The social responsibilities of family physicians - the case of Wisconsin family doctors

Earlier this week, 4 family physicians donned in white coats and stethoscopes were observed handing out sick notes to teachers and other public employees who were rallying outside Wisconsin's state capitol. At this point, the protestors have been rallying for almost 2 weeks straight. These 4 doctors were handing out sick notes to any one who needed them so that they could call in sick while continuing to protest.

At stake for teachers and other public employees was the benefits, wages and the right to protest as the Wisconsin state government tried to rein in their budget and limit public employees' labor rights.

At stake for doctors...?

Multiple media sources labeled the sick notes as fraud. They claimed that the doctors were giving these notes when:

• 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!

Here is a YouTube video based on an interview of several of physicians.

One way to approach this is to debate what constitutes as "fraud." Another way, the one I am going to take, is looking at what social and policy responsibilities of a physician. As a future family physician, I believe that we need to look at a broader definition of health and its improvement. If workers' rights are taken away and wages are decreased, do these affect their psychological health... often resulting in physical health implications? I would argue that physicians should not stick to the medical issues to the isolation of political issues. When we do so, we risk leaving the determination of policies and laws to others who may not have the improvement of health in their interests. I personally think physicians stand to gain a lot when we bring our personal narratives about our medical experiences into the realm of politics and policy making. Policy makers, and the general public shy away from statistics and scientific studies and are much more convinced and drawn to personal stories.

However, while I agree that physicians need to be active in policy and politics, I question the mode in which these Wisconsin physicians (all affiliated with UW Madison's family medicine department) engaged in policy making. While physicians need to be engaged citizenry, the professional role (writing sick notes) should not be mixed directly with the advocacy role.

Another thought I had: what is a sick note? Why do doctors write sick notes? In America (and in many countries), patients choose their physicians. I haven't seen statistics on this, but I would say only rarely does a physician refuse to write a sick note when requested by a patient. If a physician did refuse, the patient only need go to another doctor. So, what does the "sick note," so often requested by employers, really signify, if anything? Why are doctors even involved in this play between between employers and their employees?

Thoughts? On either sick notes or physicians' social and advocacy roles?

Media coverage of Wisconsin doctors writing sick notes for protestors:

http://www.theatlantic.com/national/archive/2011/02/wisconsins-real-doctors-and-their-fake-sick-notes-for-protesters/71500/

http://www.foxnews.com/politics/2011/02/19/saturdays-protests-wisconsin-expected-biggest/

http://blogs.wsj.com/health/2011/02/22/doctors-notes-for-wisconsin-protestors-spark-controversy/?mod=google_news_blog

Educating Med Students About Health Care Systems and Advocacy Should Not Rest Solely On Med Schools

Yesterday, MedScape News posted an article titled "Med Schools May Be Neglecting Health Policy in Age of Reform".  It looked at a couple of articles from the New England Journal of Medicine ("Advancing Medical Education by Teaching Health Policy" and "The State of Health Policy Education in U.S. Medical Schools") and provided a summary of the results

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.

Some may argue that clinical medicine also changes from day-to-day, which is true - though our faculty do not really have much of a choice to remain up-to-date on changes in clinical medicine.  Are we going to ask them, who we piled additional curriculum on, to also remain current in our health care system?  Will medical schools that bring in more faculty to develop and maintain curriculum in this area also find that another reason to increase medical school tuition?  This, instead of the administration possibly taking less of a pay increase or possibly a pay decrease (blasphemy!) to make up for it?

On the medical student side, we would be accountable to learn more information on top of an ever-growing medical science foundation that is already out-growing the four years we are given to learn, master, and eventually maintain in medical practice.  I whole-heartedly disagree that it should be up to medical schools to be held accountable for being the primary educators in these areas of education.  Our faculty are already stretched thin by the bureaucracy of academic medicine.

My recommendations:

1 - Educate medical students on the basics of ADVOCACY: Instead of focusing on the details of our medical system, why not just educate medical students on how to advocate for health care in the interests of clinicians, the medical team, and our patients?  Advocacy is one thing that does not change that much, whether it is by grassroots advocacy involving government, insurance companies, federal/state health care programs, etc.

