Monday, November 14, 2011

Should we Occupy Medical Schools to Effectively Occupy Healthcare?

Kevin Bernstein, MD, MMS
Co-Founder, Future of Family Medicine Blog

A social media movement is happening before our eyes with action starting to take shape.  The #occupyhealthcare movement has begun within to the blogosphere and through various areas of social media by storm, including a recent demonstration on the streets of Boston.

What does the #occupyhealthcare movement mean to me?  By now, readers of this blog may notice that my main focus in advocacy for family medicine is the production of an adequate primary care workforce distributed adequately to best serve our country.  Those close to me also know that the current climate of health care access, quality and cost in the civilian world is one of my main reasons for pursuing a medical career in the military. What does that have anything to do with occupying healthcare?

First, we must occupy healthcare to produce the primary care workforce that our country needs.  There are a number of ways that this needs to be accomplished.  We must quit investing money into procedures and interventions that provide no decrease in morbidity and mortality for patients.  We need to shift our investments towards cognitive evaluation and management of patients in an effort to prevent diseases from occurring in the first place.  If they are already present, we need to invest in the cognitive efforts that are most proven to help our patients prolong or stop the progression of disease.  By doing so, we will attract the best and brightest medical and other professional students towards professions within patient-centered medical homes.  Our patients deserve nothing less than the best to provide ongoing, life-long, multidisciplinary care.

Second, we must occupy healthcare to decrease bureaucracy within medical schools.  This starts with how medical schools are "ranked" and funded.  Consider how much emphasis is put on NIH funding for research towards rank and prestige.  When looking at funding for research, most of the research done at these institutes are within tertiary care centers, where less than 1% of our population actually receives care.  This funding needs to be shifted towards research within our communities, to best represent the needs of the 99% of those who never make it to the ivory tower, academic tertiary care centers; to the 99% who would be better served by research that actually addresses the problems that they face.

There is no incentive for schools to produce the primary care workforce necessary for our country.

Do not get fooled by "The Dean's Lie," where medical schools count all students choosing internal medicine, family medicine, and pediatrics without accounting for the 80-90% of them that will eventually specialize and never practice true primary care.  In any other profession, this would be considered fraud.  How can we let them get away with this type of misrepresentation regarding how they contribute to our primary care workforce?

Should we incentivize NIH funding in proportion to primary care workforce production?  

Medical schools argue that their main job is to educate and train future physicians and that the choices of students is out of their hands.  Is it?  How many family physicians teach core competencies, including anatomy and pathology, during the first two years of medical school?  Are they stuck teaching clinical skills?  Is primary care valued at these schools - does the school have a family medicine department?  Does the admissions committee have primary care physicians involved in the selection of potential students?  Do other departments value primary care or do they tell medical students that they are "too smart" for primary care?

Without an adequate primary care workforce, not many people are going to have access to the patient-centered care necessary to screen and/or manage the many diseases that our country suffers from, most which could be prevented with high quality primary care.  This starts with our workforce and ends with how we value services provided by our system.  We pay more to keep people sick and less to keep people healthy.  In turn, we attract more medical students to pursue careers in areas that keep people sicker and longer rather than careers in primary care where we can make the biggest impact on people's lives with the lowest cost to our healthcare system.

The current climate forces those interested in keeping their jobs to make good business decisions in return for one of the worst healthcare systems among developed nations.  What a shame.  Let's #occupyhealthcare to allow those in charge (or those who will be in charge) to make the good business decisions necessary to create a system that everybody can be a part of.

Sunday, November 13, 2011

Is maternity care still part of the family medicine continuum?

"Family doctors can deliver babies?" That's a common reaction I get when chatting with people (whether non-medical friends or medical students). And my answer is always an adamant "YES!"

But the reality now is that fewer and fewer family physicians are choosing to provide maternity care as part of their scope of practice. The most recently presented data shows that, as of 2010, only 10% of family physicians provide maternity care - down from 23% in 2000 (1). "So what?", you may ask. We have enough OB/GYNs in this country - they can do prenatal care and deliver babies. We don't need family doctors to do that.

The problem is that OB/GYNs are not well distributed across the country. Take a look at the county map below - all the red counties are the counties without a single OB/GYN doctor. That's like 50% of counties in the USA.
[Note the graph shows the number of OB/GYN doctors per 10,000 women, not the absolute number.]

Generally, family doctors are the ones who provide in these "red" counties, most of which are rural areas. In fact, family doctors disproportionately provide maternity care to Medicaid and underserved patients. Without family doctors, those in these areas would not receive adequate care.

In July 2012, new family medicine residency requirements will be implemented for FM residents. Currently, all residents must perform 40 deliveries during the course of their residency training. About 50% of programs do not meet these guidelines. As such, in July 2012, a two-tiered system will be created: an exposure track and a competency track. The exposure track will require 20 deliveries and the competency track will require 80 deliveries (3).

To many, this sounds like the death knoll of family physicians' participation in the provision of maternity care. Some residency programs will choose to only offer the exposure track while many residents unsure if they want to practice maternity care will select into exposure tracks. To students choosing between family medicine and OB/GYN, family medicine may no longer offer enough obstetric exposure to draw these students. Likewise, family medicine without obstetric care loses one of its distinguishing features from med-ped residencies. Most importantly, however, pregnancy is an essential part of and often a defining moment in a woman's life. Without maternity care, family medicine can no longer claim to provide the full continuum of comprehensive care.

We need to explore the reasons why family doctors no longer provide maternity care. Is it lifestyle? Malpractice costs? Lack of institutional support and hospital privileges? Then we have to actively evaluate whether these new residency requirements for maternity care are training the next generation of family physicians we need to best serve our nation's patients. If we don't do this, our next generation of women needing maternity care in rural and underserved areas will not have a doctor to provide their prenatal care or deliver their babies.

(1) Tong S et al. Predictors of Maternity Care Provision Among Family Physicians. Data presented at the North American Primary Care Research Group, November 12, 2011.
(2) American College of Obstetricians and Gynecologists. The Obstetrician-Gynecologist Workforce in the United States. Facts, Figures and Implications. 2011.
(3) AFMRD Presidents' Welcome. November 1, 2011.