ~ won't go into the details, except to point out that resolution of the service/education conflict is central to the future of primary care residencies. A major point of the paper is that merely shifting more training to the outpatient setting does not resolve the service/education conflict but may merely shift it to the outpatient setting from the inpatient setting. New strategies for resident education are needed, as are new ways to care for sick patients in the hospital. We are going to be seeing, in the 1990's, new concepts of what is meant by "teaching' service. Clearly, there will be more and more uncovered patients in the traditional sense in our teaching hospitals. As a result, we will be developing new cadres of faculty, both full time and voluntary who will care for patients with residents as partners. One of the most critical issues for the 1990's is the need to attract more students to apply to our training programs. This represents a key challenge which should, in my opinion, be jointly shared by all the primary care disciplines along with the support of the federal government. ~ think we need to make a major thrust in 1990 in the evaluation of our residents and of our programs. We need to pay particular attention to the professional development of our residents. Along with this, I believe our programs are going to need formally trained, Ph.D. level educators who work with the residents and faculty and help guide curricular development. Career guidance is another area needing special attention. Many of our training programs care for the poor and medically underserved. There sometimes seems to be a "marriage" between our primary care training programs and the vulnerable in our society. Our own experience, over the past ten years, has been one of an ever increasing number of poor and uninsured patients coming to our program for care. I think that is probably reflected in other places around the country as well. This needs to be dealt with in a constructive way. We have to ask ourselves about the quality of care we provide. 130

We need to examine the accessibility of care for those patients and the need for our residents to have a deeper understanding of the communities in which their patients live. At the same time, paradoxically, there is a need to provide residents with normative practice experience. By normative, ~ mean a broad distribution of patients and problems. This is a difficulty that we are encountering and will continue to encounter in the 1990's. We need to continue to fight very hard to mainstream our programs academically. Someone mentioned earlier that primacy care programs have been, to a certain extent, growing up on the periphery of academic medicine, whether it is in the community hospitals (in the case of family medicine) or in divisions of general internal medicine within large departments of internal medicine. We need to mainstream our programs through the development of patient-centered research programs. ~ am confident that the pool of monies available for such research will undergo a major expansion in the next decade. Lastly, a big question for the 1990's involves the issue of combining the various forms of primary care training into a more efficient mode] of graduate medical education. Does it make sense to consider combining training for family medicine, general pediatrics and general internal medicine in some imaginative way that reduces the cost of training, pools faculty strengths and resources, and reduces destructive competition so as to produce a better "product"? This is to me an experiment waiting to happen. ~ would like to say more but in the little time remaining would like to give you a brief precis of my experience with the federal training grant program for general internal medicine and general pediatrics. ~ have served on the review pane] for six years, as well as having been a grant recipient. Thus, ~ have experienced it from both sides. It is a vitally important program and given what has been happening to teaching hospitals, it is even more crucial now. As a grant reviewer, it has been interesting to see where programs have fallen short. One common reason for not receiving approval has been the failure of the applicant to meet the "25 percent rule", a standard which requires that 25 percent of each resident's total training time be in continuity of care. Parenthetically, this is very different from the new RRC requirements in which 25 percent of resident's time must be in ambulatory settings, not just continuity practice. ~ personally support the rule because ~ think it has forced programs to truly be committed to primary care to comply. My understanding is that this requirement will be reduced to 20 percent in the near future. ~3i

The bottom line is that, in the current climate, federal grant support is crucial to develop and to sustain the primary care programs. It may prove to be even more vital in the next few years as economic pressure continues to increase on teaching hospitals. Discussion Discussion of the presentation by program directors noted that if program directors are to be able to negotiate with hospital administrators and establish beneficial arrangements, the financial relationship between teaching hospitals and the primary care residency programs needs to be properly understood. Some discussants pointed out that hospitals derive greater revenues from patients admitted by subspecialists than from the smaller volume of admissions by primacy care physicians. Other discussants however suggested that there needs to be proper appreciation of the savings that can be derived from the existence of the primary care outpatient clinic. The length of hospital stay is reduced because preadmission diagnostic workups as well as post discharge follow-up are performed in the clinic. This reduction in inpatient costs is particularly important for hospitals that provide uncompensated care. However, it was also noted that while such savings to the hospital are real, the benefits to the hospitals of primary care ambulatory programs are small when compared with the benefits from other programs. THE ALLOCATION OF RESOURCES AT THE INSTITUTIONAL LEVEL This session of the workshop used a case study method of discussion whereby four panelists were given, in advance, a problem to address. A moderator guided the discussion. Panelists were the dean of a medical school, the chairman of a department of medicine, the president of a major teaching hospital, and a vice president of a major, not-for-profit, hospital system. Each participant was asked to consider the financial resources that he would try to obtain to support the residencies, and the negotiations in which he would engage with other actors. The exercise was developed for to illuminate the following: o the decisions that need to be made o the coalitions that must be built 0 the different sets of constraints on people involved in various positions in the negotiations process :32

