Emerging lessons of the Interdisciplinary Generalist Curriculum (IGC) Project.

The Interdisciplinary Generalist Curriculum Project (IGC) was funded in 1993 by the Health Resources and Services Administration with the goal of developing innovative preclinical generalist curricula in ten of the nation's medical and osteopathic schools. The IGC successfully completed two competitive cycles in which ten schools were awarded three-year contracts. Although the long-term goal of the project is to increase the proportion of medical students choosing generalist careers, much has been learned thus far about the processes of curricular change and interdisciplinary cooperation. Drawing on information from school reports, site visits, external evaluations, academic presentations, and annual project meetings, this report presents the emerging lessons learned in the key areas of interdisciplinary collaboration, recruitment and retention of community preceptors, faculty development, and integration of generalist-related components into the four-year medical school curriculum. These lessons should prove useful for other schools embarking upon significant curricular innovations.

Morning report revisited: a new model reflecting medical practice of the 1990s.

Given the changes that are taking place in medical practice, it is important to reexamine traditional teaching methods in internal medicine residencies. One such component is morning report, which usually focuses exclusively on patients recently admitted to the hospital by the housestaff. A new morning report format described here adds several new components, including the review of patients who have been recently discharged from the hospital. The new format has been well received by the residents in the program and is an important step toward preparing them for the medical practice climate of the future.

The interdisciplinary generalist curriculum project: a national medical school demonstration project.

The United States is facing the challenge of producing more generalists for the physician workforce. The Primary Care Organizations' Consortium (PCOC) has responded by focusing on how medical education can be modified to enhance and support medical students' interest in and commitment to generalism early in their training. Evolving from PCOC's developmental work, the five-year Interdisciplinary Generalist Curriculum (IGC) Project was developed to encourage the nation's schools of medicine and colleges of osteopathic medicine to implement interdisciplinary generalist curricula in the preclinical years. Funded by the Division of Medicine in the Bureau of Health Professions of the Health Resources and Services Administration (HRSA), the IGC Project has successfully developed and implemented a nationally competitive medical school demonstration project. Thirty-three schools submitted proposals for an IGC Project award; nine were selected for site visits, from which five were chosen to receive three-year awards. Rigorous attention to creating and maintaining an interdisciplinary focus has characterized the first phase of the IGC Project. Shared leadership among the Executive Committee's project director and two project codirectors and parity in representation among the three disciplines of family medicine, internal medicine, and pediatrics on the Advisory Committee have formed a critical foundation for interdisciplinary functioning within the project. Growing national interest in generalist training and other funding initiatives have contributed to acceptance of the IGC Project. The high level of interest in the IGC Project and the successful interdisciplinary collaboration during the first phase would indicate that the interdisciplinary process can be replicated to move the nation's medical education institutions toward the production of needed generalist physicians.

Research in medical education: the challenge for the next decade.

As we enter a very turbulent period for medicine and medical education, it is essential that the importance and value of medical education research be demonstrated. Despite the billions of dollars that our society invests annually in medical education, medical education research, the "R & D" of medical education, is best with many problems. These include a low priority for academic medicine, underfunding, and insufficient consensus on goals and directions. More important, there is a notable lack of development of the theoretical base that should underlie such research. It is critical that the medical education research community, along with educators, academic administrators, and health policymakers, join to develop strategies and set priorities to enable medical education research to guide the future of medical education in a time of change and increased accountability.

Defining the generalist physician's training.

OBJECTIVE: To determine the extent to which various specialties prepare residents in the broad competencies required for primary care practice and to propose guidelines for improving generalist physician training. DATA SOURCES: Leading causes of morbidity and mortality, 1991 National Ambulatory Medical Care Survey data, expert reports, and the special requirements for residency training. DESIGN: From the data sources we identified the common presenting conditions and diagnoses that broadly trained generalist physicians could be expected to manage in primary care practice. We then compiled a list of 60 requisite residency training components grouped according to seven practice criteria for generalist physicians. Using the special requirements for residency training for family practice, internal medicine, pediatrics, obstetrics and gynecology, and emergency medicine, we determined the extent to which the requirements addressed the 60 components and continuity-of-care training. RESULTS: Almost all of the 60 generalist training components were required by family practice (95%), internal medicine (91%), and pediatrics (91%), compared with emergency medicine (42%) and obstetrics and gynecology (47%). Family practice, internal medicine, and pediatric residencies also require lengthy, well-defined continuity-of-care experiences. CONCLUSION: Family practice, internal medicine, and pediatric programs prepare residents in the broad competencies necessary for primary care practice. To train competent generalist physicians, we recommend that residency programs require training in 90% or more of the 60 components, 50% or more of the components in each of the seven categories, and a continuity-of-care experience for a panel of patients during at least 10% of the entire residency training period.

The generalist health care workforce: issues and goals.

