The following paper by Darryl Leong, MD, MPH, then the Dorchester County Health Department, Maryland Department of Health and Mental Hygiene and Eugenie Lewis, MHSA, LCSW is the second of an occasional series of e-publications on subject matter of the National Conferences on Primary Health Care Access.
Dr Leong’s seminal work, dating from 1995, but not heretofore published, argues that community health centers that meet certain standards (such as what is now called the “federally-qualified health center” should be recognized as a center for primary care physician training and should receive Medicare funds or other designated funds for such purposes directly, rather than indirectly through hospitals. Such centers would also be active in primary care research and employ community-based faculty.
See also the related presentation Darryl Leong, MD: Family Practice and the Future of Community Health Centers, which was presented at the First National Conference on Community Health Center-Primary Care Residency Linkages. Over the next few weeks, the proceedings of that first National Linkages conference are scheduled to be published.
A New Academic Institution – The Ambulatory Teaching Center
Purpose and Environment for Change
This paper conceptualizes a new “institution” in health professions education, the Ambulatory Teaching Center as the ambulatory equivalent of the Teaching Hospital. Teaching hospitals are well known in health professions education, health research and for providing state-of-the-art tertiary medical care.
The hospital-centric teaching model grew out of the Flexner report on medical education reform. 75 years later, we question whether this model is still valid as the only home of medical education. To complement teaching hospitals, there should be ambulatory educational institutions whose survival are just as crucial to the mission of the academic health center.
We call these new ambulatory educational institutions Ambulatory Teaching Centers. Just as Teaching Hospitals represent the best in tertiary care, Ambulatory Teaching Centers should represent the best in primary care.
An exhaustive study by the U.S. General Accounting Office[i] concluded that the financing of residency training contributes to a specialist orientation in medical education by supporting training in specialist-oriented settings. The lack of reimbursement for training residents in settings other than hospitals has been repeatedly identified as a major barrier to the establishment and maintenance of community based ambulatory training[ii],[iii],[iv].
These findings are particularly relevant with the documentation of the critical influence of primary care faculty role models on student career choices[v],[vi]. The importance of faculty role modeling in influencing the selection of primary care should not be underestimated. Moreover, positions for community-based faculty and staff create new reasons to select a primary care career.
It is also noteworthy that federal policy has provided capital, developmental, and operational funds only for teaching hospitals and not for ambulatory teaching centers. This formula of specific federal financial investments has resulted in the very best in medical research and tertiary care, which has been directly related to the high cost of health care in the U.S.[vii],[viii] but also widespread shortages of primary care providers through the U.S.[ix].
Ambulatory teaching centers, especially those located in rural and other underserved areas, are needed to maintain traditional academic excellence while addressing the community needs for prevention-oriented primary care practitioners.
The Ambulatory Teaching Center is the ambulatory equivalent of the teaching hospital. It is a model primary health care center based in the community with a mission to improve the health of the community through a combination of service, education, and research (Figure 1).
The Ambulatory Teaching Center provides exemplary primary care services focused on improving the community’s health; recruits students into health professions careers from the community; teaches students, residents, practitioners, faculty, and other staff about community-oriented primary care; develops and conducts community-based primary care research; competes for and retains high quality full and part-time primary care center-based faculty; provides scholarly input to the academic health center; functions as part of the administrative leadership for the academic health center; and serves as a source of innovation and academic prestige.
There should be one or more Ambulatory Teaching Centers in rural and urban areas as part of an academic health center. Various types of comprehensive primary care practices can function as Ambulatory Teaching Centers (HMOs, community health centers, public health clinics, medical group practices, hospital clinics, Indian health clinics, etc.). The Ambulatory Teaching Center is the appropriate “home” for academic generalists.
As opposed to existing models that add teaching and research as time- and space-permitting options, the Ambulatory Teaching Center is organized to operate with a combination of service, education, and research. All health professional students, primary care residents should have extensive exposure to Ambulatory Teaching Centers.
Why This Concept Is New
The call for more ambulatory training and sites is not new[x],[xi],[xii],[xiii],[xiv]. However, ambulatory training has been viewed as a rotation away from the hospital training center to ambulatory sites as opposed to the other way around. There should also be ambulatory-centered training with rotations away to hospital training.
