The Clinician-Teacher in Managed Care Settings

Managed care has grown tremendously over the last decade.1 In 1985, there were fewer than 8 million members; in 1995, there were more than 53 million members. Increasing numbers of doctors are now working in managed care, and most new graduates of residency programs will spend their careers in capitated managed care practices. Ten years ago, we wrote about the benefits of affiliations between academic health centers and health maintenance organizations (HMOs).2 What was then an interesting idea now has become a necessity. Curricula in medical schools and residency training programs have begun to address the changes in medical practice, but they have not kept pace with managed care practice development. In fact, in many parts of the country academic institutions have been insulated from the changes in practice. The well-described gap between skills emphasized in residency training and those necessary for practice continues to widen.3–5 As a result, HMO medical directors consider the majority of primary care physicians to be “poorly qualified” for managed care practice.6 There is an alarming growth of physician dissatisfaction in practice. A recent study by the California Medical Association revealed the dimensions of the problem. On the basis of their current work experiences, nearly 40% of California primary care physicians under the age of 40 would not again choose careers in medicine. Physician claims for disability, another symptom of physician distress, are at an all time high. The majority of these discontented physicians attributed career dissatisfaction to negative experiences with managed care practice.7 Residency training program directors must ensure that their graduates do not suffer from these negative attitudes. Patients also express dissatisfaction that can be attributed to deficient training. When patients say that their doctors don’t listen, are rushed, devalue their opinions, and treat them like objects, they are indirectly criticizing the programs that have trained the doctors. These concerns reflect the current problems of primary care practice and medical education. Building excellent managed care practices that incorporate the training of future physicians can serve to correct these deficiencies. Learning to practice in real managed care sites—where residents and medical students interact with role models and participate in authentic clinical work—may be the best way to prepare doctors to provide high-quality care in a cost-effective manner and to take pride and pleasure in their work.8,9 In this article we will present the results of nearly 25 years of experience in the graduate medical education of primary care internists in one managed care organization, Harvard Pilgrim Health Care (HPHC, formerly Harvard Community Health Plan). We have chosen to describe our experience in depth rather than to survey the small number of programs that have addressed the challenge of teaching in managed care settings. We will present our view of the elements of clinical competence that excellent managed care practice requires. We will describe the roles of clinician-educators in HPHC's primary care program, and discuss the challenges they face in balancing clinical practice and teaching responsibilities. Finally, we will describe the value of graduate medical education to our organization, and the challenges that must be met in order to sustain training in a busy managed care setting.