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Clinic First: How Transforming the Teaching Clinic Will Create Pathways for Primary Care

San Francisco, CA

From 2013-2015 with support from the Macy Foundation, researchers from the Center for Excellence in Primary Care (CEPC) at the University of California San Francisco (UCSF) visited 23 primary care teaching clinics to map out what a “high-performing clinical experience” looks like for students, residents, faculty and patients. We caught up with one of the project’s lead researchers, Dr. Reena Gupta, to learn more about the current state of primary care education and the “Clinic First” model.

According to a Journal of General Internal Medicine study, 93% of residents entering a primary care track report interest in a career in primary care, but only 54% maintain that interest after completing their residency. Why do you think that is?
The biggest issue we see is how teaching clinics are structured. Historically, primary care teaching clinics have been set up in a way that doesn’t allow for students and residents to have an authentic primary care experience in high-functioning practices. Residents are very part time, with some only spending half a day a week at the clinic. Students rotating through these clinics see primary care physicians experiencing stress and burnout, causing some to abandon plans for a primary care career. Similarly, patients are frustrated when they have to see different providers each time they come to clinic and continuity of care gets lost.

If we can better design clinic schedules to prioritize continuity of care and eliminate tension between residents’ inpatient and outpatient duties, we’d see a much better system in place that works for residents, students and patients.

You’ve said “the clinic is the curriculum.” What do you mean by that?
It’s not enough to teach students in a classroom what team-based care, what an excellent primary care practice, or what building long-term relationships with patients looks like. Health care professionals learn by doing. In our field research, we found that the clinics which embrace this “clinic as the curriculum” approach have invested in creating efficient, well-functioning practices for trainees to learn what ideal primary care looks like by seeing and doing it as they care for patients in clinic every week.

This is the “Clinic First” model. “Clinic First” training includes team-based care, population health management, consistent schedules, partnerships with patients, and more.

Today we hear a lot about the looming physician shortage in primary care. How do you think this “Clinic First” model will help?

Residents who train in primary care clinics and experience dysfunction or limited continuity of care with their patients are often discouraged from pursuing careers in primary care. People choose careers based on what they like doing. If we can create high-performing teaching practices and give trainees a fulfilling experience, they’ll be able to envision a joyful career for themselves and hopefully choose primary care.

In your opinion, what does it take to create this “high performing primary care teaching clinic”? What’s the main ingredient for a program looking to restructure itself?
If you look at the building blocks of transforming teaching clinics that we’ve identified, you’ll see that the first step is to engage leadership. You need to identify the leaders at your institution who are looking to revamp the clinical experience and make the case to them for why this is needed—showing them how a high performing teaching clinic can improve both patient care and teaching.

Once you have leadership at your institution engaged, you can start to put the other building blocks in place.

UCSF

Which programs are leading the way? Who are the shining examples?
There are several bright spot programs—one is the Crozer-Keystone Family Medicine Residency Program. Their program puts a strong emphasis on team-based care. They have team huddles with interdisciplinary staff to discuss patients as a team before every clinic. What’s important to note is that the teams don’t change, so residents develop consistent relationships with their team members and feel supported in patient care. It’s a strong model for relationship-building and teamwork.

The internal medicine residency program at the University of Cincinnati is another program that stands out. A few years ago the program completely overhauled its scheduling structure so that second year residents are caring for their clinic patients for a continuous 12-month period. During this new 12-month schedule, called the “ambulatory long block,” residents authentically experience what it’s like to be a primary care clinician building meaningful relationships with patients, a care team, and faculty.

Get Involved!
With additional support from Macy, Dr. Gupta and her team are developing toolkits for the building blocks referenced above and are looking to engage 20 primary care programs that are working to transform their teaching clinics. If your program is interested in getting involved and learning more, please contact Dr. Gupta at .(JavaScript must be enabled to view this email address).


References:
1. Dupras DM and West CP. Training for careers in primary care: time for attention to culture. J Gen Intern Med 2015; 30: 1243-1244.

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