Future of Family Medicine Blog Celebrates One Year of Blogging

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

Just about one year ago, Sebastian and I decided to start the Future of Family Medicine Blog. During this time, the blog has been featured in local, state, regional, and national presentations as a successful example of social media use by medical students and residents. We were also nominated for best new health weblog for 2010, only 3 months after starting up! We have been cross-posted on KevinMD on numerous occasions and received international attention from the International Conference on Residency Education. Several of our authors have held key positions in the AAFP, STFM, AMA as well as within medical schools, family medicine residency programs, and state chapters of national organizations.

Although the frequency of postings has decreased recently since many of the authors have started internship and application/interviewing for family medicine residencies, we want to thank all of our dedicated readers, followers, and individuals who have shared our message with your communities, medical associations, patients, and most importantly, the future of our great specialty, family medicine.

This past week I released a video that I have worked on for a number of months to promote the Family Medicine Revolution (#FMRevolution).  I did not know when would be a great time to release it publicly and if it would actually make an impact.  Being as this is the first year anniversary of the blog, I figured it would be a great gift to our readers and loyal followers.  I also realized that this is a very interesting time for the future of our specialty:

• Many fourth year medical students are beginning to interview and may still be on the fence in regards to choice of specialty.
• This is the time where many third year medical students are beginning their time on the wards - learning about different specialties and encountering persuasive physicians and residents that either embrace their decision to choose family medicine, or contribute to the myths and misconceptions of our specialty.
• First year medical students are beginning to attend meetings with various interest groups and may be interested in the current hype surrounding family medicine.
• The AAFP is currently putting on a full-court press in regards to SGR, GME funding, the RUC, and medical student interest across the various regions of the country.

So far, the video has received social media attention around the world, including the AFMRD and STFM list-servs, and by the current AAFP President, Dr. Stream.

It really is amazing how much the Family Medicine Revolution has progressed and how much momentum family medicine has gained within the past year.  I am hopeful that this blog has helped in the process and that it will continue to provide fresh perspectives for the future of family medicine - the only true primary care specialty.

Rural Health Care - who's out there?

20% of Americans or approximately 60 million people live in rural America. Those who live in rural communities are older, poorer and have more chronic diseases than the typical city dweller. The problem: few doctors choose to practice in rural America. And the doctors who are out there are getting older themselves and are close to retirement.

Medical schools, with few exceptions, are located in urban areas. What, you may ask, about medical students who we recruit from rural areas? Are they more likely to go back?

Take a typical 18-year old female raised on a farm in Nebraska. She goes to college in a city, stays for medical school in a city and then marries an aerospace engineer. Is she likely to go back to her home town? Hmm... probably not. On a positive note, studies do report that those from rural areas are more likely to return there... but not enough of them do.

Who are the doctors out in rural areas now? They are mostly family doctors. Family physicians are the only specialty that's evenly distributed across all settings - inner city, large rural and frontier, isolated rural. Other specialties (as seen in the graph below) cluster themselves in cities, where they can actually sustain a practice. BUT, we've had fewer people entering family medicine over the 10 years (exception of this year) and, as such, the rural doctor pipeline is drying up.

Figure: Physicians per 100,000 people

To ensure the health of rural Americans, we need to have more doctors practicing in rural areas. From studies, we know the type of doctors who are likely to end up in rural areas:

• doctors in family medicine (not pediatricians or general internal medicine doctors... and definitely not sub-specialists)
  
• doctors with rural origins
• doctors who are married when they graduate medical school
• male doctors (not being sexist - this is a statistically proven fact)
• doctors who have rural experiences during medical school and/or residency
  

So what do we need to do? We need to support more residency and medical school experiences in rural communities. Possibilities include rural elective opportunities, expanding rural residency training programs or rural training tracks.

We also need to talk about rural medicine as an exciting opportunity! In rural settings, family doctors get to do everything - from deliveries to surgeries to colonoscopies... a family doctor gets to call all the shots (unless the patient's condition is really serious). A family doctor gets to practice his or her full scope of training.

