August 18,2012
YJHM
Primary care has withered because it
has been forced into the research-oriented programs that were created following
Abraham Flexner’s scathing report in 1910 on the deficiencies of medical
education that existed. The system that he fostered was based on the German
system which was rooted in research. The changes he instituted were good but
they were carried to an extreme and research became the core of medical
education and finally, its cynosure.
Practical medicine, the best example
of which is primary care was relegated to and has remained a second-class
entity in the medical hierarchy for the past 100 years.
Sir William Osler a respected
physician, teacher, and author differed with Flexner on which direction medical
education should take. He preferred a dual path, one for “practical” medicine
and one for research. The former would take place in hospitals by part-time
community-based physicians and the latter in research institutes. But Flexner aided by the power and influence
of the Carnegie Institute and the Rockefeller Foundation prevailed.
Some believe that the shortage of
primary care physicians is one of the unintended consequences of the Flexnerian
vision of medical education. However, it
will be difficult to reverse a trend that has been in place for over a hundred
years and one which has brought much benefit.
Be this as it may, customizing
education for primary care doctors is the first best step to take to addressing
the shortage. How can this be done? Subjects like organic chemistry, physics, and
biochemistry are of little benefit to primary care physicians. They consume an inordinate amount of time and
may even act as deterrents to some who have neither the interest nor the
aptitude for them to pursue a career in medicine, particularly in primary
care. If they were customized at least
two and maybe even three years could be shaved off the current 12 years it
takes to train a primary care doctor.
Unlike many specialties, primary
care is practice-oriented not research-oriented. And since primary care
physicians learn their practical skills in residency, not in medical school or
pre-med, a fact that is never mentioned, customizing the basic sciences by
simplifying them or combining or even eliminating some of them would shorten
the pre-residency training period. This would not solve the primary care
shortage but it would increase their numbers.
Mr. Goodman’s concerns are good but
they do not explain the whole problem.
Edward J. Volpintesta MD