From the primary care organizations consortium's proposal to the Interdisciplinary Generalist Curriculum Project.

The Interdisciplinary Generalist Curriculum (IGC) Project was one element of an overall federal government strategy designed to promote primary care education. This project, undertaken by the Division of Medicine and Dentistry (DMD), Bureau of Health Professions, Health Resources and Services Administration, U.S. Department of Health and Human Services, was the first large-scale medical education contract initiated by DMD. The IGC Project was based on a model proposed by the Primary Care Organizations Consortium (PCOC). The PCOC thesis was that "if students are to decide to pursue a generalist career they must have the opportunity to be taught by generalists." The PCOC Program required an explicit curriculum focusing on generalist knowledge and skills with an emphasis on technology, in the context of education that required training in ambulatory office-based settings. The PCOC Program specified that responsibility for the program's planning, implementation, and evaluation be shared by the three generalist physician faculties of family medicine, general internal medicine, and general pediatrics. In implementation of this demonstration project in ten medical schools across the nation, several lessons have been learned relative to enhancement of generalist education. Among these lessons is that seed money targeted to initiate modest change can act as a catalyst and improve the knowledge and skills afforded medical students concerning generalist practice. Limited funds provided over a sufficient period of time can induce schools to undertake significant curricular change.

The Interdisciplinary Generalist Curriculum (IGC) project: an overview of its experience and outcomes.

The Interdisciplinary Generalist Curriculum (IGC) Project was a competitive, seven-year demonstration project funded by the Health Resources and Services Administration (HRSA). It was established to determine whether specific interdisciplinary innovations in preclinical medical school curricula could affect students' selection of careers in family medicine, general internal medicine, or general pediatrics. Through collaboration among the three generalist disciplines, the IGC innovation exposed all preclinical students in ten demonstration schools to a new or significantly enhanced preclinical curriculum that included a direct supervised clinical experience with a generalist physician preceptor. The project was managed by an interdisciplinary executive committee that was codirected by one representative each from family medicine, general internal medicine, and general pediatrics. A national advisory committee with representation from the academic and professional organizations of family medicine, internal medicine, pediatrics, and osteopathy provided input to the executive committee in guiding the project. The project was externally evaluated. Major outcomes of the IGC Project include sustained curricular changes in ten institutions, prompted by relatively few dollars and demonstration of models for collaboration at institutional and national levels. This supplement describes the IGC Project's experience and outcomes so that others may draw pertinent information to apply to their own efforts in medical education.

A comparison of family medicine research in research intense and less intense institutions.

BACKGROUND: Family medicine is a relatively new specialty that has been trying to develop a research base for 30 years. It is unclear how institutional research success and emphasis have affected the research productivity of family medicine departments. OBJECTIVE: To examine the research infrastructure, productivity, and barriers to productivity in academic family medicine in research intense and less intense institutions. DESIGN, SETTING, AND PARTICIPANTS: A survey of 124 chairs among institutional members of the Association of Departments of Family Medicine. Departments were categorized as being associated with research intense institutions (defined as the top 40 in National Institute of Health funding) or less intense institutions. MAIN OUTCOME MEASURES: Prioritization of research as a mission, number of funded research grants, total number of research articles published, and number of faculty and staff conducting research. RESULTS: The response rate was 55% (N = 68). Of 5 potential ratings on the survey, research was the fourth highest departmental priority in both categories of institutions. Departments in research intense institutions were larger, had more faculty on investigational tracks, and employed more research support staff (P<.05). Neither category of department published a large number (median = 10 in both groups) of peer-reviewed articles per year. Controlling for the number of full-time equivalent faculty, the departments in less intense institutions published a median of 0.7 articles, while the research intense institutions published 0.5 (P =.30). Departments in research intense institutions received more grant funding (P<.005) in both unadjusted and adjusted analyses. Chairs reported a scarcity of qualified applicants for research physician faculty openings. CONCLUSION: Future initiatives should focus on prioritizing research and creating a critical mass of researchers in family medicine. Arch Fam Med. 2000;9:1100-1104

Challenges to academic family medicine in the current health care environment.

