Huisartsgeneeskunde: aantrekkingskracht en beroepstrouw ... - Lirias

78 Making General Practice Attractive: Encouraging GP attraction and Retention KCE Reports 90
US federal and state policies
In the 1990s, US federal and especially state policies were designed to mandate medical
schools to "produce" more PCPs, which resulted in proportions of PCPs graduates
reaching 25 to 35% in 1995, short of the 50% target however 150 . The particularity of
these state policies is that they were not intrusive, they were unfunded mandates and
mostly signals to hold medical schools accountable for producing more PCPs 150 .
Generalist Physician Initiative
Private initiatives were also launched, e.g. the Robert Wood Foundation, which
provided financial support to the Generalist Physician Initiative (GPI) in 13 universities
(1991-2001), targeting the supply of family practitioners, general internists, and general
pediatricians 26 , 48 , 151 . Several aspects of the GPI are close to what was observed in
Belgium with the development of Academic Centers of General Medicine. The
Generalist Physician Initiative helped catalyze educational reform in medical schools that
had had little educational change in two to three decades. Those changes included:
• elevating generalist faculty into major leadership roles,
• instituting new administrative structures to coordinate generalist
activities,
• increasing the number of generalist faculty.
Some changes the schools carried out to promote general practice were for example:
• changing the admissions process to target more students with GP
potential, along with increasing the number of GPs on admissions
committees,
• developing high school and college undergraduate recruitment
programs,
• redesigning undergraduate medical education to include the primarycare
community experiences, GP-oriented clinical medicine courses
and GP clerkships.
The Generalist Physician Initiative increased output of GPs by approximately 39% during
the course of the program, from a baseline of 26.4 % of graduates in 1988­1991 to
36.7% of graduates in 1999. By 2000, there had been a decline in GP graduates to 32.8
percent of all graduates, so the final increase was 24 percent. Note that this trend in
increased production of GPs may not be attributed solely to the GPI and that it is not
either stable: national data show that after the mid-1990s peak, the number of PCPs is
leveling off in the mid-2000s 152 . The causal effect of the GPI is then questionable, and
other incentives and determinants of career choice by physicians should be considered.
Specific US initiatives for rural and deprived areas
Since there is little evidence to support the idea that distributional issues would resolve
by themselves, several education programs were developed in parallel by US medical
schools to attract and train future GPs, with an accent on rural practice and
underserved communities for some initiatives. Programs were initiated in the 1970s and
the 1980s and are still operating (see Geyman et al 2000 153 and McDonald et al 2002
154 ). Some of these programs were evaluated. See the following references : 50 , 56 , 57 , 87 , 89
, 94 , 119 , 122 , 123 , 148 , 155 , 156 , 157 .
All these programs concern small numbers of physicians (about 30 to 100/year).
Common features of these programs include:
• selection of students with rural background, with service orientation
and interests in family medicine,
• education in community medicine,