Thursday, May 30, 2013

Primary Care, it's the Awesomest! To Be The People's Doctor, There's No Better Way to Be!

The following is a recent letter written by four soon-to-be residents who have chosen to go into various primary care fields.  The day after their graduation, they sent this letter to all medical students at their alma mater, SUNY Downstate: 

Hello, Fellow Downstaters!

Yesterday, we graduated from SUNY Downstate.  Two days ago,we were med students just like you, and now we are four soon-to-be residents who have chosen to go into various primary care fields.  We wrote this letter to you, and hope that you enjoy reading it.  Please, help spread the word!


Primary Care, it's the Awesomest! To Be People's Doctor, there's No Better Way to Be!*

            There.  The title of this memo-to-all-med-students says it all.  But we’d like to elaborate!  First of all, our title might be, well, over the top, some might say--but we’re excited about where we’re headed (!), and we’ll tell you why in a second.  Plus, we felt it was that important to catch your attention, especially since in 1940, three-quarters of all doctors were general practitioners(1), but with the subsequent proliferation and dominance of specialist fields in American medicine, by 2010, less than one-third of practicing physicians were focused on providing primary care.(2) Moreover, the need for primary care physicians will continue to increase with the aging of our population and the millions more Americans who will soon be able to acquire health insurance, as a result of the Affordable Care Act.(3)  
            What does our opinion matter to you?  We don’t claim to be the end-all-be-all, or the know-it-alls, but among us, we have a good number of accumulated experiences as MS1-MS4 medical students during the years 2008-2013.  To be sure, our experiences in primary care have spanned providing care within an efficient team-based care model at a top-tier Patient-Centered Medical Home in Portland, Oregon; to staying after-clinic-hours to join in Zumba and nutrition classes with patients, led by the spirit-rich community of caregivers at Lefferts Family Health Clinic in the resource-poor community in Crown Heights; to working on public health studies of disparities in cancer screening; to experiencing successful integrative medicine practices that are helping patients to achieve better outcomes in Brooklyn Heights; to providing primary health care for uninsured patients at free clinics; to helping determine goals of care for patients and families faced with terminal cancer.  
            In primary care, the patient--and your relationship with that patient--comes first.  If this excites you, and you haven’t considered going into primary care yet, then we recommend that you start doing some considering.  Primary care is not defined by one organ system or illness category, but by whatever it is that brought that patient to you, and keeps bringing her or him back to you, in illness and/or in health.(4)  The person, their significant other, their family, their psychology, their context, their home, their community, their daily struggles, their life’s joys, their life’s tragedies, their health, illness, growth, journey to death--they all matter, and you get to be there with them, for them and their families, when they need.  The buzzword these days is “continuity” of care.  That is what primary care does and is.
            Asfuture primary care physicians, we are excited by the chance to hone and master diverse clinical, interpersonal, research, and policy skills, depending on our interests and our patients’ needs.  One of the greatest assets of being a primary care doctor is that you truly are a lifelong learner, with your patients at the center of the learning process.  Additionally, we work with other providers including specialists, psychologists, integrative medicine providers, nurses, and home health aides--not to mention teachers,not-for-profits, and policy makers--to provide care that best fits our patients’ needs, values, and life circumstances.  As “frontline providers,” we are in a unique position to work with communities--e.g. organizing community health efforts or contributing our voices to healthcare policy--as advocates for our patients.  We are incorporated into their lives and communities, and, from this unique vantage point, have initiated the development of many social initiatives and advocacy efforts; we have been pioneers of social justice and pushers of public health policy initiatives, from vaccination to improved access to care.  In all of these endeavors, primary care doctors have led the way.
            There is also an abundance of dynamic opportunities in primary care research, from improving preventive medicine to management of chronic diseases; from the hospital-to-outpatient transition to the complex needs of our aging population; and from end of life care to ending racial/ethnic health disparities.  As just one example, take the recent changes in the U.S. Preventive Task Force recommendations for mammography, prostate cancer screening, and HIV testing: primary care doctors not only help navigate their patients through these complexities, we are the ones formulating and conducting the vital research that ultimately improves our national guidelines!  As primary care becomes the centerpiece of health care reform, the opportunities to be involved in research are becoming endless.
            If there wasn’t enough respect for and investment in primary care in our country from the mid-20th century through 2010, then at least you can be sure that in the coming months, years and decades, primary care will be the main focus of healthcare investment and reform.  Who, by now, has not heard of the “chronic care model” or the more recent Patient-Centered Medical Home (PCMH)?  While there are a number of components to understand regarding these models(5), including continuity/coordination of care and patient access, at their roots, they recognize the evolutionary shift that has occurred in modern industrialized society--that people are living longer and predominance of acute morbidity has shifted now to an overwhelming burden of chronic disease in our country.  
            The 2001 national assessment by the Institute of Medicine, Crossing the Quality Chasm(6), called for transforming a “fundamentally flawed” US health care system; this report helped to propel the momentum that has led to the first serious attempt now at implementing health care reform in our country’s recent history.  With this, is a growing focus on primary care: in the words of the Institute of Medicine, “primary care is the logical basis of an effective health care system... [and] is essential to reaching the objectives that constitute value in health care.”(7)  This recognition has led to increased reimbursement rates and medical school grants for those going into primary care (contrary to popular belief, a recent study has proven that medical students with median loans are able to pay it off on a primary care physician salary(8), and there are many federal, state and private scholarships targeted to attract brilliant and compassionate future-physicians--like yourself!--to the field), which have paralleled the overall shift ingovernmental priorities to strengthen our health care workforce through support of its frontline providers.  This growing emphasis on primary care has crescendoed over recent years and is now evident in restructured health systems and practices in many parts of the country, federal and state policy, and is even beginning to take hold in medical education(9).  There has been no better time, as a medical student, to choose primary care as your match and future career.
            In fact, many are! Check out David Margolius, a resident physician at UCSF primary health track who is speaking at conventions across the country about reinventing primary care and improving access, continuity, and clinical outcomes . Take a secondto google David Katz, an internist at Yale, and his Huffington Post article titled “The Case for Caring About Primary Care” (as well as his other great food and exercise tools!).  While you’re at it, meet a few long-time primary care leaders who have, for years, inspired doctors starting their careers: go on Amazon or to the good ‘ol library and check out, Big Doctoring in America: Profiles in Primary Care.  Among the fascinating profiles turn to “Neil Calman, M.D.: Urban Warrior,” to read about the self-proclaimed “flag-waving family physician...warrior for urban health,” who founded the trailblazing Institute for Family Health in New York City.  Or, look no farther than our current U.S. Surgeon General, Dr. Regina Benjamin, who once founded a primary care clinic in a poor shrimp-fishing village on the coast of Alabama--and rebuilt it three times after two hurricanes and a fire; we are now nearing two years since the release of her unprecedented National Prevention Strategy, which has been the centerpiece of her tenure.  Its successes mirror the improved health outcomes seen across the country, in the places where there has been increased emphasis on primary care.