The generalist health care workforce in the United States is best characterized as those practitioners who deliver primary care services. These include most family physicians, general internists, general pediatricians, nurse practitioners, osteopathic family physicians, and physician assistants. Based on a variety of factors, including health care needs, managed care/HMO hiring practices, international comparisons, and health care costs, the case for increasing the amount and proportion of generalist providers is compelling. Projections strongly suggest a worsening shortfall of generalists if no change is made. Changing the career choices of medical students to promote generalism, even significantly, will take 20 years or more to have a meaningful impact. Therefore, retraining specialist physicians in oversupply to practice as generalists is an important option to consider. To best meet the nation's health care needs, three issues need to be addressed in the context of health care reform: the creation of a "system" of generalist care that integrates into a coherent and collaborative framework the scopes of practice of the various generalist disciplines; the pursuit of a workable short-term model to convert specialist physicians into generalist physicians, led jointly by family medicine, general internal medicine, and general pediatrics, and a significant change in the medical education process to produce an ample supply of well-trained generalists.

The shortage of generalist physicians and federal funding of graduate medical education.

Graduate Medical Education (GME) payments through the Health Care Financing Administration (HCFA) represent the largest portion of federal funding in direct support of training for health professionals. Whatever the benefits of these funds, they clearly have not served as a positive factor in addressing the emerging shortfall of generalist physicians. Therefore, a variety of options are being discussed for restructuring the incentives associated with HCFA GME funds. Seven principal alternatives that have been proposed to address these problems are the following: modification of hospital GME payments, GME payments to medical schools, GME payments to residency programs, GME transfers through Medicare part B, GME transfers to the Health Resources and Service Administration, GME transfers to states through block grants, and GME payments to academic consortia. Unfortunately, each of these approaches offers substantial disadvantages and faces important opposing constituencies. To address these weaknesses, combined strategies and "all payor" federal mechanisms of GME financing have recently been proposed. These compromise approaches have their own administrative and political liabilities as well. Revisions in current HCFA GME payments may be preferable as a first step, but more comprehensive approaches involving all payor financing with mechanisms that reconnect medical school training with primary care practice will likely be required to ensure efficient and effective reform. Such major shifts in the federal funding of GME will not be quick in coming, however, and will doubtless be characterized by a compromise of policy effectiveness with political feasibility.

Ambulatory-based residency education: improving the congruence of teaching, learning, and patient care.

Residency education in internal medicine should be based in the ambulatory setting. The challenge in ambulatory education lies not only in the unique opportunities afforded by the setting but also in the careful implementation of a program based on sound educational principles. We have designed a new ambulatory-based model of internal medicine residency that adheres to the principles of adult learning theory. Four aspects of the proposed residency model are discussed: the setting, the teaching-learning model, the curriculum, and the schedule. Potential barriers to implementation of the model are reviewed, and solutions are suggested. Residency programs in internal medicine are at an important crossroad. Either we can substantially change the programs' content and focus, or we can risk the continued unpopularity and "second-class" status of the programs among medical students. Internal medicine needs to be recognized and accepted as a fundamental primary care discipline to justify continued public support in an era of overspecialization.

A national, interdisciplinary consortium of primary care organizations to promote the education of generalist physicians.

This essay begins with the history from 1989 through late 1991 of the Primary Care Organization's Consortium (PCOC), a group of representatives from nine major academic and professional organizations for primary care specialties. The PCOC was formed to discuss what might be done to reverse the alarming decrease in the number of medical students who choose primary care specialties. The article reviews some of the conditions that many believe have caused the continuing move away from primary care careers, and concludes with a description of the PCOC's program to encourage medical students to choose primary care careers, and the new opportunities for collaborative planning of such programs that are now available to medical schools. The PCOC's success in defining its program is due to a process of interdisciplinary planning and collaboration at the national level that hopefully will facilitate similar collaboration among medical school departments.

Alumni perspectives comparing a general internal medicine program and a traditional medicine program.

OBJECTIVE: To evaluate a primary care internal medicine curriculum, the authors surveyed four years (1983-1986) of graduates of the primary care and traditional internal medicine residency programs at their institution concerning the graduates' preparation. DESIGN: Mailed survey of alumni of a residency training program. SETTING: Teaching hospital alumni. SUBJECTS/METHODS: Of 91 alumni of an internal medicine training program for whom addresses had been found, 82 (90%) of the residents (20 primary care and 62 traditional) rated on a five-point Likert scale 82 items for both adequacy of preparation for practice and importance of training. These items were divided into five groups: traditional medical disciplines (e.g., cardiology), allied disciplines (e.g., orthopedics), areas related to medical practice (e.g., patient education), basic skills and knowledge (e.g., history and physical), and technical procedures. MAIN RESULTS: Primary care residents were more likely to see themselves as primary care physicians versus subspecialists (84% versus 45%). The primary care graduates felt significantly better prepared in the allied disciplines and in areas related to medical practice (p less than 0.01). There was no significant difference overall in perceptions of preparation in the traditional medical disciplines, basic skills and knowledge, and procedures. The same results were obtained when the authors looked only at graduates from the two programs who spent more than 50% of their time as primary care physicians versus subspecialists. There was no significant difference between the two groups in the perceived importance of these areas to current practice. CONCLUSIONS: These results suggest that the primary care curriculum has prepared residents in areas particularly relevant to primary care practice. Additionally, these individuals feel as well prepared as do their colleagues in the traditional medical disciplines, basic skills and knowledge, and procedural skills.