Despite an increasing need for outpatient physicians in the U.S., hospital wards continue to serve as internal medicine's primary training grounds.
In effect, this inpatient training model prepares residents to be inpatient doctors rather than primary care physicians, said Fred N. Pelzman, MD, an associate professor of medicine at NewYork-Presbyterian Hospital in New York City. “In residency, I got really good at acute myocardial infarctions and getting people out of diabetic ketoacidosis and sepsis. These were people who were incredibly sick, lying in a hospital bed,” he said. “But that isn't where most health care happens.”
Most patient visits and more than 60% of procedures now occur in the outpatient setting, according to a 2014 Council on Graduate Medical Education (COGME) report. “Still, the focus in the hospital is on really critically ill patients … and there hasn't been a commensurate change to the volume of time and the attention that is needed in the outpatient world to train the residents,” Dr. Pelzman said.
By 2030, the shortfall in primary care physicians is projected to be between 7,300 and 43,100, according to a 2017 report commissioned by the Association of American Medical Colleges (AAMC).
The COGME has pinned 40% as the ideal proportion of U.S. medical graduates entering careers in primary care (e.g., general internal medicine, family medicine, geriatric medicine, and pediatrics). However, as of 2010, only about 32% of physicians in the U.S. practiced primary care, according to the group.
There is widespread but delayed recognition of the primary care physician shortage, as well as the need to reform training and recruit a new generation of medical students to go into primary care, said Allan Goroll, MD, MACP, a professor of medicine at Harvard Medical School and an internist at Massachusetts General Hospital in Boston. “We are about 20 years late. We have let primary care training decline in intensity, both in terms of funding and in terms of structure and function,” Dr. Goroll said.
The Accreditation Council for Graduate Medical Education (ACGME) requires that internal medicine residents complete at least one-third of their training in the ambulatory setting and 130 distinct half-day outpatient sessions over a period of 30 months or more.
Despite the outpatient mandates, clinic time is often seen as secondary to the bulk of residents' work, said Heather Brislen, MD, FACP, clinical assistant professor at the University of New Mexico and the New Mexico VA Health Care System. “It's not easy for programs and residents to meet outpatient training requirements because you're mixing ambulatory education time into a predominantly inpatient work environment where hospitals rely heavily on medical residents to run their inpatient wards,” she said.
ACP has called for the ACGME and residency review committees to establish specific goals for increased time spent by residents in ambulatory settings. “Internal medicine residents should receive exposure to primary care in well-functioning ambulatory settings that are financially supported for their training roles,” the College asserted in its 2011 policy paper, “Aligning GME Policy with the Nation's Health Care Workforce Needs.”
For Jeffrey Kohlwes, MD, MPH, FACP, the ACGME's current outpatient requirements are at “an irreducible minimum.” In order to offer sufficient clinic exposure, programs must have both the institutional will to do so and faculty who are actively engaged in making sure there's a robust primary care experience, said Dr. Kohlwes, director of the PRIME residency program at the University of California, San Francisco.
“I would like to see more opportunities for residents to be able to be exposed to a successful career in primary care,” he said. “I think there are going to be a lot of fundamental roadblocks to that.” Such roadblocks include the differential in reimbursement and the fact that previous generations of primary care doctors are not always excited about their jobs, Dr. Kohlwes said. “We have to show people why it's a great career,” he said.
The right track
In the most recent resident match, 7,233 positions were offered in categorical internal medicine, and another 341 positions were offered in primary care medicine, according to 2017 National Resident Matching Program (NRMP) data. Internal medicine has seen healthy growth since 2012, when it offered 5,277 residency spots, but the number of primary care spots has barely budged from 311 in 2012, according to NRMP data.
Although it's possible to learn primary care in a traditional categorical training program, the large majority of residents in such tracks are not planning careers in primary care, said Dr. Goroll. In fact, in the ACP Internal Medicine In-Training Examination® (IM-ITE), the number of third-year internal medicine residents who reported planning careers in general internal medicine plummeted from 54% in 1998 to 23% in 2007, ACP reported in a 2009 policy paper.
That figure continues to decline and was 19% in the 2015 IM-ITE survey. “So primary care internal medicine is at risk for disappearing from the primary care realm at the very time that it should be leading in primary adult care [for] an aging population with increasingly complex chronic illness,” Dr. Goroll said.
Primary care internal medicine tracks have become more common but are not the norm, according to an analysis in the September 2016 American Journal of Medicine. Using 2014 NRMP data, researchers found 104 internal medicine primary care programs in the U.S., 64 of which had a distinct NRMP match number and 40 of which offered a primary care track within an internal medicine categorical residency.
Of importance, exposure to a primary care-specific residency track is associated with a career in primary care, according to a July 2015 study published in the Journal of General Internal Medicine. Primary care track alumni were much more likely than categorical alumni to report that the majority of their current work was in outpatient primary care (54% vs. 20%), according to the study.
