This study presents evidence that the culture of osteopathic medical schools supports learners' choice of primary care careers to a greater extent than that of most allopathic medical schools. Because we controlled for primary care orientation in our analyses, we believe we can attribute differences between the two communities to their cultural practices and not simply to the higher proportion of primary care faculty or primary-care-oriented learners in osteopathic medical schools.
The pattern of responses to this survey from members of the osteopathic community indicates the pervasiveness of their commitment to support primary care. Beginning with an explicit, stated primary care mission, the osteopathic medical community admits new members whose personal characteristics and interests fit well with a primary care culture and who are, therefore, likely to choose primary care careers. Not only are structures in place to support primary care training—i.e., mission statements, curricular hours, and a relatively high proportion of primary care faculty—but both primary care and nonprimary care faculty strongly encourage learners to enter primary care careers. Also, residents and students encourage their peers.
Despite large differences between the osteopathic and allopathic communities, there is reason to believe that the two cultures have begun to converge. At the time of this study, 63% of osteopathic graduates entered allopathic residency programs.9
This dilution of the osteopathic culture, along with the emphasis on high technology and subspecialty medicine practiced in allopathic residency programs, may diminish osteopathic residents' positive attitudes toward primary care and align their attitudes more closely with the culture of allopathic medicine than with osteopathic medicine. Because we did not differentiate between osteopathic residents in osteopathic and allopathic training programs, we cannot determine the degree to which any of these forces was associated with residents' attitudes.
Since this survey was conducted, three new osteopathic schools have opened and numerous osteopathic hospitals have closed (Zuger A. New York Times. February 17, 1998:C1). This would suggest that osteopathic students and residents will increasingly train in mixed allopathic and osteopathic settings in which the transmission of positive attitudes toward primary care may be less likely. At the same time, allopathic medical schools, especially those with primary care missions, have increasingly imitated the admissions criteria and curricular requirements of osteopathic schools.14
There are two important limitations to this study. First, we did not compare the osteopathic community with the subsets of allopathic schools with stated primary care missions or those involved in the generalist curriculum reform. Past research suggests that the cultures of these schools more closely resemble those of osteopathic schools.6
However, a recent study found that attitudes toward the competence of primary care physicians were just as negative in primary-care-oriented allopathic schools as in all others.15
Second, major changes in the health care system that have occurred since this study was conducted may affect our conclusions. Increased penetration of managed care has had a negative effect on academic physicians, especially specialists.16
Theoretically, this might cause a backlash against primary care, which could be greater in allopathic medical centers where there are larger proportions of specialists. Moreover, to the extent that managed care has not yet penetrated rural areas, 17
primary care osteopathic physicians—who are more likely than allopaths to practice in rural areas—have probably been less negatively affected. In addition, primary care, as practiced today, has become fragmented among multiple practitioners (e.g., hospitalists, nurse practitioners, physician assistants, both osteopathic and allopathic family physicians, general internists, and pediatricians) whose functions overlap, but who bring different backgrounds and hold different levels of expertise for components of primary care. This fragmentation may lead to an increased perception that primary care tasks do not require high levels of expertise.
Culture matters in its totality. Although this study demonstrates that osteopathic schools' culture may be more supportive of primary care education than allopathic, it also reveals how the lack of alignment among different aspects of the culture—namely, community members' practices and attitudes—can undermine the expressed goal of producing primary care physicians. Osteopathic schools, like allopathic schools with primary care missions, lose many graduates to the specialties. To make further advances in primary care education, we must explore why this lack of alignment between primary care practices and attitudes exists in schools that are aggressively promoting primary care training.
One explanation may lie in American society's emphasis on specialized knowledge and expertise. The belief among primary care and specialist physicians, osteopaths and allopaths alike, that primary care tasks such as managing depression and achieving patient compliance require little expertise highlights a prevailing attitude among academics that work that requires communication with patients or psychosocial expertise is not scientifically based or intellectually rigorous.18
For some time, the curricular structures and policies needed to produce primary care physicians have been clear to both osteopathic and allopathic educators. This study highlights the importance of general culture in which there is an alignment of educational structures, practices, and attitudes. Schools interested in creating positive cultures for primary care must broaden community membership to include entrants with strong socioemotional orientations or untraditional backgrounds, for example, as well as recruit, develop, and promote outstanding primary care faculty members. It is important that these newcomers be given every opportunity for professional development and be accorded the respect and status of their specialist—or specialty-bound—peers. Finally, schools need to encourage a collegial discourse about all medical specialties. Certainly, sincere, consistent, and widespread encouragement of students to enter primary care careers is a convincing form of support. Its opposite, “badmouthing” of primary care careers, has been shown to be discouraging.19
The prevalence of negative attitudes toward the competence of primary care physicians within both communities suggests that there needs to be a clearer understanding of the value added by primary care within the health care system.
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