Improvements are needed in resident primary care training in the USA

Primary care is the backbone of today’s medical infrastructure and has many proven benefits including improved health, reduced healthcare disparities and lowered healthcare costs [1]. Despite this, there is a growing lack of interest in primary care among graduating residents. Although there are many deterrents to a career in primary care, the most significant is the failure of residency programmes to provide adequate education in this field. The majority of primary care training in residency occurs in the continuity clinic but this model is flawed. Residents see high volumes of patients but may not be able to participate in other aspects of patient care, such as following up on laboratory results or telephone calls. Residents also may not have continuity with patients, as there may be months where the resident is not available due to other responsibilities. Resident clinics are often the medical home for medically and/or socially complex patients, and the lack of continuity can make caring for these patients frustrating. Because of this, residents do not feel like the patient’s Primary Care Provider (PCP) and do not receive an experience reflective of a career in primary care. In fact, in an internal medicine programme, continuity clinic was found to have an overall negative influence on residents’ attitudes towards a career in general medicine [2]. More troubling still, there is a prevalent feeling that primary care is for those who are not smart enough to match into a subspecialty fellowship. Residents may receive criticism from mentors for their desire to enter into a career in primary care. These sentiments are subtly echoed on a system level, as primary care topics are rarely discussed during educational sessions, and paediatricians may be criticised by inpatient teams for ‘missing’ the diagnosis. Thus, it is critical that residency programmes prioritise changing the primary care experience. Within the literature, there have been multiple interventions piloted to improve primary care education, yet many programmes have not taken note. We propose programmes focus on a few key areas that could dramatically improve the resident experience. First, priority must be given to improving patient continuity. This could be achieved by implementing the empanelment model, which has been adopted successfully in some programmes. Similarly, granting residents the ability to self-schedule patients onto their own panel for subsequent appointments (rather than relying on schedulers) has improved continuity for residents in our clinic. Additionally, residents should be provided with the infrastructure and time to be more involved in office responsibilities like care coordination and lab followup. Improving communication systems through the electronic medical system or email could help residents stay connected with all involved providers. Programmes should also introduce residents to different practice types to give a better representation of a career in primary care. A primary care elective could be created, where residents would rotate through local private and hospital practices to experience the breadth of opportunities available. Or, allowing residents to customise more traditional elective time may serve as an easy way to improve education. To change the systemic perception that primary care is less prestigious, programme directors and mentors simply need to be supportive, which has been shown to improve perceptions about primary care [3]. Programmes can emphasise the importance of primary care by including relevant topics in educational sessions and minimising critiques of outpatient colleagues. In the face of an ever-growing shortage of residents entering a career in primary care, it is critical that residency programmes strive to better primary care education. By improving continuity, expanding opportunities to a range of practice settings and improving mentorship within primary care, programmes can foster interest in this important aspect of medicine.