One of the most promising and rewarding career choices for the student contemplating a professional life in clinical medical research is that of a primary care physician scientist. As U.S. managed care evolves, the primary care physician (PCP) is assuming an increasingly prominent and responsible role in the healthcare system. The PCP is generally the first medical practitioner contacted by a patient. The PCP does the initial evaluation; acts as the collaborator and facilitator in referrals to specialists; coordinates the care among specialists, clinics, laboratories, and hospitals; and provides long term management of most patients. From an economic standpoint, the PCP is the “gatekeeper” who regulates access to costly consultations, studies, and procedures. Approximately one-third of practicing physicians in the United States are PCPs.
So where does the research come in? Modern medicine is increasingly oriented toward evidence-based practice; that is, treating patients according to methods and means that have been scientifically demonstrated to be the best choices. To achieve evidence-based practice requires practice-based evidence. PCPs are in the right place to provide this — to study the effectiveness of medical care and the translation of innovation from the laboratory to the bedside and the community. However, to accomplish this, prospective PCP-scientists need additional training and research capability that goes beyond the standard training provided to become a PCP, training that is both available and well supported.
The implementation of healthcare reform in the United States requires
expanding involvement and contributions from PCPs — the doctors who
truly have their fingers on the pulse of America’s health and health
care. The government and major medical institutions have recognized the
need to promote demonstration projects to implement and evaluate
innovative approaches for organizing and delivering health care.
Associated with this has been the development of 2- to 3-year
postdoctoral programs that allow PCPs to gain the necessary training for
developing careers in this area.
These programs are usually
called Primary Care Research Fellowships. They are generally centered in
Departments of Family and Community Medicine and are open to family
practitioners, internists, pediatricians, and general surgeons. Most are
also open to graduates of a doctoral program in a discipline related to
primary care, such as nursing, psychology, and epidemiology. Although
the programs vary somewhat in specifics, they all share 4 major goals:
- To provide a solid foundation in clinical research methods and statistical analysis
- To provide experience in performing research in primary care medicine through mentoring and collaboration with faculty members
- To prepare fellows to be effective teachers in the area of family medicine/primary care
- To provide the training and experience necessary for a career as a clinician-investigator
The program at the University of Wisconsin
appears representative of research fellowships in primary care
medicine. It began 18 years ago and is funded by an institutional grant
from the NIH. The program offers 6 positions a year. Fellows take
courses in epidemiology, statistics, and research methods, with most
fellows completing a master’s degree in population or public health and
some obtaining a Ph.D. Fellows spend 70%-80% (approximately 40 hours a
week) of their time doing research and writing papers. Clinicians are able to practice in clinic up to 20% of their time (10 hours a week) to
maintain and improve their clinical skills. A major goal is that each
fellow obtain an NIH or other substantive grant by the end of their
fellowship that they can take with them to an academic faculty position.
Beth Plane, the director of Research Services for the UW Department of
Family Medicine, noted that almost all fellows who begin the program
complete it. Examples of research projects include: reasons for primary
care visits, variables that affect extra lab tests and x-rays, and the
incidence and prevalence of diabetes in the region’s Hmong population.
Some graduates of the program have tenure-track academic positions.
Harvard Medical School’s fellowship in general medicine and primary care
began in 1979 and is one of the oldest in the country. The John Hopkins
School of Medicine’s Division of General Pediatrics and Adolescent
Medicine in collaboration with the University of Maryland Department of
Family and Community Medicine offers a similar program.
Ironically, one of the challenges PCP/researchers face is to devise
strategies to maintain and increase the number of practicing primary
care physicians. The New England Journal of Medicine recently
noted that currently only 16%-18% of graduates of U.S. allopathic
medical schools are likely to go into primary care. (Smith, S.R. 2011. “A Recipe for Medical Schools to Produce Primary Care Physicians“. N Engl J Med. 364 (6): 496-497.)
those considering a career in medicine with a significant research
component, the primary care physician scientist is a more fulfilling and
measured career than clinical primary care practice alone. It combines
the challenges and rewards of patient care in an academic setting with
the opportunity to develop and disseminate new knowledge regarding the
organization and delivery of primary care services–knowledge that can
help to shape and improve the overall health status of the country.