The training and career paths of fellows in the National Research Service Award (NRSA) Program for Research in Primary Medical Care.

PURPOSE: To describe the training and career paths of fellows in the National Research Service Award (NRSA) Program for Research in Primary Medical Care. METHOD: All fellows who graduated from 25 NRSA programs nationally between July 1988 and June 1997 (n = 215) were mailed a questionnaire. Personal characteristics, fellowship experiences, and current professional positions were compared between faculty researchers, faculty clinician-educators, and individuals who were not in full-time academic positions. RESULTS: A total of 146 NRSA graduates (68%) completed the survey. A mean of four years had elapsed since their fellowships. Of the respondents, 36% were faculty researchers, 32% were faculty clinician-educators, and 32% were not on full-time faculties. Faculty researchers did not differ from the other groups in demographics or acquisition of advanced degrees, but they were more often general internists than general pediatricians, family physicians, or from other disciplines (p =.002). Fellowship graduates spent a mean of 29% of their training in course work and 38% conducting research. Faculty researchers spent a greater proportion of their fellowship conducting research (46% versus 34% for clinician-educators and 31% for those not on full-time faculties, respectively, p <.0001). They were also more productive in terms of subsequent publications and grant acquisitions. CONCLUSIONS: Only a minority of those completing NRSA programs held positions as faculty researchers. The preponderance of general internists among researchers may indicate problems in the capacity of general pediatrics and family medicine to support primary care research. The amounts of direct research time during these fellowships may need to be increased to enhance the likelihood of subsequent research success.     

Job satisfaction and workplace characteristics of primary and specialty care physicians at a bimodal medical school.

PURPOSE: A few medical schools are highly successful in obtaining research funding and producing primary care physicians. The authors compared the job satisfaction of primary and specialty care faculty at one of these bimodal schools. METHODS: In 1998, all full-time physician-faculty (n = 408) in 15 clinical departments at the University of Iowa College of Medicine (a bimodal medical school) were sent a questionnaire based on the Price-Mueller model of job satisfaction. Faculty rated their global job satisfaction and perceptions about 18 workplace characteristics, stressors, and supports. Responses of primary and specialty care physicians were compared in these domains. RESULTS: A total of 71% of surveyed faculty (n = 341) returned usable questionnaires. Primary and specialty care faculty reported similar levels of job satisfaction (p =.20), and similar percentages (51% versus 54%, p =.63) reported overall satisfaction with their jobs at the medical school. However, primary care faculty perceived less opportunity to advance (p <.01), greater professional-role ambiguity (p =.02), less collegiality (p =.02), and less ability to make full use of their clinical skills (p =.01). Primary and specialty care faculty reported similar intentions of leaving the medical school within the coming year (p =.41). CONCLUSIONS: Primary and specialty care physicians at one bimodal medical school reported similar levels of job satisfaction. However, the primary care physicians rated several important job-related domains lower than did their specialty care colleagues, most notably the opportunity to advance within the medical school.     

Specialty choices, compensation, and career satisfaction of underrepresented minority faculty in academic medicine.

PURPOSE: Despite efforts to increase the numbers of underrepresented minorities (URMs), only 3.9% of medical school faculty are URMs. The authors compared the specialty choices, compensation, and career satisfaction of minority faculty with those of their majority counterparts to determine whether there were differences that might affect the recruitment and retention of minority faculty. METHOD: In 1995, the authors mailed a self-administered survey to a stratified random sample of 3,013 eligible full-time salaried faculty in 24 randomly selected medical schools. Those schools, which had at least 200 faculty, did not include the Puerto Rican or historically black medical schools. RESULTS: Of the eligible faculty surveyed, 1,807 (60%) responded; 1,463 were majority faculty, 195 were URM faculty, and 149 were other-minority faculty. Similar proportions of the three groups were in the primary care specialties. Only 11% of the URM respondents were in basic science departments. There was no significant difference in adjusted mean compensation between majority, URM, and other-minority faculty. However, URM faculty were significantly less satisfied with their careers (adjusted scores: 60 versus > 65; p = .001) and more often considered leaving academic medicine within five years (58% versus < 45%). CONCLUSION: Given the demographic changes of the U.S. population, these issues should be addressed by deans and department heads in order to enhance recruitment and facilitate retention of URM faculty in academic medicine.     