o the trade-offs and options available The Problem An academic health science center with an internal medicine program wants to establish a primary care track eventually totaling 18 residents -- six per year. The existing internal medicine program has 45 slots, 15 per year. Since it is not possible to expand the overall size of the program the primary care track will reduce the number of residency slots for the existing track to 27. Because the program intends to apply for a federal grant, each resident must, in the course of three years, meet at least the federal 25 percent continuity requirement. Thus in the first year at least one half day per week is needed in the ambulatory setting, in the second year two half days per week, and in the third year four or five half days per week are needed. Alternatively residents could do at least three half days per week in the ambulatory setting throughout three years. The ambulatory experience will be in an outpatient clinic in your hospital. The federal grant award will provide $60,000 in the first year, $90,000 for the subsequent two years, and there is no assurance that the grant will be renewed. Because of low Medicaid payments by your state, and a large non-paying patient load, patient revenues will cover roughly one third of the cost of the program (residents stipends, faculty salaries, administrative overhead). This leaves you with approximately 55 percent of costs unfunded. The problem for you to address is how to fund the remainder of this program. In particular we would like to know under what conditions you would be able to obtain funds from the program, or hospital, the faculty practice plans or other institutional sources. The state has no history of support for graduate medical education. Who in the hospital and the medical school will support and who will oppose your attempts to fund the program? Also, how would you replace the inpatient care services lost when the residents move to the outpatient clinic? Internal Medicine The director of the department of general internal medicine greeted the proposal with enthusiasm, believing that the nation needs general i33

internists, and that individuals who complete such training programs have a higher probability of practicing primary care in underserved areas than those trained in subspecialties. Since most primary care in his state is provided by internists, establishing the primary care internal medicine track, rather than a family practice program, articulates well with established, practice patterns. Moreover, some faculty members have been Urbana the chairman to move to ~ · ~· ~I ~en ~ _# ~ establish a prlmar~r care track. One program is Iortunate, and pOSSloly unusual' in having faculty with the necessary qualifications, background and interest to provide a core of teachers for the primary care track, and to write a grant applying for federal funds. The chairman believes that if a totally primary care oriented program is the eventual goal, to initially establish a track is the more prudent approach. It avoids antagonizing subspecially faculty, and allows a period during which it will be possible to test the availability of support for the training. One possible source of financial support for the program that is sometimes controlled by the department chairman is the faculty practice plan. It should, however, be noted that there exist many of ways of organizing faculty practice plans. In some schools the dean controls none of the income, in some schools the dean controls it all; similarly the control of the department chairman varies. The two principle decisions-makers with whom the chairman must trSr to negotiate for support are the dean of the medical school, and the president of the university hospital. The chairman would ask the dean for some faculty support, arguing that the medical school benefits from the teaching sernces of residents; that the new thinking and behavior taught in the primary care track would the education of medical students; and that the work of the facula in enhance the new track would be supportive of the educational and research goals of the medical school as it adapts to the changing environment and the needs of the twenty first century. The chairman would ask for support from the hospital administration on the grounds that hospital revenues would be enhanced by increased admissions. - Other sources of funds that the chairman would t~y to tap include: o o o affiliated hospitals, on the grounds that having residents would help these hospitals develop faculty and gain prestige. the local community, on the grounds that the program could help the locality provide care for low-income, or uninsured populations. the state, on the grounds that the program could put satellite clinics in underserved areas and that graduates of the program might settle in those areas. :34