Doctors, especially family physicians, are needed now in rural areas! Otherwise, in a generation's time, we may not have rural communities and rural America!

Advice for a First Year Medical Student

I recently had quite a long conversation with a college senior that was just accepted into medical school for this coming fall. As a rising fourth year medical student myself, I would like to think that I have navigated the waters of academia and figured out both efficient paths to success and avoidance of roadblocks and setbacks. However, I was quite overwhelmed with the number of questions and concerns that this particular student had. But in retrospect, I can recall my own naivete and fear of the unknown that is medical school.

After answering all of his questions, I realized that many soon-to-be first years may not have the advantage of mentors or advisers. Lacking guidance, students are willing or forced to charge forward and hope for the best. These are the same students that suffer the inevitable fatigue and burnout. But I believe that there is a smart and efficient way to approach medical school. That is not to say there are any shortcuts or cheats. Rather, I wanted to share with you my advice on 5 easy steps to being a better medical student from day 1.

1) Be willing to be selfish

You must be willing to prioritize personal time and to continue to do the unique things that make you who you are. And trust me, the time can be found in any rigorous program. Doctors aren't robots, and you should never plan to train like one. Medical school must be a time for you to continue to develop your hobbies and your personality. These are the individual characteristics that will make your patients love you one day. More importantly, these are the activities that will keep you both sane and free from stress.

2) Get 8 hours of sleep

No debating this one. First the benefits – you will study better, be healthier, and feel happier. There are enough distractions and obstacles built into the medical education that you should not be adding to the list. Sleeping in class, rereading text, and mental sluggishness are not paths to engaging the curriculum. Turn off the light, set your alarm, and keep track of your sleeping schedule. After all – you are training to be a doctor who will one day advise patients on healthy practices. Limit the sacrifices you make in your own health along the way. Healthy eating and regular exercise follow, as well.

3) Subscribe to just one health policy daily email or news blog

Medicine, particularly in the modern world, has much importance beyond the realm of clinical information. As a doctor, you will one day be called to be a leader, and your understanding of health policy and health systems will drive your success. You do not have to understand every sentence, or even read every word. But be open to absorbing what you can so you will be better aware of health care on-goings. The future of medicine is in dynamic health delivery systems. While you're cramming over the Krebs cycle, take a five minute break to review the latest info on real-world medicine issues. ACOs are being built and discussed right now – embrace that change and learn as the systems are being designed. (Feel free to email me for the full list of my daily subscriptions – aaronge@pcom.edu). Read during rounds when your attending is off ranting about something esoteric and his back is turned. Read it while your on the bus or in the bathroom. Again, time can be found if you look for it.

4) Study Smart

There is a difference between studying for a test and studying to be a doctor. While these two goals sometimes coincide, they are often very different in nature. I find that, for some reason, medical students have difficulty wrapping there minds around this concept. Here is what I mean – medical students often look to prepare for exams as if they need to know everything about a given subject. Buying multiple textbooks and review guides is more than common. Gaining this knowledge is the right thing to do, and will make them a better doctor in the long run. But it may distract you from your goal of doing your best on given test – and worse, it may lead to burnout. If an exam has questions that are drawn from lecture, then information outside of lecture is irrelevant for the scope of that test. You need to make a personal decision as to how much supplemental information you need to be successful. I'm not telling you to take any shortcuts in learning medicine, I am telling you to be prepared for what matters. You have at least 7 years to go through medical school and residency, and then a lifetime to practice. You cannot possibly learn everything in a day, month, or year. Don't sweat the details during your first year, anymore than is already forced on you.