Views of managed care--a survey of students, residents, faculty, and deans at medical schools in the United States

BACKGROUND AND METHODS: Views of managed care among academic physicians and medical students in the United States are not well known. In 1997, we conducted a telephone survey of a national sample of medical students (506 respondents), residents (494), faculty members (728), department chairs (186), directors of residency training in internal medicine and pediatrics (143), and deans (105) at U.S. medical schools to determine their experiences in and perspectives on managed care. The overall rate of response was 80.1 percent. RESULTS: Respondents rated their attitudes toward managed care on a 0-to-10 scale, with 0 defined as "as negative as possible" and 10 as "as positive as possible." The expressed attitudes toward managed care were negative, ranging from a low mean (+/-SD) score of 3.9+/-1.7 for residents to a high of 5.0+/-1.3 for deans. When asked about specific aspects of care, fee-for-service medicine was rated better than managed care in terms of access (by 80.2 percent of respondents), minimizing ethical conflicts (74.8 percent), and the quality of the doctor-patient relationship (70.6 percent). With respect to the continuity of care, 52.0 percent of respondents preferred fee-for-service medicine, and 29.3 percent preferred managed care. For care at the end of life, 49.1 percent preferred fee-for-service medicine, and 20.5 percent preferred managed care. With respect to care for patients with chronic illness, 41.8 percent preferred fee-for-service care, and 30.8 percent preferred managed care. Faculty members, residency-training directors, and department chairs responded that managed care had reduced the time they had available for research (63.1 percent agreed) and teaching (58.9 percent) and had reduced their income (55.8 percent). Overall, 46.6 percent of faculty members, 26.7 percent of residency-training directors, and 42.7 percent of department chairs reported that the message they delivered to students about managed care was negative. CONCLUSIONS: Negative views of managed care are widespread among medical students, residents, faculty members, and medical school deans.     

The case for interdepartmental research in primary care.

Research problems in human biology, clinical medicine, and health services delivery are complex, and increasingly require collaborative approaches. Despite the commitment of general internists, general pediatricians, and family physicians to comprehensive, coordinated, and longitudinal care, their substantial overlap in research topics, methods, and data sources, and their shared emphasis on research conducted in community-based settings, the three primary care disciplines rarely collaborate in research. The research enterprises of most primary care departments and divisions in the United States are small "cottage industries," while interdepartmental research units are rare. Interdepartmental research units can develop and maintain the critical mass of investigators, trainees, and staff that is necessary for an intellectually vibrant and financially sound primary care research enterprise. The University of Colorado Health Sciences Center School of Medicine has developed a successful interdepartmental research effort in primary care that includes joint fellowship training and faculty development programs and a Primary Care Research Unit that supports the analysis of secondary databases, practice-based research networks, and interdisciplinary research projects. Key elements of this collaboration include shared projects among faculty and trainees, proactive negotiation about resources, and shared research space, staff, and faculty. Such a collaboration provides the breadth of perspectives necessary to address complex health care problems, and the pragmatic infrastructure necessary to sustain research themes and careers.     

The primary care specialties working together: a model of success in an academic environment.

In today's environment of decreasing resources and increasing competition among clinical delivery systems, survival and ultimate success require interdisciplinary cooperation and, if possible, integration. Academic leaders at the University of California, Irvine (UCI), have developed a collaborative model in which faculty in family medicine, general internal medicine, and general pediatrics cooperate extensively in education, research, and patient care. Generalist faculty jointly administer and teach both a four-year "doctoring" curriculum for medical students and an array of integrated curricula for primary care residents, including a communication skills course. Several primary faculty jointly developed a collaborative unit for health policy and research, now an active locus for multidisciplinary research. Other faculty worked together to develop a primary care medical group that serves as a model for interdisciplinary practice at UCI. Recently, the university recruited an associate dean for primary care who leads the new UCI Primary Care Coalition, reflecting and promoting this interspecialty cooperation. This coalition does not represent a step toward a generic primary care specialty; UCI's generalist disciplines have preserved their individual identities and structures. Yet interdisciplinary collaboration has allowed primary care faculty to share educational resources, a research infrastructure, and clinical systems, thus avoiding duplicative use of valuable resources while maximizing collective negotiating abilities and mutual success.     