Dr. Kohlwes, senior author of the study, said it appears that exposure is key to fostering new primary care doctors. “If we really want to nurture primary care, then we need to teach residents that they can have a successful career in primary care and give them the skills to be able to hit the ground running when they start their career in primary care,” he said. Such skills extend beyond clinical knowledge, such as managing correspondence with patients, Dr. Kohlwes noted.
He said UCSF follows an every-other-month model in terms of primary care: All second- and third-year residents complete six months of inpatient care and six months of ambulatory care, alternating between the two settings each month. During ambulatory time, UCSF's primary care and categorical residents have four and three half-days of clinic per week, respectively, he said. “We try to keep [inpatient and outpatient work] very separate so people can experience what it's like to be on an outpatient schedule as they're going through their residency, at least for half the time,” Dr. Kohlwes said.
When Dr. Goroll was a Harvard medical student in the early 1970s, he worked with the faculty at Massachusetts General Hospital to design the first formal primary care track in internal medicine. Dr. Brislen also designed her own primary care internal medicine track in 2009 while training at the University of New Mexico. “A lot of it is really about confidence-building, cultivating independence, and learning how to build relationships and feel brave enough to move out on your own, away from the inpatient culture,” she said.
Interns do not match into the track at the University of New Mexico. Instead, after completing their internship year, residents may elect to opt in to the track for their second and third postgraduate years, completing three-month blocks of mixed ambulatory care rotations. The three-month block consists of six half-day ambulatory care clinics, and the remaining four half-days of the week include two half-days of resident continuity clinics, a cardiology clinic half-day, and a residency-wide educational half-day, said ACP Member Lauren Liaboe, MD, primary care chief resident and a graduate of the track.
Residents do their own networking and choose which clinics they'd like to work in, she said. “It's like a buffet: You get to choose the ones you want to target your career.”
The track offers more continuity than the standard of having to leave the hospital to attend two half-days of clinic during a month on inpatient medical wards, Dr. Liaboe said. “I think that's part of why people get annoyed with clinic when they're in residency. They're constantly being pulled from [inpatient tasks] to their clinic, and then they have to go back to that original task,” she said.
Even if an internal medicine residency program does not have a distinct primary care track, it has the opportunity to bolster the outpatient experience for trainees interested in primary care. “Because we don't have a track system, we found a different way to connect to those who were interested,” said Corey Dean, MD, FACP, associate program director of ambulatory medicine for St. Joseph Mercy Hospital's internal medicine residency in Ann Arbor, Mich.
In 2014 and 2015, program administrators surveyed residents about one to five years post-residency and found that many reported being underprepared to understand the business of medicine, quality metrics, and incentive-based care. Then, in 2015, the program implemented a “transitions to practice” curriculum, which includes evening seminars devoted to career-strengthening skills and panel discussions with outpatient physicians, Dr. Dean said. “That's been really helpful for the residents to get a good idea about outpatient medicine,” he said.
Perhaps most of all, the residents have taken to the individualized career path, wherein they develop a longitudinal mentoring relationship with a primary care physician for one to two years, Dr. Dean said. “It's really been a great way for our trainees to spend a larger proportion of their training that's usually done in the inpatient setting and get a different perspective of what outpatient medicine would be like,” he said.
Being able to partner with faculty bolstered the outpatient experience for ACP Member Ashley Schmehl, DO, an internist at IHA Internal Medicine & Pediatrics in Plymouth, Mich., who graduated from the program in 2015. “You still spend more time as a resident in the inpatient realm, but I got more time in the clinic, more time doing things like joint injections [and] skin biopsies with other primary care doctors than I otherwise would've gotten,” she said.
Programs can also take advantage of the national trend of hospital medicine, said Dr. Kohlwes. With a burgeoning hospitalist workforce at UCSF, comanagement and medicine consults no longer needed to be staffed by residents, he said. “Rather than assigning our residents to rotate more in the hospital, we left those rotations to the hospitalists, allowing [our residents] to have the clinic experience that we think is important for them,” Dr. Kohlwes said.
However, the colliding eras of inpatient-heavy residency and hospital medicine often make it difficult for residents to leave their comfort zone, Dr. Brislen noted. “Before, if you didn't do fellowship training, most people went into primary care by default. But now, there's this hospitalist job option that looks a lot like what you did as a resident,” she said. “Without feeling confident and bold enough to take the leap into this really different [outpatient] environment, people just don't make that change.”
For Dr. Goroll, internal medicine programs need to provide a robust outpatient experience in order to prepare new physicians for the demanding job of being primary care general internists. “To just say that ‘We have a primary care opportunity because we give you a few extra clinics in medical subspecialties and nonmedical specialties related to primary care,’ that in my view is very insufficient,” he said. “We need dedicated tracks with substantial protected time for the learning of outpatient medicine, which is just as demanding and difficult as inpatient medicine.”