5) Smile

As easy as this simple act sounds, this may be the most difficult of my suggestions. But stick with me! I am a firm believer in the power of positivity and confidence. You will get through medical school. That is not in question. But you have a choice as to HOW you get through medical school – to complain, suffer, and grieve through the process.....or to enjoy the ride. I believe that smiling, appreciating the best that you have, and keeping a positive attitude effects you in two ways. In the first, you will have the advantage of internal confidence and lower stress. From a medical standpoint, you will be less rattled on test day and benefit from decreased cortisol - both can go a long way! The second effect of positivity is the external impact you will have on those around you. How do you think nurses respond to medical students that complain or look upset during morning rounds. I know that a genuine smile and greeting has led to nurses and residents that have been willing to go the extra mile to offer me support. How do you think an attending or residency coordinator will respond to the stolid student, versus the upbeat one? The truth is that letting in negativity and suffering through complaint are a means of externally expressing defeat. You do not want to be that kind of medical student. Smile, you are living your dream!

I genuinely want all of you to do well, and to be great and successful doctors. After reading many other medical school advice posts on more tangible or “hard” skills, I wanted to offer a different perspective. As always, you have to do what works best for you, and everyone will find success with different methods. But I do hope that some of my advice gives you a different perspective on how to achieve that success. Good luck!

Thoughts from the 2011 Family Medicine Congressional Conference

Ok, I'll start out with a cheat sheet on the important issues and "asks" that we brought to Capitol Hill today. There was a definite sense of urgency to act, and our proposals focused on opportunities to incentivize primary care, without significant budgetary increases.

1) Fix the SGR. Stop kicking the can down the road and get realistic payment stability.
2) In regards to GME, consider a model that would secure a portion of funds specifically to primary care community and out-patient residency facilities.
3) Encourage investment in Title VII funding (specifically section 747) and further support for National Health Service Corps
4) Decrease the gap that exists between primary care and specialty salaries

Now for some reflections on the issues and discussions for family medicine here in Washington, D.C. at the FMCC:

7:00am: Wow, breakfast buffet is great! The AAFP really takes care of their own. Next, I walk into a room of over 200 family doctors convened and eager to descend on Capitol hill tomorrow and breakfast becomes an afterthought. Talk about wow - I'm speechless. I wish every medical student could be here for this program and for the good of the future of medicine.


Hot issues:

Monday, 8am: Models, models, model. You'd think with all the talk of models, their would be a Paris runway close by. Then again, I wouldn't complain if some Hawaiian tropic spokespeople walked through the doors right now.

In all seriousness, there is so much talk of models and systems. I can see that this sort of dialogue is important, as a means of establishing a strong foundation. The reality is that a 400+ pg proposal has been put forward, and we are still in the comment period prior to the final product. But the frustrating aspect is that family physicians function at the ground floor of health care delivery. Its tough to listen to mostly generalized and broad goals, when we all know how important the details really are. I do very much look forward to the proverbial "meat" at the heart of these proposed systems. I am eager to move forward and to see how these models function and to see them in place.

10am: AMA question and answer forum. This session quickly turned into a soundboard for comments. This tells me that family docs know the facts, and are more prepared to have their voice heard than the need to have questions answered. The people in this room have done their homework, and family doctors are hungry for parity and a successful balance in medicine. I'm encouraged by all of this discussion.

11am: Robert Phillips, MD, Director Robert Graham Center. This man is a visionary and his poise is inspirational. He first offers the difference between "Reducing costs vs restraining costs". This a perspective that isn't often considered. Everyone is looking for ways to lower cost, when in fact we should be looking for opportunity to curb spending growth.

Workplace continues to be framed in terms of supply and demand. Figures are often thrown around at the national level that "this many tens of thousands" of physician workforce shortage. The paradigm shift on this is to consider the implications of physician distribution. In fact, when you look at physician demographics, it is apparent that the number of physicians serving in areas of excess could cover the areas that demonstrate a shortage.

That said, it seems that the focus has shifted away from workforce and on to economic impact. That is fantastic news for the primary care front - their is amazing data on the number of local jobs, the economic impact, and cost effectiveness of family physicians. Most importantly, it has been shown that an increase in family physicians in a community led to a correlative decrease in readmissions. Every other specialty showed increases in readmissions with increased workforce in community.

