New grant from VA supports a fresh look at primary care training

The United States faces a severe shortage of physicians in the coming decades. As the health care needs of the aging Baby Boomers grow rapidly, the number of medical school students electing to enter the field of primary care is in sharp decline. According to the National Resident Matching Program, students choosing residency training in general internal medicine fell from 575 in 1999 to 264 in 2008.

One of the factors that has been found to influence students’ views of general internal medicine as a career choice is the quality of the educational experience in internal medicine.

The VA Connecticut Healthcare System (VAHCS) is now poised to address that issue with a new $5 million grant from the Department of Veterans Affairs to establish a Center of Excellence in Primary Care Education. The Yale-affiliated VAHCS is one of only five facilities in the country to receive the five-year grants, which will support a new approach to training internists and other health care professionals. Traditionally, internal medicine residents have spent most of their time training in inpatient settings, but the majority of patients are now treated in outpatient settings. “Training hasn’t really kept up with the reality of how internists practice,” says the School of Medicine’s Patrick G. O’Connor, M.D., M.P.H., professor of medicine and section chief of general medicine.

Under the existing system, residents spent just one half-day a week at the VAHCS, but they will now go there for training every day for two months at a time, a total of 10 months of intensive training over the three years of residency. Interns and first-year residents will continue to spend a half day per week at the VA in between the two-month intensive blocks. “Restructuring their schedule will allow them to really learn what a primary care doctor actually does, which is to be there every day for their patients and have longitudinal relationships,” says Assistant Professor of Medicine Rebecca Brienza, M.D., M.P.H., who will serve as director of the new center.

The center will also establish a one-year postgraduate fellowship in primary care for nurse practitioners, becoming the first program in the country to offer such training. Residents and nurse practitioners will train in teams, taking care of patients together for a 12-month period, with the nurse practitioners providing continuity of care during the time residents are training at other locations between their two-month stints.

“The current way we train postgraduate M.D.s and nurse practitioners is really a ‘silo’ model, where there’s no cross-pollination for collaboration,” says Brienza. “We’ve learned that caring for patients in multidisciplinary care teams is a better approach, with better outcomes for patients.” The center will provide training in interprofessional collaboration to residents and nurse practitioners, as well as students in medical school, undergraduate nursing programs, pharmacy, and health psychology. They will learn how to work effectively as members of a team, how to appreciate the input of others and their contribution to caring for patients, and conflict management. “All those things with regard to teamwork that are assumed that health professionals know but that there’s actually no real training for,” says Brienza.

The new training model fits in well with changes brought about by the recent health care reform legislation, with its concept of a “medical home,” an outpatient-based primary care practice through which care is coordinated. The program is itself a collaboration between the VA, Yale School of Medicine, Yale School of Nursing, University of Connecticut School of Medicine, and Fairfield University School of Nursing. The five institutions will contribute a total of over 200 trainees over a five-year period.

“Training programs need to prepare physicians not only for the present, but also for the future, when they’ll have more responsibility for team care and organization of services for patients,” says O’Connor.