Medical Education - December 2008
Tex Med . 2008;104(12):43-45.
By Ken Ortolon
Steven L. Berk, MD, is blunt as he talks about the worsening shortage of primary care physicians in Texas and the nation. " We cannot continue having only 8 percent of our medical students going into family medicine," said the dean of the Texas Tech University Health Sciences Center School of Medicine.
He's blunt, and he has a plan. Dr. Berk and his colleagues in Lubbock propose creating a new program that not only could attract more medical graduates to primary care, but also could hasten production of some new primary care physicians.
Earlier this year, Texas Tech asked the Accreditation Council for Graduate Medical Education (ACGME) for approval to launch an accelerated residency program in family medicine that would allow some outstanding medical students to combine their fourth year of medical school with the first year of residency. Tech officials hope to recruit nearly 20 other medical schools with family medicine residency programs to join them.
Dr. Berk says the "three plus three" program - three years of medical school and three years of residency - could have a "fairly dramatic" impact on the number of U.S. medical graduates entering family medicine.
"Family medicine is so unpopular as a residency choice in parts of the United States that there are family medicine residency programs that don't have a single U.S. graduate in them," said Dr. Berk, an internal medicine specialist. "So, of course, the opportunity to keep one's own students in the family medicine residency program is just tremendous."
Several national organizations, including the Robert Wood Johnson Foundation and the American Association of Medical Colleges, say at least 50 percent of the nation's medical graduates should be choosing primary care. But, instead, the number entering primary care specialties is shrinking, and Texas and the nation face a serious shortage of primary care physicians that is only likely to get worse.
The number of U.S. medical graduates entering primary care specialties has fallen 50 percent since 1998, according to a recent report by the National Association of Community Health Centers, the Robert Graham Center, and the George Washington University School of Public Health and Health Services. And in 2008, there were 44 fewer family medicine residency programs and 780 fewer filled training positions than in 2000.
Repiloting the Pilot
The accelerated residency program that Texas Tech wants to launch is not new. In fact, the American Board of Family Medicine (ABFM) approved the first accelerated residency program at the University of Kentucky in 1989. Throughout the 1990s, medical schools in Alabama, North Carolina, Tennessee, South Carolina, Ohio, Nebraska, and elsewhere started similar programs in both family medicine and internal medicine.
While each program had unique features, the general approach was to choose mature students in the top half of their class to complete the fourth year of medical school and first year of residency concurrently. All requirements of the fourth year of medical school had to be met either during residency rotations or in a four-month education block. All were paid as residents and some received scholarships or tuition deferment, as well.
Dr. Berk says Texas Tech would pattern its effort after those programs, all of which he says were successful. Students were eager to participate for several reasons. First, there was a "prestige effect" for students chosen to participate. "Where going into family medicine may not be considered that prestigious, here you were moving out ahead of your class and becoming an intern," Dr. Berk said.
Not only was training time shortened by a year, but also the medical school debt of those in the accelerated residency program was reduced.
Reports from the medical schools involved with accelerated residency programs in the 1990s concluded that the program's residents actually scored better on certification and training exams than did traditional residents.
A 2002 report [ PDF ] from Marshall University found that over nine years, accelerated residents scored on average 30 points higher on training exams. "The program demonstrates that for carefully selected candidates, the program can provide an overall shortened path to board certification and attract students who excel academically and have high leadership potential," that report concluded.
Despite that success, the early pilot programs were discontinued by 2002, after ACGME chose not to endorse accelerated residency permanently because allowing trainees to begin residency before graduating medical school violated its rules, says James C. Puffer, MD, ABFM president.
Dr. Berk says the crisis in the primary care physician workforce makes it necessary for medical educators to find innovative ways to attract graduates toward primary care specialties.
"Maybe this isn't the ideal way to do it, but we really need to think out of the box in medical education," he said.
In its proposal to ACGME, Tech said its goals are to develop an innovative residency program option available to most capable and mature U.S. medical students, expand the visibility and attractiveness of family medicine residency opportunities, and increase the number of U.S. graduates choosing family medicine careers.
Dr. Berk says ABFM supports the program. Many of the medical schools and family medicine residency programs Tech contacted about participating have been very receptive.
"We have done some vetting of the concept via e-mail and have gotten favorable responses from the Association of Departments of Family Medicine, which is a core group that would be involved, and also from the Association of Family Medicine Residency Directors," said Michael Ragain, MD, Tech's chair of family medicine.
Dr. Ragain, who also chairs the Texas Medical Association Council on Medical Education, says a few people have raised concerns about curriculum for their particular school or have philosophical issues with the concept, but he estimates between 80 percent and 90 percent of responses have been favorable. "And a number of them have said they want to participate."
While there may be concerns about the quality of education students in the accelerated program would receive, Dr. Berk believes they are unfounded because of the breadth of experience a resident would receive in a family medicine program. "When you think about doing a year of family medicine, you're doing OB, maybe some surgery, and lots of clinics. You usually really surpass by quite a bit all of the things that a fourth-year student would do anyway," he said.
Texas Tech officials also presented the proposal to the TMA Council on Medical Education and Committee on Physician Distribution and Health Care Access during TMA's Fall Conference. While neither panel officially endorsed the idea, both Dr. Ragain and Conroe family physician Troy Fiesinger, MD, who chairs the physician distribution committee, say members were general supportive.
Dr. Fiesinger was doing his residency at East Carolina University when the program was operating there. He says bringing it back is a good idea.
"The people we had were academically very strong, usually at the top of their class from medical school," he said. "They were equal to those of us who had done the traditional four years of medical school, there was no difference in knowledge base, and they were able to hold their own."
Dr. Fiesinger says the program was successful in training primary care physicians interested in practicing in an underserved area of eastern North Carolina and could do the same for Texas.
The number of fourth-year students who might go into the accelerated residency program is unknown. That likely will depend on how many schools participate and the size of their residency programs. Dr. Ragain says there could be as many as 100 participants if 20 schools participate, with an average residency size of 10 slots per year. That's because participation likely would be limited to no more than half the slots in any one program, he says.
Dr. Ragain says Texas Tech will not formally enlist other schools to participate in the program until the ACGME Board of Directors approves it. ACGME spokesperson Julie Jacob said the proposal could be considered at the board's next meeting in February. If so, Dr. Ragain says they could begin recruiting participants at the winter meeting of the Association of Departments of Family Medicine, which also will be held in February.
Even if the ACGME approves the program, there still would be other obstacles, at least here in Texas. When the program was tried in the 1990s, the licensing boards in each state had to agree to grant some type of temporary license to the participants. There was no accelerated residency program in Texas so it is unknown whether the Texas Medical Board (TMB) would approve such a license for a fourth-year student/first-year resident.
Texas Tech officials have not yet approached TMB with the idea, and board officials would not comment on it until a proposal is presented.
"Until we have specific details, we can't comment other than to say the board would review any such proposal, and there may be statutory issues involved," said Jaime Garanflo, TMB licensure director.
If approved, Tech officials hope to enroll their first students into the program in July 2009. Dr. Ragain says all Tech campuses would be involved.
Tech would like to expand the program beyond the pilot stage and make it available to all U.S. medical schools.
"We'd really like it to be a national project rather than just a regional or local project," Dr. Ragain said.
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .
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