Thought: data, data, charts, graphs and data. Proof and facts are the name of the game in directing change.

One thing that really sticks out to me is the continual rhetoric and future tense employed by many speakers. It seems that words such as "planning", "committee" "considering" "taking suggestions" "reviewing proposals" far outweigh any directions or indication of activity. Right now its a waiting and planning, and few seem to want to take the first step. Which is counter intuitive to the needs of medicine. We have an outmoded system that is functioning on an outdated payment schedule. In order to meet the demands of the modern health care climate, we need to stop the rhetoric and start the reaction. It was clear from the medical student voice, that we demand as quick resolve to act as any group.

2pm: Panel on health reform movement. After spending the better part of the past year and a half focused on health reform, it seems that their is a general health care fatigue on Capitol Hill. On top of this, the magnitude of the funding deficit makes any movement in the positive direction extremely challenging.

Two of the COGME recommendations that struck me: to adequately meet the needs of American health care, it is recommended that the physician workforce be composed of at least 40 percent primary care. The second recommendation was to encourage enhancement in medical school social accountability in training. See my most recent post on this site for some of my thoughts that are right in line with this.


Some other random thoughts:
1). Check out Wellmed a non-hospital aco based in san antonio that is producing outlier numbers in reduced mortality, cost saving, and family physician salaries. (http://www.wellmedmedicalgroup.com/)
2). Its inspiring to meet and see all of the energetic and engaged medical students here. Debt is a huge issue, but these passionate students are willing to sacrifice for the goals of primary care. More apparent is the medical student urge for activity. We are saying, we can't wait, we can't put things off - we need to act now.

Medicine is a team game…and every team needs a good family physician

I recently matched into family medicine in the 2011 NRMP residency match, and I have to say the process reminded me a bit of “draft days” where the NFL, NBA, and other professional sports organizations carefully consider their current strengths and weaknesses and choose prospects accordingly. In light of the recent match and the exciting conclusion of the NCAA basketball tournament (yes, this post might clue you in to my interest in sports medicine), I thought I’d take the opportunity to discuss just what it is that makes teams work well and how family physicians and other specialists can learn from sports philosophy.

I’ve played a multitude of sports throughout my life, and I’ve been on teams that won championships and teams that were absolutely awful, bottom-dwellers of their league. And I’ve seen incredibly gifted players on both kinds of teams. It still never ceases to amaze me how some teams incorporate this talent into their overall strategy while others self-destruct in spite of it. Either way, one player does not make a team, no matter how good that player is. If you’ve followed NCAA basketball this year, you might have watched BYU’s Jimmer Fredette almost single-handedly dismantle New Mexico, going on a 52-point scoring rampage. But a team like this year’s BYU squad will never win an NCAA championship; despite advancing to the sweet 16, they were ousted by Florida in a game where no BYU player other than Fredette scored in double figures.

I admit that I wasn’t the star forward on the soccer team in high school, but I will venture to guess that without solid defenders and skilled passers (I’ll give myself a little credit for being one of these), a teammate of mine who would go on to play in Major League Soccer would never have scored 26 goals in his freshman year.

The practice of medicine is no different. Games against formidable opponents like myocardial infarction and diabetes are being played on a daily basis in hospitals and outpatient offices around the country. And as in sports, the glory or derision often is directed at the 52-point scorer, whether that be Jimmer Fredette, MD, who performs the triple bypass to defeat symptoms of unstable angina, or Jimmer Fredette the saddle pulmonary embolism which no thrombolytic therapy can beat. (Sorry Jimmer, don’t mean to equate you with sudden death; this is all metaphorical.)

Stars take the limelight, and sometimes little recognition goes to the supporting cast – the other players who come to every practice, put in hard work day after day, and set the star up for success.