How do academic health centers value and encourage clinical research?

To investigate whether there is a misalignment of the perceived values of and incentives for clinical research within U.S. academic health centers (AHCs), in 1999 the authors surveyed medical school deans, academic administrators, department chairs, and faculty members at 80 AHCs that are the members of the University HealthSystem Consortium, a not-for-profit consortium of AHCs. A total of 358 faculty from 58% of the institutions surveyed responded, with a mean of 3.76 responses/institution. There was general agreement that clinical research offers AHCs a considerable spectrum of benefits, including prestige, recruitment and retention of faculty, criteria for promotion of faculty, and financial support. Investigator-initiated research and government-funded research ranked highest in terms of their desirability compared with industry-sponsored and contract research. This preference was agreed upon across all categories of respondents and types of research (translational, clinical tests, and outcomes). Significant differences existed between the perceptions of deans/AHC administrators, who stated that they were increasing their emphasis on clinical investigation in the areas of research space (56% of responders), administrative support (81%), and patient recruitment (61%) and the perceptions of their departmental chairs/faculties in the same areas (34%, 52%, and 40%, respectively; p <.05). Faculty opinions documented few new investments in the actual infrastructure dedicated to clinical research. The authors conclude that their findings, which they consider reasonably representative, strongly suggest that the value of clinical research to AHCs is well understood. Their findings also identify important opportunities for AHCs to provide a wider range of incentives for the conduct of clinical research.     

Academic ranks and medical schools of underrepresented minority faculty in family medicine departments.

PURPOSE: To examine academic rankings and educational backgrounds of underrepresented minority (URM) family medicine faculty and compare their academic ranks with national trends. The authors also determined the extent to which international and historically black educational institutions contributed URM faculty to family medicine. METHOD: In 1999 questionnaires were sent to 129 family medicine departments asking for academic ranks and educational institutions attended by their URM faculty. Comparisons were made between URM faculty's academic ranks and all family medicine faculty, medical school minority faculty, and medical school faculty. RESULTS: A total of 80% of URM faculty were assistant professors or instructors, and 4.4% were professors. URM family medicine faculty had significantly lower rankings compared with medical school minority faculty and all family medicine faculty. URM family medicine faculty at historically black medical schools were more likely to have received their degrees from historically black undergraduate institutions and medical schools than were URM family medicine faculty at non-historically-black medical schools. CONCLUSIONS: URM family medicine faculty appear to experience a double disadvantage: being minority and working for family medicine departments. Their academic ranks remain far below those of both minority medical school faculty and family medicine faculty, a discouraging finding considering the current shortage of URM faculty in family medicine departments. Historically black medical schools cannot address the shortage alone, so non-historically-black medical schools need to both recruit URM faculty and follow up with appropriate mentoring of those faculty.     

Specialty choices at one medical school: recent trends and analysis of predictive factors

Recent reports have raised the concern that personal care specialties, especially primary care specialties, are attracting fewer medical school graduates. In the present study, the authors evaluated the proportions of University of California, San Francisco (UCSF), medical school graduates entering personal care specialties and technology-oriented specialties from 1982 through 1988 and found no significant trend away from personal care specialties such as internal medicine, family practice, pediatrics, and psychiatry during these years. For the graduating class of 1988, admissions and questionnaire data were used to evaluate the importance of pre-admission, medical school, and postgraduate factors as determinants of specialty choice. The group entering personal care specialties (66% of all 1988 graduates) was significantly older and included more women and fewer minority students than the group entering technology-oriented specialties. Students rated income and lifestyle factors as being less important determinants of specialty choice than are medical school experiences and intrinsic qualities of the chosen specialties. However, compared with the students who entered personal care specialties, those who chose technology-oriented specialties over an alternate choice in personal care rated as significantly more important the opportunity to do procedures (p less than .001), income (p less than .005), the lesser degree of diagnostic uncertainty (p less than .005), and the rejected specialty's allowing less time for family (p less than .005) and for other interests (p less than .008). Exposure to acquired immunodeficiency syndrome and loan indebtedness were rated the least significant influences on specialty choice.(ABSTRACT TRUNCATED AT 250 WORDS)     

Faculty expectations and primary care residents' perceptions concerning residents' growth in competence at one medical school.

