What Would Primary Care Education Look Like?

This is an attempt to outline what we might want to do to create Primary Care Education. Hopefully we can discard as much of the past ineffectiveness as possible and focus on what we feel would best serve patients, now and in the future. Certainly we can expect obstacles and competition, but we need to go beyond compromise.

The focus is on the kind of primary care doctors that we need to be able to deliver care where it is most needed, and then going designing a curricula that would accomplish this. Our priority should be to train the doctors that are needed, not just doctors who are intellectually competent. Some of our candidates may not be able to meet the needed competencies, but they will have skills that they can use regardless of graduation. This is better than giving doctors skills that they may never use and having them go where they are not needed to use resources that we cannot afford to waste.

Length of Training The required curricula would be approximately 6 years with another year to tailor the final preparation. Students wanting to specialize would have to do a traditional residency (the prospect of 9 years of training and the specific focus on primary care would be pretty discouraging for career fence-sitters).

Primary care schools would screen candidates with service programs. The candidate would need to initiate or supervise the program. We would monitor their efforts over several months. No interview for admission would be needed.

The primary care school would choose half of the class or more from established leaders in communities that needed physicians rather than have them come to us. It would be a great honor to be chosen.

The tough decision would be in the hands of the candidates where they had to decide if they were called to the task at hand. They would decide if what they wanted to accomplish with their lives would be facilitated by primary care training and whether it was worth the sacrifice. This is in stark contrast to many candidates who go to medical school because it is the next step. Candidates would not be worried about finding a spouse in a small town or whether they would be safe in the inner city. Candidates would be looking to recruit others in their communities to join them and replace them, almost before they begin training.

Ongoing connections with the community would notify us of appropriate candidates. Candidates and referencees would include people that we often work with now such as public health nurses, various coordinators, public health people, educators, social workers, psychologists, community leaders, volunteers, etc.

A college degree would not be as important as demonstrate competency in areas that matter to patients: culture, language, communication skills, and problem-solving in multiple dimensions.

Candidates would be mature individuals who would continually challenge the relevance of the curricula.

Costs The tuition costs would be minimal, certainly not enough for the school to make a profit. Service-learning would exchange for tuition. Candidates would have little debt upon graduation, at least for educational costs. (for those disbelieving that this can be done, Florida just antied up millions for the prospect of getting the right folks in geriatrics and the underserved in a state that has massive physician importation.)

Students would stay in their communities of origin as much as possible during training.

Students would do longitudinal clinical training from day 1.

The school would matriculate 3 or 4 classes a year. This facilitates small group learning.

The focus of the professors is education, not research. They are facilitators of an entire quarter, semester, or year, rather than teaching one or two days. Students having difficulty would then be able to master the concepts rather than having to fake it or having to sit back an entire year.

Classes would gather together for required hands-on and interactive sessions one week out of each 4 - 8 weeks. Students could pursue service or education or personal projects at any time to facilitate their needs.

The first 2 years of curriculum that was not clinical would be internet-based. Some of this could be completed before official acceptance. Students could complete the curriculum and pass required exams 1 year minimum and 4 years maximum.

As students reached the 5th year, they would interview around and begin to transition to practicing in their eventual location. This would be their current location or a site that they were courting. They would finish their 5th and 6th years there and then they would work with the site to set up their final year of training. When they begin, they will hit the ground running, fully oriented and well-trained.

Evaluations would be quarterly in group and in individual sessions. Curricula would be individualized to meet interests, career needs, and remedy areas where candidates did not have the required competency. The competency approach also allows some individuals with experiences to gain extra experience and credit. This experience would also be put to work as service-learning for the school.

Schools would work closely with teaching sites to assist them with information systems, quality, community efforts, and business consultation. This would compensate them for their effort, assist educational efforts, and help practices to be state of the art in both the medical and business sense. This is of course the only way to be for them to be able to train our students well. Students trained in these areas would assist in these efforts as part of their required service-learning.

Graduate Characteristics Graduate will be ready to serve, ready to teach, located where they are needed, oriented to the practice situation of their communities, familiar with the community leadership, and understanding of community needs. Targets would be 80% to graduate, 95% in primary care, 80% located in same or similar community of need, and 100% serving patients as top priority. Numbers, location of training, and characteristics of training would self regulate. As needs were met, fewer candidates would be referred from served locations and more would come from underserved locations.

Hopefully this is a Never-Ending Story. There is room to grow and discuss and refine. Obviously we can only see as far as the immediate obstacles will let us. When we knock some down, others will rise to challenge us.

it is also an experience which creates attitudes and expectations A. Flexner

We are not talking about simple changes and steady progress any more. We are talking about core changes in the basic foundation and principles of health care education so that we can center the new primary care schools on education and service and community.

Our family practice education, even with its shortcomings, created some attitudes and expectations that current medical education is not fulfilling. We are left with the legacy and the responsibility, but we have little of the authority. We really have no choice but to create a different experience. At stake is nothing less than the future of medical practice.

Robert C. Bowman, M.D. 12/12/2000