There are many good examples of ambulatory training, perhaps best exemplified by Area Health Education Centers and Family Practice Centers, and this is not to suggest otherwise. However, unlike teaching hospitals, these teaching centers do not receive direct payments to support their teaching functions. For family practice centers, this means that the hospital’s needs remain paramount. For AHECs, this means a constant struggle to raise funding for educational activities.
The Ambulatory Teaching Center is distinguished from the common private practice preceptor model by being organized to provide primary care services, teaching, and research as part of its normal operations. As such, the Ambulatory Teaching Center is a primary care center with full and part-time community-based faculty and staff engaged in a wide range of scholarly activities.
The Missing Complement of the Academic Health Center
Today, the typical academic health center operates with one or a network of large teaching hospitals and many ambulatory preceptor sites (Figure 2). This model has worked well for developing advances in medical technology and techniques but has not worked as well in producing primary care practitioners for rural and other underserved areas.
The shift to ambulatory training requires a shift in thinking about the nature and the role of academic ambulatory facilities. Rather than relying only on ambulatory sites and preceptors, a network of Ambulatory Teaching Centers offers facilities and faculty as part of the academic mission.
Financing of Teaching Hospitals and Ambulatory Teaching Centers
Federal and state policies have long supported the post-graduate hospital-based training of medical interns, residents, and fellows and other health professionals through Medicare and Medicaid hospital payments, fees paid to physicians for patient care services, special federal and state grants for primary care training, state and local appropriations for university hospitals, federal appropriations for the Department of Veterans Affairs and Department of Defense, and fellowship stipends from biomedical research sources[xv].
The total amount of these funds is unknown, although Medicare alone will pay $5.8 billion in graduate medical education payments in federal fiscal year 19944 and at least $.735 billion in Medicaid payments[xvi]. Moreover, teaching hospitals have reported that only 81% of the cost of graduate medical education is reimbursed through patient services[xvii]. Training of a variety of health professionals is currently allowed (physicians, oral surgeons, podiatrists, nurses, medical technologists, physical therapists, occupational therapists, nutritionists, etc.).
In 1989, the Institute of Medicine recommended that Medicare Graduate Medical Education funding be shifted to specifically support ambulatory training[xviii]. The Physician Payment Review Commission[xix], the Council on Graduate Medical Education, and the Clinton Health Plan have proposed expanding GME funding for non-hospital entities.
With the increasing prevalence of managed care, there are active proposals to remove graduate medical education and disproportionate share payments from the capitation formula. Changes in GME policy should result in direct support for teaching residents in primary care centers. An Ambulatory Teaching Center should be accredited and eligible to receive direct and indirect graduate medical education dollars (Ambulatory Graduate Medical Education Payments) to support its teaching activities. It would continue to be eligible for service reimbursement dollars, research, training and other grants.
Networking in the Community
A network of Ambulatory Teaching Centers with primary care residencies could accommodate a significant portion of required and elective student experiences offers definite advantages over the status quo method of relying on a large number of primary care preceptors. Each Ambulatory Teaching Center could also serve as the hub of a large ambulatory teaching network and arrange for student and resident rotations in its surrounding area (Figure 3), making it highly compatible with current preceptor arrangements.