Family physicians are the most crucial of these supporting players in medicine. They are the modest team leaders, assisting other specialists in executing their temporary functions while also making sure that team coherence and morale stays consistently high over the course of a patient’s life. They perform the menial work in the trenches, modifying medications to optimize Hemoglobin A1cs and forming long-standing relationships to encourage smoking cessation. Family physicians are also those teammates most poised to involve other skill players in team play: these include the patient and his family, nurses and nurse practitioners, physician assistants, social workers, behavioral health professionals, and pharmacists, among others. In short, family physicians are player-coaches, managers, and cheerleaders rolled into one.

Team success goes south when teammates don’t see eye to eye. Disagreement about each player’s level of responsibility or about team strategy can quickly lead to failure. Jim Thome, when he was a slugger for the Phillies, described his philosophy for guarding against team dysfunction: “I just stay in my lane,” he said, maturely recognizing that his contribution to the Phillies success was in his bat, his first base glove, and his quiet work ethic.

The NRMP match separates us, as physicians, into different specialties, just as athletes are specialists at their respective positions. But when we start to make a distinction between the value of each specialty, that is when team health care loses its effectiveness. In a prior post on this blog, one of the student authors described the “hazing of family medicine,” in reference to stereotypical condescension by other physician specialists towards the specialty of family medicine. Certainly this condescension exists, although I’ve encountered it more rarely than frequently, I'm happy to say. Some family physicians, however, are as guilty as some of their specialist brethren of perpetuating this supposed professional divide. Certain of us in family medicine are quick to decry the missions of large academic medical centers and proclaim that they don’t place enough emphasis on the specialty of family medicine. By doing so, these family physicians are lending validity to the stereotype and alienating our specialty from all the rest.

Any academic distinction we make between primary care physicians and specialists is a bunch of hooey. We can only blame any “us and them” rhetoric on ourselves as a whole body of physicians. In terms of patient care (reimbursement aside), there is no difference between primary care physicians and specialists. We all have a responsibility to provide the best care possible to our patients, and we need to respect the unique special training we each receive. We wear the same white uniforms. We are a team.

The best way to influence medical students to choose family medicine (and thus fulfill the ambitious goals of vastly increasing the number of primary care physicians in this country over the next several decades) is not necessarily by fighting our colleagues for reimbursement equality or by distancing ourselves from them by elucidating the differences between FM and other specialties, but instead by making sure we as current and future family physicians are well integrated into large academic centers and smaller community hospitals alike. By working hard day in and day out to provide quality patient care along side of our colleagues, who all have their own special unique training. By coaching our patients who, if they love who we are and what we do, will clamor for more of us and force insurance companies and policymakers to recognize our value, both in monetary and intangible terms.

To bring the NCAA basketball metaphor full circle, we who are current and future family physicians need to rebrand ourselves as the hard-working team player that all the other members of our health system teams can rely on every game, not the player who whines about not getting the ball enough. We need to be outspoken in our leadership of the team, but we also need to be patient and non-antagonistic in our criticism of the current health care strategy. We need to be as accessible as possible to our patients and to our peers. The way to win the hearts of medical students, health administrators and insurance company CEOs alike over to an FM-based team strategy is through hard work, dedication, and serving as role models for students and the rest of our colleagues. As for our patients, many already know our value, and they just want to win more games than not. No 52-point outings necessary.

Is There an Underlying Specialty-Bias in Medical Schools?

A multitude of factors drive students towards, or away from, the path of family medicine. Much has been made recently of reimbursement schemes that incentivize specialty practice. Certainly, medical students strapped with debt are showing preference to more lucrative fields for residency. But is there more to this choice beyond the surface of financial incentive? What about the very environment that cultivates the growth and decision-making of our medical students? Does an underlying, or perhaps hidden, bias to specialty care exist within the modern academic community and curriculum?

