Eric M. Wall

Retraining the subspecialist for a primary care career: four possible pathways

The degree to which a reformed U.S. health care system relies on an adequate supply of primary care physicians will determine the urgency of change in the composition of the medical workforce. In many areas of the United States, the demand for primary care physicians, particularly in managed care settings, far exceeds the supply. In contrast, reports of reduced practice opportunities for medical and surgical subspecialists in the same settings are increasing. As opportunities for and incomes of primary care physicians are enhanced, some medical subspecialists may seek retraining in primary care. This article provides a context for understanding the development of physician retraining programs, examines precedents for retraining physicians, describes four possible pathways through which medical subspecialists might acquire primary care training, and emphasizes the importance of defining the scope of practice and necessary skills for providing primary care. Obstacles to retraining appear to be economic (Who will pay? Is the cost worth the benefit?) and jurisdictional (Who will define core competencies? Who will credential programs and trainees?). The current absence of demand for such retraining programs suggests either that marketplace-induced changes will not take place or that the notion of a primary care provider shortage and an oversupply of medical subspecialists is overstated. The inclusion of physician retraining programs in proposed health reform legislation suggests that policymakers are convinced that such programs offer one viable solution to the nations medical workforce needs.

A Retrospective Study Of Patient Care Needs On Admission To An Inpatient Hospice Facility

Background: The care and support of dying patients and their families are among the most important skills of a family physician. In this century, an increasing proportion of deaths have occurred in hospitals with resulting medicalization of the dying process. Hospice care has emerged to focus on the relief of suffering rather than the cure of illness. This descriptive study reports information about the diagnoses, care needs, and attending physicians of a cohort of patients admitted to a free-standing, inpatient hospice program. Methods: We undertook a retrospective chart review of 335 patients admitted to a hospice program during a 26-month period, collecting data recorded on standardized nursing assessment forms. These forms provided information on 19 biologic, functional, and psychosocial symptom groups at the time of admission. Results: Family physicians were the admitting physicians in a minority of hospice admissions. Pain and mobility problems were the most frequent symptoms encountered. Other common issues included bowel, respiratory, and nutritional problems. Emotional difficulties were noted less frequently than these common biomedical problems. Conclusions: Family physicians should be trained to address core problems encountered in the care of dying patients. Multidisciplinary team approaches are essential in the management of many problems encountered in hospice care.

Will The Real Primary Care Provider Please Stand Up

The supply of primary care providers becomes ever more important with a marketplace that emphasizes the delivery of cost-effective care by primary care physicians. The promise of federal reforms combined with marketplace forces suggests that incentives for primary care physicians will increase while opportunities for subspecialist physicians will diminish. The widespread perception,2 that there are insufficient numbers of primary care providers to meet this nations health care needs and that an adequate supply cannot be restored for a very long time has prompted policy makers to think that the training of non-primary-care providers to deliver primary care services might be a critical short-term solution in the United States.3 In this environment the issue of who delivers primary care and who properly can be called a primary care provider has become especially contentious. An increasing number of specialty medical organizations and non physician health care providers now assert that they provide important amounts of primary care. Indeed, there is some support for their contention that some of the clinical activities which occur in the offices oflimited spe•. . •• 4-6 cialists are appropnate pnmary care actlVlt1es. The current debate appears to center on the competencies of different provider groups to deliver primary care services7 and the degree to which primary care services are provided byexisting health care providers. Primary care has been characterized in many ways. Its attributes include the following: first-contact care that is neither organ-specific nor disease-specific; illness-based care and care for undifferentiated health concerns; comprehensive, person-centered care; continuous or longitudinal care; coordinated care or responsibility for orchestrating a range of other health services that relate to the patients care; accessible care; community-oriented care; and care