Ambulatory Equivalents: Characteristics Similar to Teaching Hospitals
Ambulatory Teaching Centers
|High Quality Tertiary Care Services System.||High Quality Primary Care Services System.|
|Faculty, Full and Part-Time – Subspecialists.||Faculty, Full and Part-Time – Generalists.|
|Curriculum – Care of patients with rare diseases and requiring tertiary care diagnosis or treatment.||Curriculum – Care of primary health care problems of the community.|
|Space – Beds, Wards, ICUs, CCUs, Operating Rooms, Recovery Room, Imaging Suites, Emergency Room, etc.||Space – Exam Rooms, Lab, Conference Rooms, Library, Waiting Room, Triage Area, Linked Services, etc.|
|Equipment – Scanners, Heart-Lung Machines, Fluoroscopes, Monitors, MRI, etc.||Equipment – Endoscope, Tonometer, Otoscope, X-Ray, Opthalmoscope, Culposcope, etc.|
|Selection process for student, resident, fellow, and faculty hiring.||Selection process for student, resident, fellow, and faculty hiring.|
|Opportunity to participate in awards, fellowships, meetings.||Opportunity to participate in awards, fellowships, meetings.|
|Selection as department chairs, deans, vice-presidents, and other academic leaders.||Selection as department chairs, deans, vice-presidents, and other academic leaders.|
|Support Staff And Services.||Support Staff And Services|
|Reference Materials and Library.||Reference Materials and Library.|
|Operating Funds For Educational And Research Support.||Operating Funds For Educational And Research Support.|
Benefits of the Ambulatory Teaching Center for the Academic Health Center
The benefits for academic health centers of having a network of Ambulatory Teaching Centers to complement the network of Teaching Hospitals are multiple, with improvements categorized as 1) increasing primary care training capacity, 2) improving the process, and 3) changing the outcomes:
Increasing Primary Care Training Capacity
- Increasing the Number and Quality of Primary Care Training Sites
- Increasing the Number and Quality of Community Based Faculty
- Assuring the Quality of Education and Training
- Recruiting and Retaining Minority and Rural Students and Community-Based Faculty
Improving the Process
- Community Oriented Primary Care Curriculum
- Linking Social and Behavioral Sciences with Biomedical Sciences
- Expanding Prevention Services, Research and Education
- Enhancing Rural Training and Research
- Integrating Public Health and Medical Care Concepts
- Training in Practice Management and Managed Care
- Developing New Methods for Primary Care Service, Research and Education
- Exposing Students to the Normal Spectrum of Disease Types and Processes
Changing the Outcomes
- Improving the Quality of Care Provided by the Academic Health Center
- Serving Medically Underserved Communities
- Enhancing the Organization Mission of Caring for the Community’s Health
- Prevention of Diseases
- Addressing Long Standing Health Problems in the Community
- Increasing the Number of Generalists
- Reducing the Cost of Health Care
Perhaps most importantly, the Ambulatory Teaching Center provides the opportunity for students, residents, faculty, and staff to see primary care as an exciting and vibrant part of the academic community, providing role models in terms of faculty, services, and research.
The Ambulatory Teaching Center serves as the proper institutional base for primary care academicians by providing them with the appropriate structure to pursue academic excellence in primary care services, education and research.
The Ambulatory Teaching Center changes the image of a primary care career from the “local medical doctor” (what one does if he or she chooses not to specialize) to becoming a critical part of the academic health center along with appropriate academic prestige.
Operating Ambulatory Teaching Center Models
There are a number of operating models of Ambulatory Teaching Centers that are based in the community and perform the three functions of service, education and research. The models that are highlighted here all have the mission of improving the health of the community. By successfully developing and operating ambulatory models they serve as a source of expertise to further expand the concept of the Ambulatory Teaching Center.
Although only these three are highlighted here, there are many others that serve as Ambulatory Teaching Center models including the: Blackstone Valley Community Health Center in Pawtucket, Rhode Island[xx]; East Dayton Health Center in Dayton, Ohio; Sequoia Community Health Foundation in Fresno, California[xxi]; Salt Lake City Community Health Centers in Utah; Broadlawns Primary Health Care in Des Moines, Iowa; Rainelle Medical Center in West Virginia; Lincoln Heights Health Center in Cincinnati, Ohio[xxii]; the AHEC in Morehead, Kentucky; the Teaching HMO at the Harvard Community Health Plan[xxiii]; Sea Mar Community Health Centers in Seattle, Washington; Denver Health and Hospitals in Colorado; Akron Health Department in Ohio; East Boston Health Center and other Kellogg Community Partnership sites; and others.
Rural Alabama Health Professional Training Consortium
The Ambulatory Teaching Center at West Alabama Health Services, a rural community health center (CHC), operates an interdisciplinary training program entitled the Rural Alabama Health Professional Training Consortium, which has trained over 300 students representing 8 health professional disciplines (medicine, dentistry, nursing, optometry, pharmacy, social work, nutrition, and public health).
