Unprepared for primary care
Date: February 7, 2011
A Hopkins study calls into question the effectiveness of resident training for outpatient care.
Doctors who have completed training in internal medicine generally are poorly prepared for jobs as primary care physicians, most notably lacking the knowledge to best care for patients with chronic conditions such as diabetes, hypertension and high cholesterol, the study findings suggest.
The researchers also found, however, that physicians who completed internal medicine residency programs at community hospitals were significantly better prepared to treat patients in an outpatient setting than physicians who trained at academic medical centers.
One likely reason for the gaps in knowledge is the focus in medical training on inpatient care at the expense of outpatient care, the bread and butter of any physician, the researchers say. Ninety percent of all doctor-patient visits are outpatient, even in specialty care.
“The average resident doesn’t know what the goal for normal fasting blood sugar should be,” says Hopkins internist Stephen Sisson, the leader of the study published in a January issue of the American Journal of Medicine. “If you don’t know what it has to be, how are you going to guide your diabetes management with patients?”
The need for primary care doctors is growing. Studies have shown that populations with better access to good internists spend less time in the hospital and cost less to treat. One-third of internal medicine residency is supposed to be devoted to outpatient care, but not all of that time is spent on primary care. Some is spent on outpatient specialty care and some is even spent rotating through the emergency department, Sisson adds.
Sisson’s study looked at the performance of internal medicine residents on a curriculum created by the Johns Hopkins Internet Learning Center and used, during the 2006-07 academic year, by 67 medical residency programs in the United States. The Johns Hopkins curriculum is now used by twice that many programs, serving 10,000 residents.
Sisson looked at the performance of residents at the end of their first, second and third years. At the beginning, residents from academic medical centers and community hospitals both performed equally poorly. But by the end of the third year, there was a much wider knowledge gap, with community hospital residents doing better, particularly in acute-care areas.
Still, residents at both kinds of hospitals failed to score more than 55 percent overall on topics such as chronic disease management, preventive care and acute care—exactly the type of cases a primary care doctor would encounter in private practice.