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- the doctors were not the regular providers for the protestors
- the doctors were not taking histories or examining before handing out the sick notes
- the protestors were not actually sick!
..fresh perspectives by residents & students committed to the only true primary care specialty
A survey of medical school deans conducted by 4 students at Harvard Medical School reveals that although 94% reported some form of policy instruction at their institutions, the average amount was only 14 hours over 4 years. In the lowest quartile of schools, students received 6 hours or less of formal schooling on issues such as quality improvement, medical economics, and health insurance design.
....physicians at the University of Pennsylvania and the University of Michigan conclude in an article in the current issue of NEJM that "medical education has failed to keep up with policy changes as the US healthcare system has evolved" and that without some catching up, "healthcare reform will not be able to achieve its greatest possible impact."When the AAMC was approached about this area, their response was the following:
...medical students receive instruction in practice management, medical record-keeping, quality improvement, healthcare systems, medical economics, and medical licensure and regulation — all grist for policymaking — as evidenced by annual AAMC questionnaires completed by medical school graduates. Those same questionnaires, however, point to room for improvement. In the 2010 questionnaire, a majority of graduates said that instruction in practice management, medical economics, and medical licensure and regulation was inadequate, and almost half said the same about managed care.With the medical environment forever changing, providing hours upon hours of information about health care policy, systems, etc. would be a difficult task - much like trying to hit a moving target. To ensure an adequate education in these areas, medical schools would need to either bring in new faculty or pile more work on existing faculty (and probably with very little additional salary) - I would put money on it being the latter. Moreover, with a Congress that has no idea what to agree on, our information in these areas have more of a chance of being outdated tomorrow than many of the things we are learning in the basic sciences.
AAFP Family Medicine Congressional Conference
AMSA Annual Convention and Advocacy Day
AMA National Advocacy Conference
ACP Leadership DayThe best part is that at some of these conferences, we actually head out with other students, residents, and physicians and meet with leaders of these medical associations as well as members of Congress. This benefits medical schools and students in many ways. First and foremost, medical students get a chance at a change of scenery. We also get to network with other students, physicians, and leaders which helps advance our professional careers - there is only so much we can do to network with our own institution. Next, we get to hear effective, concise presentations by people who live/eat/breathe medical systems, health care, and advocacy. Medical schools would not have to hire more faculty, further stretch other faculty, or try to incorporate more educational time during the school's curriculum - usually at the expense of something else that may be important (nutrition, humanities, clinical skills/simulation, and maybe learning how to do an effective physical exam instead of relying on a pan-scan).
Between COGME’s 20th report recommending expansion of the nation’s primary care workforce (see 1/28/11 post) and the health care rhetoric and legislation coming out of Washington over the past few years, it seems that those in health care industry and policy are in full agreement that a primary care shortage exists in the United States and that the number of primary care physicians we produce in the coming years will have a significant impact on both cost of and access to quality care.
But how do we as a nation produce more primary care physicians? And is setting a numerical goal (i.e. 40% of physicians will be primary care physicians by 2020) enough?
Assuming we can improve reimbursement for primary care physicians (both male and female – see 2/3/11 post on gender-based physician salary gaps) such that family medicine becomes a more desirable financial option for those students who see reimbursement as a barrier to a primary care career, we will still have to address the disparity in access to primary care that occurs between geographical boundaries in the U.S.
In 1970, the federal government created the National Health Service Corps (NHSC) in an attempt to combat the changes in access to care that had begun over the prior two decades as rural physicians retired or moved to cities, where medical practices offered higher salaries and job opportunities for spouses. With the passage of the act that created the NHSC (and its subsequent amendments), the government recognized that proportion of patients living in areas with a population to practitioner ratio of 2,000:1 as “underserved.” These geographical areas were termed Health Professional Service Areas, or HPSAs.
Currently, the Health Resources and Services Administration (HRSA) website states that
“As of September 30, 2009, there are 6,204 Primary Care HPSAs with 65 million people living in them. It would take 16,643 practitioners to meet their need for primary care providers.”
Although over the past two years President Obama has reversed a trend in dwindling HRSA funding and expanded HRSA health workforce programs (including doubling NHSC funding to $300 million in the fiscal year 2010 budget and increasing that number by an additional $27 million for 2011 along with increasing funding for community health centers), we have to realize that more federal funding alone isn’t the panacea for curing the problem of geographic health workforce disparities.
