In a national survey of practicing family physicians, pediatricians, internists and surgeons, the majority reported that their training in chronic care medicine was too thin overall to meet the demands of their practices. Specifically, nearly two-thirds felt poorly trained in skills related to the care of chronically ill patients, including the management of geriatric syndromes, end-of-life care and nutrition.
The Johns Hopkins-led study also found that family practitioners and younger physicians reported more satisfaction with their training, suggesting that medical schools are beginning to address the problem.
"Despite the prevalence and burden of chronic illness, healthcare delivery in the United States is largely organized and financed around acute illness," says Eric Bass, M.D., M.P.H., coauthor of the study, published in the June issue of Academic Medicine, and associate professor of medicine at Hopkins. "As a result, current delivery systems are poorly adapted to the needs of patients with chronic conditions.
"In our study, the majority of practicing clinicians in both primary care and specialty fields had positive attitudes about their ability to care for patients with chronic conditions, but felt they had received less training than needed. Medical educators at all levels should reassess curricula for content on chronic care, ensuring that students get the basics during medical school, and the skills specific to their specialty during residency."
Chronic problems, such as diabetes, heart disease, pain and asthma, account for more than 75 percent of health care spending in the United States, the authors note. More than 80 percent of people over the age of 65 have one or more chronic diseases, and more than 10 percent of children have a chronic condition. Chronic illness here was defined as any condition expected to last a year or longer that limits what one can do and may require ongoing care.
For the study, Bass and colleagues conducted telephone surveys of 1,236 physicians nationwide regarding the physicians'' attitudes about caring for the chronically ill, and assessing how well they feel they were trained to do so. Interviewees were selected randomly from American Medical Association and American Osteopathic Association member lists.
On average, those interviewed were 46.7 years old and had graduated from medical school 19.4 years prior to taking the survey. Twenty-six percent of the respondents were female and 72 percent were white. Respondents included 270 family or general practitioners, 231 internists, 129 pediatricians, 335 non-surgical specialists and 271 surgical specialists. Twenty-six percent of respondents worked mostly with elderly adults and 24 percent reported that 80 percent to 100 percent of their patients had a chronic medical condition.
Most physicians responded that medical training had a positive effect on their attitudes toward caring for the chronically ill. However, overall, 60 percent to 65 percent of physicians reported that they had not received adequate training in 10 chronic care skills: approaches to educating the chronically ill, end-of-life care, coordination of in-home and community services, management of geriatric syndromes, management of psychological and social aspects of chronic illness, assessment of care giver and family needs for patients with chronic illness, chronic pain management, nutrition, interdisciplinary teamwork with non-physician providers for the chronically ill, and assessment of developmental milestones in chronically ill children.
Family practitioners were less likely than other physicians to report that their training was inadequate. This may be because family practice training is focused more on outpatient care rather than acute care settings, Bass says. In addition, those who graduated from medical school within 10 years of taking the survey also were less likely to report inadequate training.
"This finding indicates that some change in the culture of medical education has taken place over the past decade, perhaps as new physicians have adjusted their practice expectations to changing patient demographics and practice situations," Bass says.
A previous study published in January by Bass and colleagues showed that medical school course directors greatly vary in their teaching of caring for the chronically ill.
The current study was funded by the Partnership for Solutions, a national program of the Robert Wood Johnson Foundation, the Health Resources and Services Administration, and the National Heart, Lung and Blood Institute. Coauthors were Jonathan D. Darer, M.D., M.P.H.; Wenke Hwang, Ph.D.; Hoangmai H. Pham, M.D.; and Gerard Anderson, Ph.D.