Has the RUC Destroyed Medical Student Interest in Primary Care?

A recent study in the Archives of Internal Medicine comparing med students’ attitudes about internal medicine careers in 1990 and 2007 found that "while about the same percentage of med students — 23% in the earlier survey of 1,244 students, and 24% in the later survey of 1,177 students — plan internal med careers, the proportion planning to go into primary care fell to 2% from 9%... the appeal of primary care as a reason to go into internal medicine fell to 33% from 57%."

This study is also receiving attention from a number of media sources, including the Wall Street Journal, which specifically makes mention of the RUC:

To significantly shore up the appeal of primary care with more money and improved work-life balance, “bolder payment and practice reform” are necessary....

As the WSJ has reported, however, where the rubber meets the road on incentives — at least for Medicare, which also drives Medicaid and private reimbursement — is the Relative Value Scale Update Committee, known as RUC, which is made up of physicians who decide how to divvy up the Medicare pie between types of procedures and visits.

Any tipping of the financial balance from specialties to primary-care doctors would likely have to take root there, and primary-care docs have argued that the makeup of the committee makes that unlikely.

What is the RUC? Below is a summary - Click here for a more comprehensive explanation.

The AMA advocates for fair and accurate valuation for all physician services within the Resource-Based Relative Value Scale (RBRVS). To ensure that physician services across all specialties are well-represented, the AMA established the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The RUC makes annual recommendations regarding new and revised physician services to the Centers for Medicare and Medicaid Services (CMS) and performs broad reviews of the RBRVS every five years.

The RUC has faced a lot of scrutiny; more recently from those involved with "Replace the RUC." One graph attempting to link the RUC to the growing income-gap between primary care and specialists is shown below.

The income gap is referenced many times when looking at medical student interest in primary care. There must be some reason why between 70-90% and 50-70% (depending on source) of medical students choosing internal medicine and pediatrics choose to sub-specialize respectively. When examining the RUC, is it a coincidence that interest in primary care careers has decreased at a relatively similar rate to the increase in physician gap since taking form in 1992?

Who is on the RUC?

The RUC represents the entire medical profession, with 23 of its 29 members appointed by major national medical specialty societies including those recognized by the American Board of Medical Specialties, those with a large percentage of physicians in patient care, and those that account for high percentages of Medicare expenditures.

The above link contains the specifics. Basically, there are 29 members, 26 voting members. There is one family physician (via AAFP), one internal medicine physician (via ACP - currently an oncologist), one pediatrician (via AAP - currently a general pediatrician).  The AOA and CPT members are both general internists, the RUC Chair a gyn surgeon, and the AMA rep is a psychiatrist.  It is worth noting that the physicians representing specialties are nominated by their specialty societies and approved by the AMA - in regards to the primary care physicians, most could end up as sub-specialists within their nominating specialty society, the lone exception being the family physician. The RUC touts that 14 of the 26 voting members are from specialties that rely on Evaluation and Management ("E/M", "cognitive care") for the majority of their payment. The one problem here is that, at the maximum, about 5 physicians on the RUC will practice "primary care" as we know it. That leaves primary care representing much less than the "majority" of voting members relying on E/M. This is also an area of argument for many of those who oppose the RUC.

In response to many critics, the AMA released a statement, "The American Medical Association/Specialty Society RVS Update Committee’s Long History of Improving Payment for Primary Care Services," summarized below:

Recent concerns regarding primary care workforce issues and resulting comparisons to specialty physician income have led many health policy experts to question the accuracy of the Resource-Based Relative Value Scale (RBRVS). As a key advocate for improvements in the RBRVS, the AMA/specialty Society RVS Update Committee, commonly referred to as the “RUC,” is erroneously assigned blame for any perceived flaws in this payment system, utilized by Medicare,Medicaid, and private payors. The RUC has actually led the effort to improve primary care relativity within the RBRVS since 1992. The implementation of the RUC recommended improvements have been over-shadowed by a flawed sustainable growth rate (SGR) formula, reluctance by the Centers for Medicare and Medicaid Services (CMS) to adopt several recommendations, and distortions created by private payors in their implementation of the RBRVS....

Improved Payment for Evaluation and Management (E/M) Services: The RUC has recommended increases in E/M services each time that the primary care organizations and/or CMS have requested review....
Improved Payment for Preventive Services: The most dramatic improvement, immunization administration payment increases from less than $4 in 2002 to $23 in 2011, is a result of years of advocacy by the RUC and the AMA to ensure that the resource-costs required to provide immunizations are recognized.....