A study published in the November 2010 issue of the American Journal of Public Health analyzed interview responses from primary care physicians in Los Angeles County, California concerning their reasons for practicing in their particular geographic location1. Only 24% (5 of 21) of interviewees practicing in underserved areas in the county chose their practice location because of loan repayment obligations, which seems to indicate that federal funding is a minor player in the eventual retainment of primary care physicians in such areas. Compare that to the 19% (4 of 21) of physicians in nonunderserved areas serving in their respective areas due to loan repayment obligations, and one starts to wonder whether loan repayment money really has an impact at all.
Digging deeper into the numbers of the study reveals that those physicians working in underserved areas were most likely to do so because of mission-based values (a “sense of responsibility or commitment to a particular community, a defined patient population, or a moral obligation”) and self-identity (including “language, personal, family, cultural, socioeconomic, and geographic backgrounds”). A 2003 study of a rural physician workforce in Florida provides similar insight, noting that physicians from rural backgrounds and physicians who were exposed to rural experiences in medical school and residency were more likely to practice in underserved rural areas2. To further the connection between training and practice, a 2009 study in the Annals of Family Medicine looked at training residents in community health centers (CHCs) and found that family medicine residents who trained at CHCs were four times more likely than their colleagues to go on to practice at CHCs3.
In addition, among primary care specialties in the L.A. study, the vast majority of physicians practicing in underserved areas were family physicians, whereas internal medicine and family physicians shared an equal percentage of the total in the nonunderserved cohort.
So what does all this mean? It would appear that prior experience in an underserved community and a sense of responsibility to that community is truly the major motivator in where a primary care doc practices. It means that medical schools and residencies need to partner with CHCs to encourage graduates to work with the kinds of populations that frequent them. Even more importantly, it confirms what we should have known all along: the best medical school candidates are those who already enter with mission-based values and who self-identify with those communities that most require family physicians.
Easier said than done, but we can’t hope to rely on loan repayment opportunities and training alone to funnel more students into family medicine. Opportunities to train with an underserved population best stimulate those who already want to work in that setting. It’s up to medical school admissions committees to select medical students who fit that bill.
The Robert Graham Center (RGC), with private foundation money, is already producing objective data on how well medical schools and training centers are fulfilling their “social mission” (that is to say, how well they are meeting the health care needs of the public)4. The RGC uses geographical information systems mapping tools to display these results visually. The only limitation of this data is that it is elicited from the American Medical Association Physician Masterfile which, although fairly comprehensive, still is prone to a small amount of error.
Knowing that, I propose a more effective use of federal money to improve the primary care services in the United States: create a national database of registered physicians and their specialties and locations of practice; then, instead of tying the majority of a medical school’s funding to the amount of research it produces, tie a large portion to the percentage of each school’s graduates who end up working as primary care physicians in underserved communities.
It would be a carrot approach, much like President Obama’s “Race to the Top Fund” for improving primary school education, and perhaps it would create an incentive (to compete with incentives from research funding and alumni donations) for admissions committees to take a closer look at the values of their applicants.
References:
As the only female contributor to this blog, it seems only appropriate that for my first post I tackle some gender issues. The February 2011 Health Affairs Table of Contents came out today and the very first article I noticed was “$16,819 Physician Gender Gap”. This sort of article occasionally appears, long enough to elicit some guilty feelings and an apathetic hope for change, then disappears quietly until the next round.
In a world where over half of entering medical students are female, and a disproportionate amount of those are pursuing careers in primary care, the gender-based income gap is a huge workforce issue that we never really address. We’ve paid a lot of attention to disparate salaries across specialties, but not within our own profession. It’s something we toss out to the free market, assuming that the gap will close under the appropriate conditions. Some of us may even silently think things are fine as they stand.
This is issue is not unique to the specialty family medicine, and it is certainly one that appears across many non-medical professions. According to this graphic from the New York Times, physicians are actually at the bottom of the barrel where the income gap is concerned – that is to say we’re doing worse than lawyers, pharmacists, medical scientists, teachers, postal workers, and pretty much everyone else.
