Training Tomorrow's Comprehensive Primary Care Internists: A Way Forward for Internal Medicine Education

Managing Comprehensive Care

For sake of brevity, we assume that readers are familiar with the Accreditation Council for Graduate Medical Education (ACGME) requirements for resident education in internal medicine.17 In addition to this vital foundation and the 6 ACGME competencies, we emphasize 2 additional competencies: comprehensive scope of care and longitudinal care planning.

Comprehensive primary care practices will need to expand their scope of care in the areas of advanced chronic disease, common outpatient procedures, and inpatient continuity of care. Two innovations will be important for managing advanced chronic disease: (1) patient registries, with responsibilities shared across the interprofessional primary care team,18,19 and (2) decision support by subspecialists, selected and incentivized to promote high-quality care in the comprehensive primary care practice.20

Tomorrow's comprehensive primary care internist, similar to current family practice physicians, will be able to competently perform common outpatient procedures needed by their patient population (eg, intrauterine device placement, colposcopy, suture of lacerations, incision and drainage of abscesses, joint injection). In some settings, comprehensive internists will provide integrated care by managing their patients in both the inpatient and outpatients arenas. The frequency of the need for the procedure or service, the individual's ability to develop competency in performing them, and ongoing quality monitoring should determine the scope of any physician's practice. At stake in each of these elements of expanded practice is the need to optimize continuity with a longitudinal care team.

Longitudinal planning refers to creating care plans congruent with patients' preferences and the time horizons for their conditions. For diagnoses of limited expected duration (eg, minor orthopedic injuries), care plans will be relatively short, ending when the episode of illness concludes. For chronic diagnoses expected to last a lifetime, care planning should encompass interventions to slow the progression of illness, reduce the severity and frequency of acute exacerbations, and when appropriate, facilitate end-of-life planning. During vulnerable transitions between care sites, longitudinal planning should begin with input from patients, their families, and their primary care team, and then optimize coordination between sending and receiving providers.

Becoming Effective Members of Patient-Centered Teams

In the area of effective team membership, 2 additional competencies are needed: team leadership and team “followership.” Team leadership requires skills in process improvement, workflow refinement, purposeful delegation, responding to performance metrics, and providing ongoing team member education and mentoring.21 Equally important is team followership and creating conditions that foster trust and enable others to act. At the heart of interprofessionalism is the recognition that multiple kinds of expertise (clinical, social, system, population, etc.) are needed to deliver comprehensive primary care.22,23 Tomorrow's internists must therefore practice participant leadership, inviting other team members to lead in turn, using their specific expertise to meet the patient or population needs at hand.

Empowering Community-Oriented Partnerships

Substantial evidence indicates that social determinants of health have a profound bearing on the public's health.15,24 Yet actions to modify those social determinants have traditionally fallen outside the purview of the health care sector. The comprehensive primary care internist of the future should actively seek out community partners and work to amplify their reach and impact. The physician's role is to adopt an open, community-oriented stance, foster trusting relationships with key community stakeholders, and then work with those stakeholders to identify priority social determinants and develop integrated clinical and community-based interventions to address them. This approach harkens back to the original US community health centers in Boston, Massachusetts, and Mound Bayou, Mississippi.25,26

Training Reform 1: Teach Comprehensive Care Management, Team Membership, and Community Partnership to Primary Care Residents

Formal training in these areas should include classroom-based learning, project/goal-directed learning, and longitudinal reflective practice (ie, both “reflection-in-action,” which occurs in the workplace, and “reflection-on-action,” which occurs later).27 Assessment of developing competency in these areas should proceed throughout residency training. For residents to be capable of caring for most problems with which patient populations present, patient need, rather than traditional specialty boundaries, should drive the skills taught in residency. This will require that faculty develop competency in new procedures and, in the meantime, that residents learn these skills from the appropriate mentors.

We recommend that part of the evaluation for board eligibility include direct observation of performance in teams of various types (eg, multilevel inpatient teams, interprofessional medical home teams). We recognize that learning advanced teamwork and communication skills is a lifelong endeavor. The graduates' early years in practice should deliberately supplement residency learning in these domains.