BACKGROUND: Changes in health care delivery and funding have placed strains on academic medical centers' ability to meet their multiple missions. To gain insight into how this new academic landscape is affecting academic primary care, this study examined the current status and perceived challenges at nine departments of family medicine at allopathic and osteopathic medical schools. METHODS: Site visits were made to nine academic departments of family medicine where key informant interviews were conducted with several individuals in key leadership positions. Sites were chosen to maximize diversity among departments along a variety of factors, such as location, size, mission, and type of school (private versus public). Interviews were transcribed and analyzed by a three-person multidisciplinary team for key themes. RESULTS: Analysis of interviews revealed five major challenges for academic departments of family medicine: 1) adjusting to new clinical demands in the academic health center, 2) organizing and administering new initiatives in community-based education, 3) recruiting and retaining faculty, 4) developing and maintaining research capacity, and 5) serving multiple missions (education, clinical care, and academic pursuits) in times of financial restraint. CONCLUSIONS: Significant challenges face academic departments of family medicine. The success or failure of departments of family medicine to meet these challenges could serve as a bellwether for how primary care fits into the future overall scheme of academic health centers.

Eliminating primary care health professional shortage areas: the impact of Title VII generalist physician education.

Most policy-makers and researchers agree that although the United States is headed for a significant physician surplus, problems of equity in access to care still remain. To help meet this challenge, Title VII of the Public Health Service Act focuses on producing generalist physicians to serve in medically underserved areas (MUAs). This study estimates the impact Title VII support for generalist training has on reducing and eliminating health professional shortage areas (HPSAs) under multiple scenarios that vary either the Title VII funding level or the percentage of Title VII-funded program graduates who practice in MUAs. For each scenario, the number of Title VII-funded residency graduates who initially practice in MUAs and the time it would take to eliminate HPSAs are estimated. Using 1996 rates, the analysis predicts that 1,214 generalist physicians will enter practice in HPSAs annually, leading to elimination of HPSAs in 24 years. In 1997, Title VII-funded programs increased the rate of graduates entering HPSAs, resulting in 1,357 providers and reducing the time for HPSA elimination to 15 years. Doubling the funding for these programs would increase the number of Title VII-funded generalist physicians entering MUAs and could decrease the time for HPSA elimination to as little as 6 years. The study concludes that eliminating HPSAs requires broader Title VII influence and continuous improvement in rates of production of graduates who practice in MUAs. Without Title VII graduates and continuous improvement of Title VII program, MUA rates, the number of HPSAs and the number of Americans with reduced access to essential health care will continue to expand.

The impact of graduate medical education financing policies on pediatric residency training.

OBJECTIVE: To review special issues related to pediatric residency training in managed care organizations, the effects of the changing health care system on the demand for pediatricians and the potential impact on financial support for residency training, current methods of financing graduate medical education (GME), possible future approaches to financing GME, and policy directions to support training of pediatricians well prepared for future practice. METHODS: We reviewed current information on residency education in managed care settings, including the rationale for training in such settings and the realities of such educational experiences. We then assessed the evidence concerning the supply and demand for pediatricians in the present health care marketplace, with its evolution to managed systems of health care. We summarized current approaches to financing GME through Medicare, Medicaid, private insurers and purchasers, and direct federal and state support, with emphasis on the financing of ambulatory training which could occur in managed care settings. Lastly, we described factors influencing the upcoming revolution in GME financing and outlined possible new policy directions for the financing of relevant GME training experiences. RESULTS: Appropriate training experiences in managed care organizations may be a valuable strategy to address the current disconnect between the traditional hospital-based education of pediatricians and the expanded competencies necessary to practice in intensively managed, integrated and accountable health systems. Present pediatrician supply appears to be in relative balance with health maintenance organization staffing patterns and with needs-based requirements estimates. However, the pediatrician-to-child population ratio is predicted to increase rapidly over the next decade, leading to an oversupply of pediatricians under likely future health care delivery system scenarios. Medicare is the largest explicit payer of GME training costs, historically directing reimbursement primarily for hospital-based education. Numerous innovative financing strategies are being considered to facilitate funding of GME training in ambulatory settings and to open up funding to greater public scrutiny and accountability. CONCLUSIONS: Although reforms in federal GME financing have been limited to date and other significant changes have been largely state-based, it is likely in the future that explicit funds will be targeted to specialties in demand that prepare physicians well for future practice. Pediatricians and medical educators must intensify their voices in the financing debate to ensure a productive future for quality pediatric residency training.

