In My View  |   June 2014
Shorter Training Is No Solution for Building the Primary Care Physician Workforce
Author Notes
  • Address correspondence to Carol L. Henwood, DO, American College of Osteopathic Family Physicians, 330 E Algonquin Rd, Arlington Heights, IL 60005-5320. E-mail:  
Article Information
Medical Education / Practice Management / Professional Issues / Graduate Medical Education
In My View   |   June 2014
Shorter Training Is No Solution for Building the Primary Care Physician Workforce
The Journal of the American Osteopathic Association, June 2014, Vol. 114, 420-421. doi:
The Journal of the American Osteopathic Association, June 2014, Vol. 114, 420-421. doi:
In “A New Pathway for Medical Education,”1 which was published in the November 2013 issue of Health Affairs, Shannon et al propose a faster, less expensive, competency-based continuum for the education of a new type of primary care physician. 
The article, which summarized the report of the Blue Ribbon Commission for the Advancement of Osteopathic Medical Education (established by the American Osteopathic Association [AOA] and the American Association of Colleges of Osteopathic Medicine), defined 20 foundational knowledge and behavior capacities, including data management, medical home and accountable care organization concepts, and leadership, among others. It is these capacities that would make up the competency-based curriculum for primary care physicians. As stated in the report,1 “Outcomes specific to medical education would be established to assess graduates' readiness for professional practice at multiple points in the physician education continuum” and that many students would complete the program in “as few as five years.” 
The American College of Osteopathic Family Physicians (ACOFP) agrees that primary care physicians should be skilled in applying these competences in their clinical practices. However, we strongly disagree with the Commission's belief that acquiring these competencies, in addition to the clinical training necessary to produce fully qualified and compassionate family physicians, is possible by shortening the training period. Indeed, the role of primary care physicians is expanding and new competencies are certain to be added in the near future. More time may be needed to achieve competence for all the skills required of an effective primary care physician. 

The expertise and professional uniqueness of these physicians will be diminished.

Continuity of Care Training Over Time Is Essential for Family Physicians
A family physician is required to possess a broad knowledge of health maintenance and disease processes that is inclusive of all body systems and how those systems interact. However, the length of postdoctoral training proposed for these new board-eligible, practice-ready osteopathic primary care physicians abbreviates both the didactic and clinical experiences, resulting in the probability that the expertise and professional uniqueness of these physicians will be diminished. 
The Commission's report recommends a competency-based training model over the current time-based training model.1 The ACOFP counters that primary care specialties require progressive and longitudinal time and repeated patient contact that are learned through clinical training in a continuity of care environment. Experience in the development of primary care specialists in osteopathic graduate medical education programs has demonstrated that the 1650 patient care visits over 3 years required for osteopathic family medicine is an important factor in developing competency.2 Such depth of experience and breadth of both inpatient and outpatient clinical training are distinguishing features of physician training over other health care professionals who are not exposed to the complexity of patients encountered by a family physician. 
A standard mechanism remains to be determined for competency evaluation across multiple medical schools and residency programs. Also, although the proposed competency-based training model may decrease time and costs, the model could increase these factors, as well as require more faculty for competency evaluation when there is already a shortage of qualified faculty.3 
The ACOFP believes that the Commission's recommendations1 would result in limited clinical training and exposure. Whereas primary care physicians recognize the important role that non-physician clinicians play in providing access to health care for the nation, the ACOFP maintains that the clinical role of a primary care physician in the medical home and primary care team should not be filled with a health care professional of limited clinical training and exposure. To endorse training that would be comparable to that received by many nonphysician clinicians diminishes access to the full spectrum of medical care and science and endangers patient safety. In addition, it would likely lead to an increase in the cost of care when these less-trained clinicians find that they do not have the knowledge or skill required to treat the patient and must order additional tests and refer the patient to additional specialists. 
It is also the ACOFP's belief that the osteopathic medical profession must not develop physicians who face a lifetime of limitations on their practice and capability because of unintended consequences of competency-based training. Physicians with limited training would likely have restrictions on scope of practice and prescribing put in place to protect the patient. Such actions do not expand access to care but rather limit it. We believe it is not ethical to develop physicians who possess what may be seen as lesser training or limited scope by state licensing boards, hospital medical staffs, and insurance panels. Such actions may make their education more expensive, not less expensive, over the duration of their careers. 
ACOFP Recommendations
At its March 13, 2014, meeting, the ACOFP Congress of Delegates passed a resolution4 for consideration at the July 2014 AOA House of Delegates meeting that opposes all efforts to diminish the quality and depth of training for primary care physicians, including but not limited to shortening the length of training. In our resolution,4 the ACOFP asks that the AOA cease all efforts to further promote or implement the recommendations of the Blue Ribbon Commission. 
As an organization committed to improving the knowledge and clinical and leadership skills of students and family medicine residents and physicians, the ACOFP hopes future efforts to reform the education and postdoctoral training of primary care physicians, especially family physicians, will include representation from the ACOFP and other primary care specialty colleges. Together, it may be possible to achieve the goal of producing caring, highly qualified primary care physicians in a more efficient manner. 
   Financial Disclosures: Dr Henwood is the president of the American College of Osteopathic Family Physicians.
   Support: None reported.
Shannon SC, Buser BR, Hahn MBet al. A new pathway for medical education. Health Aff (Millwood). 2013;32(11):1899-905. doi:10.1377/hlthaff.2013.0533. [CrossRef] [PubMed]
Basic Standards for Residency Training in Osteopathic Family Practice and Manipulative Treatment. Chicago, IL: American Osteopathic Association; July 2011.
Out Of Order, Out Of time: The State of the Nation's Health Workforce. Washington, DC: Association of Academic Health Centers; 2008. Accessed May 8, 2014.
Resolution 6 - osteopathic medical education. American College of Osteopathic Family Physicians website. March 13 , 2014. Accessed April 25, 2014.