The curriculum features primary care clinical experiences, community health care, rural health, transcultural health care, health education, outreach and effectiveness in working in interdisciplinary teams. Education and research are integral to the mission of West Alabama Health Services.
Their service model exposes students to a range of health care interventions such as outreach and home care, health education, transportation, social services, school health and substance abuse prevention, in addition to traditional medical/clinical services. Educational programs extend beyond health professional training to reach minority children in elementary and secondary schools and improve educational outcomes.
Research programs include a wide range of primary care, community health topics such as maternal and child health, geriatrics, and women’s health. The center has developed partnerships with over 10 health professional schools. The faculty is based in the community and students from each discipline are exposed to faculty across other disciplines. The program is headed by family practitioner and clinical professor Dr. Sandral Hullett.
Lawrence CHC Family Practice Residency
The Ambulatory Teaching Center at Greater Lawrence Family Health Center (GLFHC), an urban community health center in northeastern Massachusetts holds institutional and program accreditation from the American Council for Graduate Medical Education for 24 family practice residents. Every aspect of the program has been designed to educate and encourage physicians in a way which reflects the mission of the community health center of improving the community’s health.
The curriculum is designed, implemented and centered with an ambulatory, community-oriented focus by CHC-based faculty. During the first year, residents participate in an 8 week family/community medicine rotation in addition to the traditional family medicine curriculum. Because many patients of the health center speak Spanish, an intensive language course is provided to all residents during orientation of the first year. Other areas of emphasis include behavioral medicine, COPC, and practice management.
The program is affiliated with the Tufts University School of Medicine and with the Area Health Education Center of the University of Massachusetts. The program is headed by family practitioner and clinical assistant professor Dr. Scott Early.
The GLFHC works to improve the health status of individuals and families in Greater Lawrence through a number of medical and non-medical programs. These include prenatal case management, HIV counseling, education, outreach, nutrition counseling and health education services.
As new health care problems emerge, the health center responds by creating innovative, culturally sensitive programs to address particular needs of the community. Family practice residents train in this community-oriented environment. The faculty of the program are based in the community health center, serving as primary care role models.
The Upper Peninsula Campus of Michigan State University
The Ambulatory Teaching Center at the Upper Peninsula (U.P.) Campus of Michigan State University College of Human Medicine was established in 1974 to train medical students for careers in rural medicine. Despite its location in the small, isolated town of Escanaba 400 miles from the main campus, the main ambulatory training site, the Medical School Family Health Center, fulfills all of the criteria for a Teaching Ambulatory Primary Care Center.
Eight third-year medical students per year are based at the center for five months as they complete clerkships in Family Practice, Ambulatory Pediatrics, Community Medicine, and Behavioral Science. Approximately 70% of the students clinical work is at the MSFHC with the remainder at the local community hospital, other private physician offices, and community health care agencies such as the public health department and the Native American clinic. Details of the curriculum have been published previously[xxiv],[xxv],[xxvi].
Besides clinic space, the MSFHC is equipped with a small library with MedLine access, a conference room, a research area and faculty offices. Full-time faculty include two family physicians, a pediatrician, a psychologist, two physician assistants, and a research coordinator. Many local physicians volunteer their time as clinical preceptors, and they participate in clinical research projects as well.
The faculty not only design and run the student clerkships, but also are fully immersed in academic work. Besides curriculum development, academic research and clinical research have been an important part of faculty life for the past twenty years. Faculty publish regularly in refereed medical journals and present their work at annual meetings of national and international medical societies including the American Association of Medical Colleges, the Society of Teachers of Family Medicine, the North American Primary Care Research Group, and the Network of Community-Oriented Educational Institutions for Health Sciences of the World Health Organization.
The Upper Peninsula Campus is known nationally in family medicine research circles for its computer-linked rural primary care research network, UPRNet. For the past five years UPRNet has completed an average of two clinical research studies per year. Clinicians from the 15 rural practices gather twice yearly to develop studies and learn about the research process.
The rural family physicians have been enthusiastic participants. The Medical School Family Health Center has felt the pressure of managed care, poor funding for rural health care, and diminishing financial support for medical education. The clinical practice has been sold to the local hospital, but the educational and research programs remain with Michigan State University.
