What Can the Giant Do? Defining the Path to Unsupervised Primary Care Practice by Competence, Not Time

In this issue of Academic Medicine, Dewan and Norcini examine the significant variability of time-in-training between patient care "giants"-the physicians, nurse practitioners, and physician assistants who practice primary care-and they call for further studies to determine optimal training duration and eventual scope of practice. They ask, what is the minimum education and training required to practice primary care, or "how tall is the shortest giant?" In this Invited Commentary, the authors reframe the question from identifying the minimum length of training required, to identifying desired patient care outcomes. Primary care is not a uniform entity. It ranges from complex elderly chronically ill patients, to twentysomething millennials with acute problems, to pregnant women, to families, and everything in between. The authors argue that training should be fit for purpose and produce high-quality outcomes for patients. Competence should be defined by these outcomes. Drawing parallels with Major League Baseball, the authors note that time to competence development will be variable for different training programs depending on purpose, and also variable for people within those programs, even with shared purpose. While time is a tool for competence attainment, it should not be the metric by which readiness for practice is measured.