Matching physician supply and requirements: testing policy recommendations.

Managed care has been growing and likely will increase market share. This movement will require fundamental alterations in the number and specialty distribution of physicians. Under current production, future supply does not appear well-matched with requirements. Although the adequacy of generalist supply is of concern, the oversupply of specialists is the overriding problem. Neither reducing the number of first-year residents nor increasing the generalist output alone would bring both generalist and specialist supply within requirement ranges. Combining an increase in generalist production to 50% with a reduction in first-year residents to 110% of the number of U.S. medical graduates would minimize the projected specialty surplus while maintaining generalist supply within the requirement range.

State practice environments and the supply of physician assistants, nurse practitioners, and certified nurse-midwives.

BACKGROUND: Most proposals to increase access to primary care in the United States emphasize increasing the proportion of generalist physicians. Another approach is to increase the number of physician assistants, nurse practitioners, and certified nurse-midwives. METHODS: We analyzed variations in the regulation of nurse practitioners, physician assistants, and certified nurse-midwives in all 50 states and the District of Columbia. Using a 100-point scoring system, we assigned numerical values to specific characteristics of the practice environment in each state for each group of practitioners, awarding a maximum of 20 points for legal status, 40 points for reimbursement for services, and 40 points for the authority to write prescriptions. We calculated coefficients for the correlation of summary measures of these values within states with estimates of the supply of practitioners per 100,000 population. RESULTS: There was wide variation among states in both practice-environment scores and practitioner-to-population ratios for all three groups of practitioners. We found positive correlations within states between the supply of physician assistants, nurse practitioners, and certified nurse-midwives and the practice-environment score for the state (Spearman rank-correlation coefficients, 0.63 [P < 0.001], 0.41 [P = 0.003], and 0.51 [P < 0.001], respectively). Positive associations were also found in the states between the supply of generalist physicians and the supply of physician assistants (r = 0.54, P < 0.001) and nurse practitioners (r = 0.35, P = 0.014). Nevertheless, in the 17 states with the greatest shortages of primary care physicians, favorable practice-environment scores were still associated with higher practitioner-to-population ratios for physician assistants (r = 0.68, P = 0.003), nurse practitioners (r = 0.54, P = 0.026), and certified nurse-midwives (r = 0.42, P = 0.09). CONCLUSIONS: State regulation of physician assistants, nurse practitioners, and certified nurse-midwives varies widely. Favorable practice environments are strongly associated with a larger supply of these practitioners.

Correlates of emergency room utilization in the first year of life.

We conducted a case-control study to examine the correlates of emergency room use in the first year of life, particularly the role of parental health beliefs, among the families of inner-city children enrolled in a hospital-based primary care program. Data was collected by structured interviews and by medical record review. Emergency room users were more likely to have single mothers and to have acute, recurrent medical conditions than were non-users. Health beliefs differed between groups by maternal report of worry about the kinds of illnesses that her child acquires. Emergency room use was predicted by: maternal marital status, maternal worry and concern that illness interferes with her child's activity, acute recurrent illnesses, hospitalization. This model may be applicable to other populations in designing intervention strategies to modify emergency room utilization.

Sickle cell crisis and sensorineural hearing loss: case report and discussion.

Patients in sickle cell crisis may complain of unilateral or bilateral hearing loss which is typically a mild to moderate high-frequency sensorineural hearing loss in the affected ear(s). Auditory acuity can return to precrisis levels. A literature review suggests that the etiology is cochlear ischemia. A review of the literature, case study, and discussion will be presented.