Dean of Medical School In most schools the issue of providing support for the new primary care track would be discussed between the dean and the chairman, without much involvement of other departments. The dean would view a proposal to create a primary care general internal medicine track from the position of a decision-maker with responsibility first for medical students. Graduate medical education takes second place. Thus, the chairman's argument that the new track would strengthen faculty in ways that mesh with the missions of the medical school would carry weight. The dean would discuss the ambulatory practice arrangements and the quality of the practice, and consider whether the model would be one into which he might ultimately want to integrate the medical students. The dean would agree to provide some support for faculty, but finds no reason to directly support residents in this track. Since federal grant support may cease after three years, the dean would not put himself in the position of offering ongoing financing of residents, which might in the future conflict with his primary responsibility -- medical students. Sometimes the dean has substantial control of the faculty practice plan, making it possible for the dean to make allocation decisions that benefit the institution as a whole, and the hospitals with which the medical school is closely affiliated. Even so, the dean must be assured of the support of the members of other departments. Since he does not believe that the new residents would bring significant numbers of new patients to the subspecialists, and since it is not clear that the additional patient volume would be composed of paying patients, it would be very difficult to make a case for giving the department of medicine a greater share of the faculty practice plan income for the purpose of supporting the primary care track. This would be the case despite the fact that there is precedent for some cross subsidy for support of facula from the high earning groups to the lower earning groups. Hospital President Before embarking on discussions of what support the hospital would offer the primary care track, the hospital president wanted to clarify some notions that the chairman of internal medicine may have. First, it is often stated that the prime reason that hospitals have residents is because they provide less expensive care than fully trained physicians. It would be more accurate to say that hospitals support house staff programs in response to faculty definition of what the residents need, and that despite its own service needs a hospital would not create a residency program unless there was a qualified department head, adequate patient volume, and a belief that it is appropriate to train the particular type of resident. ~ 3 5

Second, the notion that the hospital benefits from the revenue from ancillary services generated by house staff is false. Hospitals are increasingly reimbursed on a per diem, per case. or cavitation basis. ~ ·~ ~e ~`_ · ~ ~ _ ~_ . ancillary services is financially negative, not positive. Thus increased use of The approach that the hospital president would take to a request for support of the primary care track residency is one of bargaining. How would the faculty help with coverage of the inpatient services that are left uncovered by the reduction in inpatient service time of the residents? Would the faculty build a cadre of non-teaching patients for whom they would be responsible? The department must help the president of the hospital reconcile the competing values of sustaining a financially viable hospital while fulfilling the requirements of a quality teaching program. Thus the more important question for the hospital president is whether the size of the residency programs relates to the population being served, and whether the residency programs together form a coherent and uniformly strong whole. These are the overarching considerations within which the question of financing a residency is considered. Community Hospital Administrator The principle question that the administrator must ask, is whether the ambulatory care residency fits into the hospital's long range plans. Will the residency undermine plans for the relationship with community physicians? How does it mesh with the plans for physician recruitment? The administrator must also ask whether the hospital has the prestige needed to recruit physicians into the primacy care residency program. To enhance its academic standing an affiliation with a nearby medical school might be warranted. However, this is feasible only if the teaching hospital and the community hospital do not compete with each other. Whether an affiliation can be established is to a large extent dependent on the leadership of the institutions, particularly on how the department chairman views the role of the community hospital. With interested leaders the chances of establishing a successful affiliation are high. i36

POLICY OPTIONS Sandra C. Peinado, Fellow, General Internal Medicine end 'John M. Eisenberg, Sol Katz Professor of General Internal Medicine University of Pennsylvania School of Medicine (This presentation summarizes the paper that can be found in Appendix B). To satisfy the nation's need for well-trained primary care physicians, graduate medical education in primary care requires adequate financial support. The current mechanisms of GME financing favor inpatient and procedural care, making the support of primary care programs difficult, since they are more oriented towards outpatient evaluation and management. The majority of graduate medical education funding comes from patient care reimbursement through Medicare Part A direct and indirect payments, and other third party payers. This scheme results in difficulties for primary care programs in resident and faculty compensation, as well as general difficulties for primary care program development. Criteria for evaluating proposals that aim to improve the financial support of primary care programs include financial, administrative, and educational implications of the options, as well as the views of interested stakeholders. The financial criteria are: 1) Any proposal should be budget neutral, at least in terms of the federal budget; 2) All those who benefit from GME in primary care should contribute to paying its costs; and 3) Funding should be both predictable and sufficient. The administrative criteria are: 1) The implementation of any proposal should be administratively feasible; 2) The ongoing administration of any new funding scheme should be both simple and 3) inexpensive. The educational criteria include: 1) Any proposal should maintain curricular autonomy and flexibility for primary care educators; 2) The growth and development of primary care curricular elements in already established residencies should be fostered; 3) High quality programs in non-primary care specialties should not be adversely affected; and 4) Proposals should include incentives that favor hi~h-nllr~lit.v primacy care programs. ~^~ ~ ~ ~ ^ ~ ~ _~ ^ VJ Stakeholders are the entities that are most likely to be interested in and/or affected by change in GME financing. These stakeholders include the following: society; the federal government; the Health Care Financing Administration; state governments; private payers; teaching and non-teaching hospitals; physicians; primary care specialties' educators and residents; non-prima~g care specialties, educators and residents; and patients. 137

