In reply

摘要

Kleczek and Baumert make 2 related and important points. They argue that residency work environment affects trainees' decisions to enter primary care and that residency training should reflect future practice. We agree on both counts. Residency training sites serve large numbers of poor, minority, and uninsured patients, and faculty are dedicated to insuring high-quality care. Yet, despite increasingly early exposure to patients and faculty, fewer students and residents pursue careers in primary care and even fewer work with underserved patients.This paradox may result from a hidden curriculum that undermines the very skills and values that faculty aspire toteach. Trainees often witness 2-tier systems of care where affluent patients are cared for by faculty in "private" practices, while patients with Medicaid or no insurance are seen in crowded, understaffed resident clinics. Time and resource constraints force trainees to "make do" during time-pressured visits with patients with complex, seemingly overwhelming needs. Trainees may learn that comprehensive care, patient-centered communication, cultural sensitivity, teamwork, and community linkages are ideals with little clinical relevance, as they struggle to get through hectic clinic sessions on time. Such training may have the unintended consequence of perpetuating rather than ameliorating health care disparities.