2 - Effective hours are more important than total hours: These studies point out the number of hours spent learning about health care systems, delivery, management, etc. but fail to objectively analyze the subjectivity of the hours spent learning this information.  If we really wanted to be most effective at teaching these complex topics, we would expand medical school education by at least one year and have students graduate with an MBA, MPH, etc.  Options exist to do this, but are exactly that - options, not requirements.  I have personally seen a large number of 1-2 hour presentations on these topics at conferences and learned a TON more than I learned at my medical school, which does provide several lectures on these topics...  leading to my last point

3 - Stop trying to reinvent the wheel!  Much how residencies provide CME and time away for conferences, medical schools should budget time and money for medical students to attend advocacy conferences by medical academies/societies/associations of their choice.  Medical students who find a way to these conferences often have to use vacation time or time away from rotations (excused and unexcused).  This time should be built into the curriculum, not taking away from much-needed vacation time.

As an attendee at various conferences put on by my state and national organizations, I have learned an incredible amount of knowledge and information about the basics of our system and how to effectively advocate for medicine, specific specialties, and patients.  Additionally, these meetings provide leadership development opportunities, something that these studies fail to mention as being vital for our future involvement within the health care system.  As future physicians, we are going to be looked at as role models and leaders in our communities that we practice within.  These conferences provide leadership development to help prepare us as future leaders in our community.

Here are some examples of conferences/meetings that students can attend:

AAFP Family Medicine Congressional Conference

AMSA Annual Convention and Advocacy Day

AMA National Advocacy Conference

ACP Leadership Day

The 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).

In summary, we do have deficits in our learning of the health care system.  However, by outsourcing this education to those already proficient while including opportunities for advocacy, networking, and leadership development, future physicians will be armed with the knowledge to not only understand the system, but with the ability to change it to better serve our patients.

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.

Analyzing COGME: Increase The Number of Primary Care Physicians

As mentioned by mdstudent31 mentioned, I plan on doing a 5-part series analyzing each of the recommendations behind COGME's report, Advancing Primary Care.

Before I look at the first recommendation, let's take a brief look at what COGME is and what it's authorized to do. COGME stands for the Council on Graduate Medical Education and is authorized by congress to make continuing assessments of physician workforce trends and training issues; recommend action to address identified needs; and advise the HHS Secretary and Committees responsible for health in the Senate and House.

Now onto the recommendations... the first COGME recommendation is: Policies should be implemented to raise the % of PCPs to at least 40%. This sounds like an ambitious goal given that the current level of PCPs is 32% and this number has been actively declining.

Add these 4 facts:

• In 1960, 50% of US physicians were practicing primary care
• For the past few year, 14-20% of US medical graduates have expressed interest in primary care
• Studies have shown that optimal health care outcomes and health system efficiency occurs when 40-50% of the physician workforce are PCPs
• If all those who are uninsured today receive health insurance, we will need an additional 122,000 PCPs to provide services to these patients

How can this goal be accomplished?

COGME suggests that:

• primary care needs to be made more attractive by improving compensation and providing support for restructuring practices
• changing the culture of medical student education to promote student interest in primary care
• creating policies that reward institutions for increasing GME commitment to primary care

Some short-term solutions that are proposed to better serve our patient population include:

1. Implement policies that increase non-physician clinicians (PAs, NPs, nurses and other staff positions for coordinated, integrated practice in primary care teams). This also means that we have to ensure that graduates from these programs enter program and not subspecialty care!
2. Provide incentives and regulatory reform so that all clinicians and staff work at the top of their degree. This means that primary care doctors, who have more training than PAs or NPs in terms of length and breadth of training, would move more towards coordination of care. This also helps manage health care costs.
3. Encourage and support the roles of other physicians to provide comprehensive, longitudinal primary care. It is possible for non-primary care doctors to provide some longitudinal care, although they are not fully trained for these positions. Possibly a short term response for now? Especially for some cardiologists or endocrinologists who already treat patients with chronic diseases.

Personally, I think these initial recommendations seem focused more on serving our growing patient population on the short-term but do not answer how we can best increase the % of primary care doctors so that we can better serve our nation's population. What do others think?

Next week: Recommendation 2 - changing physician payment and practice transformation for primary care (to help fulfill the first recommendation?)

Gender-Based Income Gap for Docs Should Elicit Call To Action

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?

_________________________________________________________________

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.