The alternatives for sources of funds to support primary care GME include changes in existing Medicare payments, an increase in categorical GME funding, an increase in ambulatory payment, an increase in grants, commitments from future employers, and a redistribution of current funds. Alternatives for spending these funds to aid primary care programs include dividing the sources in three ways: on a per-resident basis, by competitive grants, or by incentives for primary care education. Each alternative for changing GME financing was analyzed using the criteria and stakeholder views outlined. No single remedy will be sufficient to rectify current GME financing mechanisms. Instead, several solutions will be needed simultaneously. Judged against the proposed criteria, the preferred options for raising money for primary care graduate medical education are as follows: 0 Adopt a Resource Based Relative Value Scale for payment of physicians and improve coverage of outpatient services. o Include residents' primary/ambulatory care time in the calculation of resident FTEs for Medicare direct and indirect medical education payment, add incentive for primary care training in direct payment, and recalibrate payment per resident to maintain budget neutrality. 0 Increase state support through Medicaid participation in payment for GME and through grants for primary care education. 0 Require participation in payment for GME by other payers, including HMO's and private insurers, coupled with a surcharge or tax on revenues of non- teaching hospitals. O Increase and redistribute Title VI] funding for faculty development, curriculum design and other innovations. Encourage foundation support for similar purposes. Faculty development, in particular, should be allowed a separate funding stream. 0 Experiment with programs to commit residents to future employers, who in turn would support primary care GME. O Experiment with a direct medical education subsidy for outpatient payments to complement payment to hospitals to cover the costs of medical education. Consider an indirect adjustment to compensate for the higher cost of practice (e.g., overhead, more severely ill patients) in teaching setting. 138

The spending options judged best would involve division of the funds on a per resident basis to residencies in internal medicine, pediatrics, and family medicine for the development of primary care curricular elements through faculty support, resident support, ambulatory site costs, curricular support, academic unit costs, increased ambulatory time, and primary care cooperative efforts, or to use as the individual residency chooses. This base funding would be coupled with competitive grant funding to stimulate innovation and faculty development. In addition, the appropriate and designated use of Medicare direct payments should be enforced by HCFA. Discussion Discussion of the paper presented by Dr Pienado and Dr Eisenberg focused mainly on the implications of the options for change listed in the paper. A theme that underlay most of the discussion was the pervasive sense that health policy today is being driven by the politics of deficit reduction. Thus the federal, state or local government budget impact of recommendations was frequently the subject of comment. I, The option of paying for services on the basis of a resource based relative value scale (RBRVS) was generally thought to have potential for both facilitating the financing of primary care residency programs, and for making the primary care specialties more attractive to physicians by decreasing the income differential between primary care and other specialties. There was also support for the elimination of the differential in payment for the same services when performed by different specialists that occurs under the customary, prevailing and reasonable basis of payment used by Medicare. While the adoption of the RBRVS by Medicare would effect only Medicare payments, (by one estimate the impact would be on only 10 percent of the revenues of the average family physician) it would be an important move signaling to the medical profession and others an enhanced appreciation of the importance of primary care services. Equally important, it would increase revenues available to faculty practice plans thus easing the financial stress of financing ambulatory training. On the other hand RBRVS would not substantially increase support for training programs with substantial numbers of non-paying patients. Unless all payers adopt a RBRVS, is a strong possibility that physicians who provide procedurally-oriented care will continue their usual charges for 139