Lest you think I’m approaching this from a purely feminist angle, I have considered the free market argument potentially justifiable. I mean, women in medicine choose primary care careers, and take time off for children, and spend more time with patients for lower total reimbursement, right?
Wrong.
Let me rephrase – all of those points are true. However, these classic rationalizations have been proven inconsequential by the authors of the Health Affairs article. Men simply make more money than women for the same work.
The authors used survey data from New York State to examine salary trends from 1999-2008. Their data not only shows that an income gap exists, but that it has grown almost five-fold in the last 10 years, from a gap of 12.5% to 17%. To avoid confounders of experience and rank, they only looked at starting salaries. More importantly, this study is the first to my knowledge to show that disparities exist across specialty, practice type, and work hours. Controlling for these and other factors slightly reduces the gap, but does not eliminate it entirely.
The high prevalence of women in primary care has often been cited as a reason for the income gap; however, a decreasing proportion of women are choosing primary care. As the authors point out, this argument would predict the gap to decrease, rather than increase as it has in recent years. A stratified analysis of primary care versus non-primary care specialties revealed similar results – unfortunately, the analysis lumped family medicine together with pediatrics and internal medicine, three specialties that have very different post-residency workforce dynamics.
The vague concept of “productivity” has been another rationale for the discrepancy, often as measured by patient visits over time, rather than on the more clinically relevant measures of quality or outcomes. Results presented at the WONCA 2010 Conference show that among Canadian physicians, women spend more time with patients (17.8 minutes vs. 13.3 minutes), are more emotionally engaged, and allow more time for discussion and questions. Unfortunately, these women also report more signs of burnout and physical stress. Ultimately, studies regarding productivity have been mixed.
“Quality of life” is often used as a euphemism in these discussions to reflect the part-time and re-entry options available to balance family and work obligations. The authors postulate that quality of life may be a direct cause of the discrepancy. As more practice options become available, “female physicians may be seeking out employment arrangements that compensate them in other – nonfinancial ways.” Women are the typically beneficiaries of these changes, but men are increasingly attentive to quality of life concerns as well. I remember a professor of mine, a retired physician, who recalled (with a smile) a successful presentation at rounds some fifty years ago because he chose to stay at the library all night instead of returning home to his wife and newborn. It is fair to say this is not the current day expectation. And no, he was not a family physician.
While causality data for the gap is patchy and contradictory, evidence does exist that debt load and anticipated future income affects specialty choice. The average debt for a medical senior graduating in 2007 was $145,000 for public schools and $180,000 for private schools, and over 23% of students had debt above $200,000. Less than 8% of those students are pursuing careers in family medicine, a majority of them women.
The COGME Report included a recommendation to increase primary care physician income to 70% of the median level of specialists. I propose we pay equal and special attention to the less discussed income gap in medicine that exists along gender lines. With women as a historical majority of the primary care workforce, and female graduates increasingly choosing subspecialty fields, income discrepancy may be contributing more to workforce dilemmas than we realize.
With that said, I challenge to you to think about this - what can family medicine do to lead the change?
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References:
(1) Sasso AT, Richards MR, Chou C, Gerber SE. The $16,819 Pay Gap For Newly Trained Physicians: The Unexplained Trend Of Men Earning More Than Women. Health Affairs, 30, no.2 (2011):193-201.
(2) Palmert M, Pipas C, Wadsworth E, Zubkoff M. Economic Impact of a Primary Care Career: A Harsh Reality for Medical Students and the Nation. Academic Medicine, 85, no.11 (2010):1692-1697.
(3) Sullivan MG. Women Physicians Connect Emotionally With Patients, But Are More Stressed Out. Elsevier Global Medical News. Published online on June 29, 2010. Available at http://www.medconnect.com.au/tabid/84/s22/Neurology/ct1/c337421/Women-Family-Physicians-Connect-Emotionally-With-Patients-But-Are-More-Stressed-Out/Default.aspx. Accessed February 3, 2010.
(4) Why Is Her Paycheck Smaller? New York Times. Published online May 18, 2010. Available at http://www.nytimes.com/interactive/2009/03/01/business/20090301_WageGap.html?src=tp. Accessed February 3, 2010.