First, consider the structure of the academic course itself. The systems-based approach to medical education remains the predominant curricular modality. Under this structure, organ systems are taught by specialists who are invited to profess the proceedings of their specialty. This leaves students with cardiologists teaching cardiology, pulmonologists teaching pulmonology, and family doctors, often, on the sidelines. Certainly, every school employs faculty to a differing degree. In fact, my medical school chooses to bring in primary care providers to approach a 1-2 hour discussion on the broad implications of each system. However, these brief family medicine lectures are all ultimately followed with 2-3 weeks of intensive specialist-driven lecture. This leaves the overwhelming prevalence of educators to be drawn from the specialty fields.

I understand and appreciate the necessity of this approach, but one cannot deny the potential effect on students. How does specialty-driven, systems-based curriculum effect student perception of medicine? Does this leave a dearth of primary care role models at the frontlines of our classrooms?

Next, consider the content and focus of standardized examinations, such as “shelf” exams and USMLE step exams. Exam passages often tell a story, starting with something along the lines of,

“Mr. Smith is a 76 year old male who was referred by his family doctor for difficulty swallowing. He presents to your office today with…”

In my experience, I have rarely come across questions that highlight the role and duties of the family physician. The implication is reasonable – test-writers hope to hone in on minute details of pathology or physiologic consequences of disease. However, in doing so, is their an unintentional belittling or underplay on the value of the family doctor? Does this continued focus on the details and complexities of disease have the effect of placing an unintentional bias towards specialty care in medicine?

Further, consider a medical student’s experience in clinical rotations. Take myself for example – I am now a full ten months into my third year of medical school. Meanwhile, I have spent approximately nine of those months working on inpatient wards or in the operating room. Like most of my colleagues, I have reached the point in academic career in which I must make a decision on my residency path. Yet, is it reasonable for me to do so with 4-6 weeks of total outpatient family medicine exposure? Certainly, I would never argue with the necessity for medical student exposure to the fullest array of clinical experiences. However, does a built-in bias towards inpatient, hospital, and specialty medicine exist within this process?

Certainly, in my experience, specialists do not necessarily paint the best picture of family physicians. Far too often, I hear comments such as, “Oh boy, would you look at what their PCP did? I guess we’ll have to clean up the mess”. These sort of comments are rarely balanced by accolades or praise for general practitioner care or referral. I often found the family physician to be portrayed as a guy on the outside looking in. Ultimately, does the prevailing impression of the inpatient experience in clinical rotations generate a bias towards specialty care?

An article published in the New England Journal of Medicine on February 10th addressed the importance of the involvement of medical schools in the encouragement of primary care selection. The paramount responsibility that was implicated was that the school should place primary care physicians in leadership roles within the administration and deans offices1. This further emphasizes the importance of the medical school curriculum and environment in the process of supporting and advancing the mission of primary care.

I have asked many questions in the preceding paragraphs – this was purposeful. I believe these are all questions that remain to be answered, or questions that could be answered differently depending on the academic institution or environment. Certainly, the modern world of academic medicine provides for limitless variation. I am confident that many medical schools exist that take a balanced approach to exposure and encouragement of residency choice.

The sentiments that I have expressed are drawn from my experience, as well as discussions with my peers. I encourage you to help me answer some of these questions and contribute to a robust discussion below. At the very least, keep these considerations in your mind as you move through your training, or think about the training of others. Does this underlying bias towards specialty training exist in academic medicine?

1. Smith, Stephen R. “A Recipe for Medical Schools to Produce Primary Care Physicians”. New England Journal of Medicine, Feb. 10 2011. Vol. 364;pg 496-497.

Future of Family Medicine Match Day Coverage - The 2011 Family Medicine Match Results

Disclaimer: This post will be an evolving post that will change throughout the course of the week as results and statistics are released for the match in regards to family medicine.

Well, medical students - the day is here!  NRMP Match Day - a day that brings us full circle to US Grads matching into residency programs throughout the country.  It all started back in December with the military match, then continued with early match, the Osteopathic match, and now the NRMP match.

Military match stats this year had family medicine listed along with peds, ob, surg, and ortho as the most competitive for medical students participating in the military match.

Osteopathic match: "Primary care specialties of family (medicine) saw a 15% increase and internal medicine saw a 28% increase. Family (medicine) was the largest matched specialty with 373 positions filled."