Key Strategies for Expanding the Role of Ambulatory Teaching Centers
With the now widespread consensus on moving toward more ambulatory and community-based training answering the why question, we focus on how academic health centers could achieve such a change.
Vision and Strategic Planning. Like any major change, there must be vision and leadership. We suggest that academic leaders look seriously at the concept of Ambulatory Teaching Centers and incorporate it into their strategic planning. The validity of a hospital-centered vs. an ambulatory-centered training system should be openly discussed and debated.
Ventures of this size also require capital and start-up funds which will be hard to acquire without the concept of Ambulatory Teaching Centers being part of the overall strategic plan of the academic health center, the medical school, the nursing school, and other health professional schools.
Capital and Startup Funds. Foundations and the federal government should provide the capital and startup funds to test and refine what will eventually be standard models for training and excellence in primary care. Models should be developed in both rural and urban areas.
Partnerships. The concept of Ambulatory Teaching Centers assumes that teaching and research is done in an ambulatory institution that is providing high quality comprehensive primary care services. One obvious option for the development of these centers is through existing and well-established comprehensive primary care practices.
Some community and migrant health centers, public health department clinics, Indian Health Service clinics, school health clinics, and other community-oriented primary care providers should be considered as primary care models that could become Ambulatory Teaching Centers. In addition, some medical group practices and health maintenance organizations could become Ambulatory Teaching Centers as well.
Community-Based Faculty. Besides the obvious funding needs for Ambulatory Teaching Centers, the need for high quality community-based faculty is paramount as these are the people who will actually provide the teaching, research and role-modeling. Many of the existing practitioners with expertise in primary care services have the capacity to become teachers and researchers as well. There should be university and federal strategies to develop community-based primary care faculty for Ambulatory Teaching Centers.
Research. As the concept of the Ambulatory Teaching Center includes scholarly research as a core part of the concept, support for clinical research is an important part of the development of these centers. Fortunately, there has been an increasing recognition of the need for primary care and community-based research6. The Ambulatory Teaching Center provides an excellent base for research activities.
This analysis points to the importance of developing new and redeveloping old partnerships between primary care providers and the academic health community. Moreover, minority and poor communities are not likely to welcome becoming patient fodder for students and researchers.
Primary care providers that have the trust of these communities are much more likely to be able to add teaching and research to their mission. Much of the existing primary care capacity in terms of human and financial capital is already in place and academic health centers need to partner with these entities to develop a network of Ambulatory Teaching Centers.
Providing a quality education in primary care is as important as anything else that the academic health center does and it is the only institution charged with this responsibility. Academic health centers have a marvelous record of bringing quality to what they do and developing a high quality ambulatory training system for primary care can be accomplished.
Primary care education should not be treated as an unfunded add-on to already busy primary care practices. Ambulatory Teaching Centers offer a realistic way for academic health centers to meet societal needs and maintain traditional academic excellence and freedom.
With the near universal agreement on the need to shift education of medical students and residents from hospital settings to ambulatory settings, the role of ambulatory educational institutions should be addressed. We challenge the assumption that rotational experiences in practicing preceptors offices offer the best model for primary care medical education by describing a new ambulatory educational institution, the Ambulatory Teaching Center.
While hospital training is well-established in teaching hospitals, the complementary health care institution for ambulatory training is not. Ambulatory Teaching Centers offer a rational and logical method for meeting societal needs for primary care generalists without sacrificing academic freedom and research. The Ambulatory Teaching Center should function as the ambulatory equivalent of the teaching hospital.
Acknowledged are the contributions of Mr. Jim Coleman and the staff of West Alabama Health Services, Inc., Eutaw, Alabama, Ms. Edith Mas and the staff of the Lawrence Family Health Center, Lawrence, Massachusetts, and the staff of the Upper Peninsula Campus of the Michigan State University College of Human Medicine. Acknowledged also are the contributions of Peter Curtis, MD, Glendon O’Grady, MD, Glenn Hughes, PhD, Steve Wilhide, MSW, Bery Engebretsen, MD, Richard Wright, MD, Jaime Cruz, MD, Marc Clasen, MD, PhD, Marc Rivo, MD, MPH, William Burnett, Robert Walker, MD and Tom Van Coverden, MS.
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