The authors studied at one school both the developing confidence of primary care residents and the expectations of both internal medicine and specialty faculty members regarding the abilities of the residents. From 1980 to 1988, residents in the study institution's program in internal medicine primary care completed self-assessments concerning their diagnostic and management skills in primary care and several specialties at the start of their training and at the ends of their first, second, and third years. In 1988, the authors elicited the expectations of the primary care and specialty faculties regarding the levels of competence that residents should achieve in the specialties by the end of their third year. When the faculty assessments were compared, the specialists were found to ascribe greater levels of autonomy to residents. The authors conclude that involving residents and faculty members from various disciplines in developing expectations and evaluation criteria can enhance faculty members' perceptions of residents' clinical competence and residents' achievement of it.     

The effect of medical education on primary care orientation: results of two national surveys of students' and residents' perspectives.

PURPOSE: To examine changes among a nationally representative sample of students and residents in their orientations toward primary care as reflected in their attitudes toward the psychosocial and technical aspects of medicine and their perceptions of the academic environment for primary care. METHOD: Confidential telephone interviews of stratified national probability samples of first- and fourth-year medical students and residents were conducted in 1994 and 1997. The 1997 survey included 219 students and 241 residents who had also been interviewed in 1994. Participants were asked about their attitudes toward addressing psychosocial issues in medicine and their perceptions of faculty and peer attitudes toward primary care. Responses were compared over time and across groups. RESULTS: Between the first and fourth years of medical school, there was a decline over time in students' reported orientations to socioemotional aspects of patient care (61.6% versus 42.7%, p =.001) and their perceptions that working with psychosocial issues of patients made primary care more attractive (56.3% versus 43.5%, p =.01). This pattern continued for 1997 residents (PGY-3), who were even less likely to say that addressing psychosocial issues made primary care more attractive (26.9%). For fourth-year students in 1994 who became PGY-3 residents in 1997, there was an increased perception that non-primary-care house officers and specialty faculty had positive attitudes toward primary care (20.8% versus 33.0%, p =.005; 28.3% versus 45.7%, p <.0001; respectively). CONCLUSIONS: Between 1994 and 1997 students and residents perceived a positive shift in the attitudes of peers and faculty toward primary care. During the course of their education and training, however, the students experienced an erosion of their orientations to primary care as they progressed through medical school into residency.     

Lessons not learned from the generalist initiatives.

The grouping of the primary care specialties (general internal medicine, general pediatrics, and family medicine) for research purposes is at best limiting the value of the information that is found and, at worst, leading researchers to erroneous conclusions. For example, three large studies each showed differences in abilities to predict students' specialty choices in primary care (e.g., in one study, the investigators correctly predicted 3% of those choosing general internal medicine, 29% considering general pediatrics, and 51% considering family medicine). These and related findings suggest that medical students entering the three primary care specialties are not a homogeneous group. While there were some factors predictive for all primary care specialties, there were more factors that were unique to the individual specialties Grouping the specialties may not reveal factors that are significantly related to only one of the specialties. In addition, when a variable operates in different ways for different specialties, findings where the specialties are combined can show a reduced effect of that variable or even no effect, because the directions of effects cancel each other. Researchers can fruitfully examine the primary care specialties as a group but at the same time report their data for the individual specialties, which would greatly increase our knowledge both of primary care and also about the similarities and dissimilarities of its component specialties. However, the best models continue to be either research in which the sample size is large enough to compare specialty groups statistically or research with a focus on just one of the primary care specialties.     

Solutions and strategies from medical and nursing school leadership for the challenges facing the clinical research enterprise.