Last year's family medicine match results: "more U.S. medical students chose family medicine as their specialty.. resulting in a fill rate of 91.4%, the highest percentage for family medicine ever."

This year, 172 more students chose family medicine - 2,576 family medicine positions were filled out of 2,730: a fill rate of 94.4% - impressive when taking into account that 100 more positions were available for family medicine vs. last year. Of the 2,576 candidates who selected family medicine, 1,317 of them are U.S. medical school graduates - this as a result of 133 more US Grads choosing family medicine this year (7.9% of US students chose family medicine last year vs 8.4% this year).

At 1PM EST, the NRMP released exciting results in regards to primary care!

For the second year in a row, more U.S. medical school seniors will train as family medicine residents, according to new data released today by the National Resident Matching Program (NRMP).  The number of U.S. seniors matched to family medicine positions rose by 11 percent over 2010....
  Among primary care specialties, family medicine programs continued to experience the strongest growth in the number of positions filled by U.S. seniors. In this year’s Match, U.S. seniors filled nearly half of the 2,708 family medicine residency slots. Family medicine also offered 100 more positions this year. 

This link will take you to AAFP's perspective on this year's match data.  Here is a summary of discussion:

Although the Match results are encouraging, student interest, however, is still not at the level it needs to be. Although the match rate in family medicine among US medical school graduates has increased, the majority of positions offered and filled in the NRMP, especially among US graduates, continue to be in non-primary care sub-specialties. In its 20th Annual Report “Advancing Primary Care”, the Council on Graduate Medical Education (COGME) affirms that the US physician workforce needs to be made up of "at least 40% primary care physicians" to ensure the nation's health, health care access, health care expenditures and health outcomes for the future.  
COGME projects that to reach this 40%, 63,000 additional primary care physicians are needed. If health reform succeeds in increasing the number of insured individuals, more than 100,000 additional primary care physicians will be needed. 
The number of students entering family medicine is most reflective of the future physicians who will provide primary care for adults in the future. The vast majority of internal medicine residents sub-specialize; only 2% of students entering an internal medicine residency choose to do general primary care after residency graduation in one study.

AAFP President, Dr. Roland Goertz, comments about this year's match results in AAFP's press release: 2011 Match Results Again Spotlight Family Medicine Gains

“This year’s results mark the second consecutive year of increased interest in family medicine,” Goertz said. “Although several factors likely contribute to the increase, we believe an important element is recognition that primary care medicine is absolutely essential if we are to improve the quality of health care and help control its costs. Of course, sustaining this interest will require continuing changes in the way America pays for and delivers health care to patients.” 

“Primary care has become much more visible as a result of the discussion about improving our health care system,” he said. “More people understand that if we’re to have high quality care at a controllable cost, we need to rebalance our system on a foundation of primary medical care.

Add in the heightened awareness through activities of the Family Medicine Interest Groups, and students began to understand that family physicians will be able to practice the kind of medicine they envisioned when they decided to become a doctor.” 

MedPage Today joins in on the mix and offers their perspective on primary care in an article titled "Primary Care Again a Top Choice on Match Day."

"This is good news for internal medicine and adult patient care in the U.S.," J. Fred Ralston Jr. MD, president of the American College of Physicians (ACP), said in a statement.
The organization appeared guarded, however, adding that the primary care work force still has "a long way to go" to meet the needs of an aging population with various chronic diseases.
"We're cautiously optimistic and hope that the positive trend continues, but the U.S. still has to overcome a generational shift that resulted in decreased numbers of students choosing primary care as a career," Steven Weinberger, MD, executive vice president and CEO of the ACP, said in the statement

While we continue to compile data, we invite you to visit Mike Sevilla, MD's Family Medicine Rocks! Podcast recorded earlier today on BlogTalkRadio - info about this podcast can be found at his new site, http://www.familymedicinerocks.com.

