Reframing Medical Education: A Focus on Primary Care

To the Editor:

Changing the medical curriculum to meet the challenges of modern health care is a good idea.¹ Perhaps the area of greatest need is primary care.

Most primary care physicians (PCPs) no longer take care of hospital or nursing home patients. Increasingly, their time and their office staffs' time is consumed by administrative work in the form of insurers' regulations: prior authorizations for medications, referrals, and the distractions posed by electronic health recording, among others. These intrusions have led to widespread dissatisfaction and burnout among many PCPs.

A severe shortage of PCPs exists. Although policy-makers have expressed the need for more PCPs for more than 50 years,^2–4 the response from medical educators has been lackluster.

Today, only 17% of U.S. medical students are entering primary care residencies. Clearly, it will be impossible for medical schools to train enough PCPs. However, by taking a pragmatic approach, by customizing and shortening the college and medical school curricula, and by providing PCPs clinical training in community health centers rather than in hospitals, primary care doctors could be ready for service in 6 or 7 years, not 11.

If medical educators trained more PCPs for more rapid entry into the workforce, the workload per individual physician would be more manageable, enabling more time to spend with patients. Of course, this would cut into PCPs' incomes; but with shorter training time and less burdensome educational loans, the tradeoff may be acceptable.

More likely, however, nurse practitioners⁵ will be entering the primary care workforce to provide the primary care services that they trained for—a position endorsed by the National Academy of Medicine (formerly the Institute of Medicine). Although the idea of nurse practitioners as independent providers of primary care has not been enthusiastically received by doctors, it is a good idea.