PURPOSE: For decades, the U.S. clinical research enterprise and its workforce have faced diminishing numbers and significant challenges. This study, conducted by the Institute of Medicine's Clinical Research Roundtable (CRR), sought to learn about the perceptions by medical and nursing school deans of these challenges or the efforts and strategies needed to address them. METHOD: The authors mailed structured questionnaires about clinical research and workforce issues to medical and nursing school deans in the continental United States in the fall of 2003, and on October 16 and 17, 2003, the CRR held a two-day workshop with deans and their representatives to discuss the survey findings and to propose solutions. RESULTS: Survey participation was 55 (45%) for medical school deans and 37 (46%) for nursing school deans. Various efforts exist at individual schools for recruitment, training, and retention of clinical researchers. Most of the responding medical (53; 96.7%) and nursing (28; 75.4%) school deans reported that demand for clinical researchers exceeded or sharply exceeded supply, and about half of these institutions had a formal mentor program for their students. The percentage of graduates with methodological training in clinical research varied widely, with a mode of 10% and 100% for medical and nursing schools, respectively. Most medical school deans (47; 85.5%) rated their basic research enterprises good to excellent, whereas only a third (19; 34.6%) rated their clinical research programs similarly. Likewise, nursing school deans rated their basic research programs more favorably (23; 62.2%) than they rated their clinical research enterprises (17; 46.0%). However, prioritization of changes needed to address the challenges facing clinical research and its workforce were similar for medical and nursing school deans. CONCLUSIONS: Clinical research is underdeveloped and underrepresented within the clinical research enterprise. There is a need to develop and execute uniform strategies to grow and expand the clinical research workforce. Workshop participants, including 14 deans or their representatives as panelists and CRR members, proposed solutions and strategies.     

Results of a gender-climate and work-environment survey at a midwestern academic health center.

AND CLIMATE determine how faculty's perceptions of medical school gender climate differ by gender, track, rank, and departmental affiliation. METHOD: In 1997, a 115-item questionnaire was sent to all University of Wisconsin Medical School faculty to assess their perceptions of mentoring, networking, professional environment, obstacles to a successful academic career, and reasons for considering leaving academic medicine. Using Fisher's exact two-tailed test, the authors assessed gender differences both overall and by track, rank, and departmental cluster. RESULTS: Of the 836 faculty on tenure, clinician-educator, and clinical tracks, 507 (61%) responded. Although equal proportions of men and women had mentors, 24% of the women (compared with 6% of men; p < .001) felt that informal networking excluded faculty based on gender. Women's and men's perceptions differed significantly (p < .001) on 12 of 16 professional environment items (p < .05 on two of these items) and on five of six items regarding obstacles to academic success. While similar percentages of women and men indicated having seriously considered leaving academic medicine, their reasons differed: women cited work-family conflicts (51%), while men cited uncompetitive salaries (59%). These gender differences generally persisted across tracks, ranks, and departmental clusters. The greatest gender differences occurred among clinician-educators, associate professors, and primary care faculty. CONCLUSIONS: Women faculty perceived that gender climate created specific, serious obstacles to their professional development. Many of those obstacles (e.g., inconvenient meeting times and lack of child care) are remediable. These data suggest that medical schools can improve the climate and retain and promote women by more inclusive networking, attention to meeting times and child care, and improved professional interactions between men and women faculty.     

An integrated model for inner-city health-care delivery: the Deaconess Center.

Under the auspices of the Buffalo General Hospital and the faculty of medicine of the State University of New York at Buffalo, a comprehensive delivery system for primary care has been established in a local inner-city neighborhood. At the Deaconess Family Medicine Center, located within an inner-city location of Buffalo, New York, several divisions have been integrated to provide comprehensive patient-oriented primary care. These divisions include a primary care clinic, an urgent care clinic, a substance abuse clinic, and a community pediatrics clinic. Professional services are provided by attending physicians and residents. The horizontal integration of these four divisions is in turn vertically integrated with the tertiary care teaching hospital inpatient and obstetrical services, providing a continuum of patient care. The horizontal integration serves as an entry point for patients to enter the hospital''s health-care system, while the vertical integration capability serves to capture any specialized referrals or inpatient needs. This article discusses the structure of the center, with special reference to service integration, service delivery, and patient capture; medical education; and the place of integrated units in the strategic plan of a tertiary care hospital.     