services, or even increase them to make up for income lost by reductions in Medicare payments, while primary care physicians are likely to charge all payers at the increased medicare level. Thus total costs for physician services in the private sector would be at risk of escalation. Whether third park payers would be able to counteract this is doubtful. However, groups such as Preferred Provider Organizations may be able to negotiate RBRVS payments on a budget neutral basis. Medicare Payment for Direct GME Costs The Pienado and Eisenberg paper suggests the option of incorporating incentives for the development of primary care GME programs into the Medicare direct GME payments, and recalibrating the per resident payment to maintain budget neutrality. This idea was included in a bill introduced by Congressman Henry Waxman in 1985. Although some other restructuring of Medicare direct payments has been accomplished, this proposal was not adopted. It is now, however, a more familiar concept than when first proposed, and may therfore have a greater chance of success. While this proposal incorporated incentives to expand primary care programs, it did not directly tackle the question of funding residencies in ambulatory settings However, the additional revenues obtained by primary care programs should help make available resources to succors ambulatory training. _. ~ , ~ . . . . . . . . . ~ , _. . . O ~ ,, {I Policy approaches to improving the specialty distribution of physicians and the appropriateness of primary care training that try to equalize the financing of training for primary care and other specialties are based on the assumption of deficiencies in the revenues streams, and excesses in the costs of Primarv and ~ ~ -~ ambulatory training for which compensation must be found. This policy approach requires analyses of comparative costs and revenues for which the data are today inadequate, and is subject to change as methodologies develop. A policy that creates financial incentives for primacy care training uses a simpler concept. It is based on the notion that if existing funding patterns do not generate the desired outcome incentives should be introduced that will encourage the desired behavior. Such a policy can be evaluated by the extent to which its goals of furthering primary care manpower are achieved, rather than by using cost accounting methods to calculate whether a level playing field between primary care and other specialties has been achieved. Medicaid The option of mandating that Medicaid programs should support GME by following Medicare regulations, or any other procedure, in an era of constrained budgets requires a reallocation of resources. It will be difficult, and undesirable, to persuade policy-makers that GME deserves support at a time when states are attempting to assemble resources to sustain or improve coverage of such populations as pregnant women and children. :40

Medicare Payment for the Indirect Costs of Education It is argued that ambulatory settings that train residents incur additional costs similar to those incurred by inpatient GME training. This provides a rationale for fully extending Medicare indirect payments to ambulatory settings. Furthermore, Medicare indirect cost payments are roughly double the direct cost payments, therefore reallocation within that pool wait be less painful to the losers. However. since the level of Medicare indirect payments is being reexamined and cuts are likely to occur, the impact of a policy based on manipulation of this shrinking revenue sources is likely to be weakened. Furthermore, cuts in revenues from Medicare indirect cost payments that erode hospital operating margins are likely to reduce commitment to GME, with primary care bearing the brunt of cuts. , , Federal Grant Programs Grants to sunnort family medicine. general internal medicine, and pediatrics training programs have played a major role in generating new primary care residency programs. However, it is unrealistic to believe that any expansion of the grant programs will occur, and even if additional money were to become available it would not be prudent to rely on grant money to rectify the fundamental financial problems of placing primary care residents in ambulatory settings. Grants can be vital to the initiation phases of a programs and provide the impetus for innovation, but should not be relied upon for ongoing support. Third Party Payers Policy options to improve GME financing through contributions from third party payers are sometimes based on the proposition that This proposition is disputed on the third party payers do not contribute to GME. grounds that GME is incorporated in charges paid by third partner payers. However, this contribution is being eroded as payers increasingly negotiate discounted charges. A proposal to urge third party payers to make voluntary contributions to GME is unrealistic. The insurance industry is highly competitive and operates with low margins, as evidenced by the number of companies that have abandoned health insurance because of low or zero profitability. In such a market the industry wait neither absorb the cost nor be able to pass it on to the payers, generally employers, who are becoming increasing concerned about the cost of health care coverage. The alternative -- trying to pass legislation to tax the insurance infusing is also problematical. The increase would be passed on to employers, who are vocal in legislative arenas. Furthermore, such a tax would be inequitable since it id:

could not be imposed on self-insuring corporations, and by increasing insurance costs it would also be likely to cause greater numbers of employers to turn to self insurance. Another, indirect, approach to taxing third party payers would be to tax hospitals which, in turn, pass the cost on to the third party payers. This strategy poses dangers to hospitals that provide large amounts of uncompensated care and may lack a sufficient base of charge paying patients on whom to pass the cost. Furthermore, some states use a tax on hospitals to garner revenues with which to pay for uncompensated care, making this mechanism less accessible for use by policy makers attempting to enhance GME revenues. 142

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Primary Care Physicians: Financing Their Graduate Medical Education in Ambulatory Settings Get This Book
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Because of changes in the health care system, the hospital has become less suitable as the primary focus of graduate medical education for primary care physicians. However, the current system of financing health care education and services makes it difficult to accomplish the needed shift to training in primary care ambulatory settings. This book suggests ways of lowering financial barriers to primary care training in ambulatory settings.

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