Primary care residents should also spend time learning from, and working alongside, leaders in their local communities outside the confines of the clinic. Residents could, for example, be embedded in community care teams composed of social workers, behavioralists, dieticians, and home health nurses. Community dwell time may be needed if residents are to learn how to build durable and productive relationships with community partners.

Training Reform 2: Redesign Training Programs to Prioritize Comprehensive Longitudinal Care

Currently, most internal medicine training—even in primary care–oriented residencies—occurs in the hospital.17 As a result, graduates pursuing careers in primary care are underprepared for ambulatory practice.28 For training programs to produce graduates with the necessary skill sets, experience delivering comprehensive, longitudinal care must become the central priority.29

During the past few years, many internal medicine residency programs have implemented block-rotation approaches to meeting Residency Review Committee requirements for ambulatory training.30,31 Although current block models do provide an immersion experience for trainees, the program design remains fundamentally discontinuous. Little is known about the optimal duration of these ambulatory blocks as a strategy to inculcate the knowledge, skills, practices, and values needed for mastering competencies in managing comprehensive care, providing effective team membership, and empowering community-oriented partnerships. Mastery takes time. Total duration of training in patient-centered ambulatory care settings must be sufficient for residents to have a chance at becoming competent.

There is no single best way of restructuring residents' ambulatory experiences to ensure longitudinal and comprehensive training; creativity and flexibility in partnership with clinical leaders will be required. At the very least, residency programs must abolish the common practices of “flexing” clinic days and no-clinic rotations to accommodate inpatient service needs. Without predisposing any particular rotational design solution, residency programs must be held to a minimum patient-centered and learner-centered continuity requirement. This stability is a precondition for incorporating residents into longitudinal teams, which will be necessary for them to observe, learn, and practice effective teamwork.32

Training Reform 3: Improve the Performance of Primary Care Teaching Practices

Many primary care teaching practices do not exemplify the highest standards of comprehensive care management, patient-centered teamwork, or community partnerships to modify the social determinants of health. As a result, primary care residents are taught 1 thing and shown another. This is not only a setup for suboptimal learning but also a promotion of cynicism, burnout, and avoidance for a primary care career.33 Learning environments matter.34,35 We propose that primary care teaching practices should become focal points and exemplars of high-quality, efficient, comprehensive community-oriented care.

Teaching practices cannot achieve a transformation of this magnitude in isolation. Bold leadership and institutional commitment will be needed to integrate the primary care delivery mission with the education and training missions within academic centers. Clinical leaders must identify resources to catalyze necessary changes in personnel, work flows, space, and so on. Community training programs, by virtue of their smaller size and reduced “inertia,” may actually be better positioned to develop exemplary teaching practices. Learning collaboratives should be organized to share and build on lessons learned from their experiences.

Three relevant initiatives are underway. The Harvard Medical School Center for Primary Care has launched an Academic Innovations Collaborative to foster innovation in education and care delivery at 18 Harvard-affiliated primary care teaching practices. Students and residents work with practice leaders to improve performance in 4 areas: (1) team-based care, (2) management and prevention of chronic illness, (3) management of patients with multiple illnesses, and (4) patient empowerment and behavioral change.36 Meanwhile, the Kraft Center for Community Health (currently in Boston but with plans to expand to western Massachusetts in the coming year) has developed a 2-year fellow and practitioner program to foster hybrid leadership careers in community health. Kraft trainees practice primary care in a community health center, have protected time to participate in formal learning sessions and complete a mentored scholarly project, and receive loan repayment in exchange for a 2- to 3-year service obligation in a federally qualified health center.37 In addition, the Veterans Health Administration is funding 5 Centers of Excellence in Primary Care Education to redesign education and training for health professionals, including internal medicine residents, nurse practitioners, pharmacists, and psychologists, among others.38 Faculty, trainees, and clinical team members are collaborating to improve learning about and delivering patient-centered care in interprofessional, team-based, primary care practices. Experience from these initiatives may help lower the bar for public-private partnerships to replicate and scale these models to other academic medical centers and freestanding community training programs.