PhD faculty in clinical departments of U.S. medical schools, 1981-1999: their widening presence and roles in research.

PURPOSE: To analyze the growth, research activities, and academic status of PhD faculty in U. S. medical school clinical departments between 1981 and 1999. METHOD: Full-time U.S. medical school faculty who had PhDs and appointments in clinical departments in 1981 and 1999 and junior PhD faculty who became assistant professors between 1981 and 1990 were selected from the Faculty Roster System of the Association of American Medical Colleges. Their research activities and academic statuses were compared with those of MD or MD/PhD faculty in clinical departments or PhD faculty in basic science departments in the same years. RESULTS: The number of PhD faculty in clinical departments now exceeds the number of PhD faculty in basic science departments. PhD faculty in clinical departments come from diverse research backgrounds, contribute substantially to the research intensity of their institutions, and are more likely than their counterparts in basic science departments to become involved in research involving human participants or human tissues. PhD faculty in clinical departments are less likely than their counterparts in basic science departments, but are as likely as physicians in clinical departments, to be rewarded with academic promotion. They are less likely than their physician colleagues to be promoted in research-intensive departments such as departments of medicine and at top 20 research-intensive schools. CONCLUSIONS: The burgeoning career opportunities for PhD faculty in clinical departments should be reflected in the course work, mentorship, and potential thesis topics of PhD training programs. In lieu of tenure, research-intensive medical schools should develop alternative career tracks providing somewhat greater job stability for these faculty.     

Scholarship in the medical faculty from the university perspective: retaining academic values.

Academic medicine and research universities have enjoyed a close relationship that has strengthened both, spawning an era of discovery and scholarship in medicine that has earned the U.S. academic medical enterprise a high level of public trust and a deserved leadership position in the world. However, changes in the financing of medical care and in the organization of health care delivery have dramatically affected the medical school-university partnership. The growing emphasis on delivery of clinical services and the concomitant decrease in time for tenured and clinician-educator faculty to teach and do scholarly work jeopardizes both the potential for continued discovery and the education of the next generation of medical scholars. The background of the medical school-university relationship and the factors leading to the development of clinician-educator faculty tracks are reviewed, and recent trends that impact faculty scholarship are discussed. Both tenure-track and clinician-educator medical faculty, as members of the broader university community, should expect from their university colleagues a continued demand for scholarship and educational activity that reflects the underlying philosophy of the parent university. As a corollary, the university, through its medical school, must provide these faculty the time and the financial support necessary to fulfill their academic mission. The size of the clinician-educator faculty should be determined by the academic needs of the medical school rather than by the service demands of its associated health care delivery system. To accomplish this, academic medical centers will have to develop cadres of associated or clinical faculty whose primary focus is on the practice of medicine.     

Sixteen years' experience with a required third-year family medicine clerkship at Jefferson Medical College.

Jefferson Medical College has developed a program to successfully meet the goal of teaching ambulatory care to all medical students, by providing each of its 223 third-year students with a required six-week clerkship in family medicine. The structured clerkship takes place at one of seven residency-based family practice centers, is supplemented by a formal curriculum, and is based on the active clinical involvement of caring for patients under full-time family medicine faculty supervision. This clerkship has been in existence for 16 years, and has added over 400,000 student-patient encounters to the clinical education of over 3,500 students. Student evaluations of the clerkship have rated it the highest of the six required core clerkships at Jefferson. In addition, over 16% of Jefferson graduates have entered family medicine residency training programs, a rate higher than that of any other school in the northeastern United States, and significantly higher than the average for all U.S. medical schools (12%). Jefferson's experience suggests that ambulatory care can be taught as a core component of the clinical education of all medical students. To be successful, however, strong institutional support, a structured curriculum, an adequate number of patients, a dedicated faculty, a sufficient number of training sites, an appropriate evaluation process, and significant financial support are all necessary.