            Going back to the title of this memo, “Primary Care, it's the Awesomest! To Be People's Doctor, there's No Better Way to Be!,” we aren’t really claiming that primary care is “the best” of all fields.  Obviously, the right field for you is a personal preference, and no person or memo can dictate otherwise any more than they can tell you which person to fall in love with.  But what we are saying is that, the way we see it, too few of us med students realize how awesome primary care really is, and that it is indeed the field for them.  And that really is the main and only point of this whole thing: if in a few years, we helped just one more medical student get to thisrealization, then all of our over-the-top titling and fun writing this memo together would have been worth it.  Please, come join the fun!**

-Abraham Young, soon-to-be resident in Family Medicine! atEinstein/Montefiore Hospital, Bronx, New York
-Jessica Bloome, soon-to-be resident in Primary Care Internal Medicine at UCSF Medical Center/San Francisco General Hospital, San Francisco, California
-Alinea Noronha, soon-to-be resident in Family Medicine at UC Davis leadership track, Sacramento, California
-Rachael Maciasz, soon-to-be-resident in Pediatrics atBrown, Providence, Rhode Island

*Please forward this message and spread the word to all other med students you know

**If you have any questions for us, or simply would like to join a listserve of students, residents, doctors and health care professionals interested in primary care, please go to:!forum/primaryhealthcare

(1) We recommend you see “Ch. 1: Primary Care Roots” inFitzhugh Mullan’s Big Doctoring in America: Profiles in Primary Care(University of California Press, 2002)
(2) See the Agency for Health Research and Quality (AHRQ) website for some more recent statistics.
(3) Stephen M. Petterson, PhD, Winston R. Liaw, MD, MPH, Robert L. Phillips, Jr, MD, MSPH, David L. Rabin, MD, MPH, David S. Meyers, MD, Andrew W. Bazemore, MD, MPH. Projecting US Primary Care Physician Workforce Needs 2010-2025. Ann Fam Med. 2012;10(6):503-509
(4) We recommend you see “Ch. 2: Principles of FamilyMedicine” in Ian R. McWhinney and Thomas Freeman’s A Textbook of FamilyMedicine (Oxford University Press, 2009)
(5) For a helpful primer, we recommend browsing through the AHRQ's website, “Defining the PCMH”.
(6) Institute of Medicine. Committee on Quality of HealthCare in America.Crossing the Quality Chasm: A New Health System for the 21stCentury . Washington, DC: National Academy Press; 2001.
(7) Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds.Primary Care: America’s Health in a New Era . Washington, DC: National AcademyPress; 1996;52.
(8) James A. Youngclaus, MS, Paul A. Koehler, PhD, LaurenceJ. Kotlikoff, PhD, John M. Wiecha, MD, MPH. Can Medical Students Afford to Choose Primary Care? An Economic Analysis of Physician Education debtRepayment. Academic Medicine. 2013;88(1):16-25.
(9) As examples, please see the articles, “FamilyMedicine Welcomes Mount Sinai Into the Fold,” and “Medical schools taking additional steps to highlight primary care,” published 6/20/2012 and 5/8/2013, respectively, on the AAFP’s blogs.