Reconsidering Reimbursement

The image and role of the family physician in American medicine has shifted from the house-calling doctor with a black handbag to the integrated coordinator of patient care. Despite this, reimbursement remains largely unchanged, with fee-for-service the dominating payment structure. The modern health care climate demands a robust health policy strategy that restructures these outdated reimbursement schemes. Realigning appropriate payment would address issues with ongoing care for patients with chronic conditions and continuity of treatment. Further, restructuring reimbursement would have an effect to revitalize interest and incentive for medical students to enter the field.

Primary care physicians (PCPs) are recognized as family physicians, general internal medicine practitioners, general pediatricians, and obstetrician/gynecologists. As a group, PCPs are often the first point of physician contact for patients with new health issues. PCPs typically serve as coordinators of comprehensive care, and as mediators between specialists. Studies show that one-fourth of Medicare beneficiaries sees an average of 13 physicians each year, and fills 50 prescriptions in that time. PCPs are the primary point for consistent medical contact for these patients – the proverbial glue that holds the pieces together. These are the doctors that are at the front lines of medicine, but who also work in the trenches of prevention and management of chronic care.

While new models for health care are continually considered, such as the Accountable Care Organization (ACO) and the Patient-Centered Medical Home (PCMH), the common theme among all is the central role of the primary care physician. The fundamental key lies in placing the PCP as the coordinator for a patient within a system of care. This is particularly important in rural or underserved areas. PCPs are called not only to treat patients at point-of-care, but also to manage and facilitate physician extenders.

One of the foundational problems in fee-for-service is that it essentially encourages payment for sickness. Through the course of a year, a diabetic patient may see a PCP for a total of two hours. Yet that same patient has to manage their disease for 8,765 hours in that year. The PCP is reimbursed for the sum of two to three visits of point-of-service care, but the disease is ongoing. This would be akin to having a leaky kitchen faucet and asking a plumber to come look at it twice a year, paying for those two visits, but never having the leak quite fixed. While it remains impossible to completely “fix” a diabetic patient, reimbursement must be restructured to account for ongoing and chronic care. The existing plan provides compensation for volume of care. This model must be updated to consider compensation for counseling, diagnosis, and continuity. Moving away from fee-for-service would shift the perspective of reimbursement from one that pays for sickness to one that encourages payment for healthiness.

Finally, shortages in primary care medicine, long considered the gatekeeper of health care, are now threatening national access to care. Studies show that over 60 million Americans, or nearly one in five, lack access to primary care due to shortage in their communities. Meanwhile, only 8% of the nation's medical school graduates enter family medicine. This compares to 14% of the same graduates in 2000. Restructuring reimbursement would have a profound impact on the incentive for students to enter the field of primary care medicine.

It is often said that an ounce of prevention is worth a pound of cure. This analogy certainly has profound implications for our modern health care system. Primary care physicians, the vanguards of preventative medicine and caretakers of chronic disease, should be reimbursed for the broad level of responsibilities they conduct. Our nation must undertake a sincere evaluation of our reimbursement models and engage in the development of a more robust payment scheme for primary care physicians.

Does Building a Primary Care Workforce Start with Medical School Admissions Committees?

Between COGME’s 20^th 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:

1. Odom Walker K, Ryan G, Ramey R, Nunez FL, Beltran R, Splawn RG, Brown AF. Recruiting and retaining primary care physicians in urban underserved communities: the importance of having a mission to serve. Am J Public Health. 2010 Nov;100(11):2168-75.
2. Brooks RG, Mardon R, Clawson A. The rural physician workforce in Florida: a survey of US- and foreign-born primary care physicians. J Rural Health. 2003 Fall;19(4):484-91.
3. Morris CG, Chen FM. Training Residents in Community Health Centers: Facilitators and Barriers. Annals of Family Medicine. 2009 7:488-494.
4. Bein, Barbara. Robert Graham Center to Study 'Social Mission' of Teaching Hospitals, Health Centers. AAFP News Now. 27 July 2010.