Continued Advocacy Related to Coordination of Care and Medical Home: The RUC
has proposed valuation and separate payment for care coordination, team conferences, patient education, and telephone calls, however CMS has failed to recognize these services as distinct, and therefore has declined to pay for these services. CMS has announced, however,appreciation of the RUC recommendations related to the Medicare Medical Home Demonstration Project. CMS, the American Academy of Family Physicians, and the American College of Physicians all expressed appreciation for the RUC’s unanimous decision to submit robust recommendations for the physician work and practice costs required to serve as a medical home....

The document is a very well-written piece semantically, with plenty to read between the lines.

1 - The use of "key advocate" is correct in that the CMS has accepted 95% of the RUC's work relative value recommendations since 1992. Some may argue that the RUC is the "main advocate" and not necessarily an "appropriate advocate" in the interest of primary care.

2 - The RUC did indeed lead the effort to improve primary care relativity within RBRVS since 1992. Did the RUC also "lead the effort" to further improve specialty relativity within RBRVS since 1992. As in number 1, there really are not many alternatives in regards to others who are making recommendations to CMS.

3 - The SGR has overshadowed many things, and is more of a distracter in this paragraph in regards to what CMS has not done rather than what the RUC has done specifically to help fix this issue. We all know it is about politics... keep reading

4 - Increase in payment for E/M services (cognitive care) is VERY important and I appreciate that the RUC continues to advocate for proper payment for cognitive care. However, E/M services are advocated by many specialties that may not rely as heavily on cognitive services as much as procedural services. Remember, up to 14 members on the RUC are considered to bill a majority of E/M services, but only a small minority are considered "primary care." Also, in a response to a blogger who dare question the entire process, the RUC specifically points out its impact on E/M services. This response is a very good read and is worth taking a look at. All RUC responses to publications can be found on this page.

5 - Preventive services, including immunizations, are offered by almost every specialty I have rotated with - primary care and sub-specialties - as well as the pharmacies and retail stores within my neighborhood. This improvement looks great on paper, but is not translating to practice. Advantage - primary care? I'll leave that to the physicians to answer.

6 - Coordination of care/medical home - This is a very positive area of support by the RUC for primary care. Again, good for the RUC for recognizing the importance of the medical home for primary care delivery. Hopefully, semantics will also not get the best of the RUC when non-primary care specialties and non-physician providers attempt to organize their practices to make them qualify as a "medical home." Will the RUC defend primary care physicians? Additionally, the term "medical home" has taken on scrutiny itself - is it worth re-branding? (we'll save that for another post)

In a June 2008 letter from CMS to the RUC ("Commendation of the RUC's efforts" on AMA's website, on the page "CMS Applauds RUC Efforts to Improve the RBRVS"), the CMS makes an interesting point:

A necessary component in moving to a value driven health care system is accurate pricing payment systems. As you are aware, there has been considerable concern expressed by the Congress, Medicare Payment Advisory Commission (MedPAC), and other stakeholders regarding accurate pricing under the Medicare physician fee schedule.

Despite the large increase in work RVUs for many medical visits during the last 5-year review of physician work, there continues to be concern that the presence of many overvalued procedures within the physician fee schedule disadvantages primary care services and creates distortion in our payment system that makes moving to value driven health care more difficult. Critics have pointed out the relative imbalance in the number of codes for which the relative values are increased rather than decreased in the three 5-Year Reviews of work RVUs.

This is a bit confusing. The RUC states that they are a key advocate for primary care, releases robust statements in which they argue the contrary, and defends stances taken since 1992 to defend primary care... yet in 2008 the CMS specifically points out inadequacies in recommendations from the RUC for primary care. Again, it is worth noting the headline: CMS Applauds RUC Efforts to Improve RBRVS.  Is CMS applauding the RUC's continued failed effort at valuing primary care?  What is being lost in translation? The CMS does like a lot of what the RUC recommends....

The CMS relies on 95% of the RUC's recommendations. Should there be another entity involved? This is an argument used by many societies, brought forth by the Medicare Payment Advisory Commission (MedPAC) in 2006:

The Secretary should establish a standing panel of experts to help CMS identify overvalued services and to review recommendations from the RUC. The group should include members with expertise in health economics and physician payment, as well as members with clinical expertise. The Congress and the Secretary should ensure that this panel has the resources it needs to collect data and develop evidence.

This idea is also the central component of Representative Jim McDermott's (D-WA) bill, HR 1256 - The Medicare Physician Transparency and Assessment Act of 2011, to require the use of analytic contractors in identifying and analyzing misvalued physician services under the Medicare physician fee schedule and an annual review of potentially misvalued codes under that fee schedule.  It is worth noting that Rep McDermott, a psychiatrist, is also joined by an orthopod, Rep Price (R-GA) in expressing arguments against the RUC.  

Psychiatrist and Washington liberal Jim McDermott is taking up the cause of primary physicians and targeting an AMA committee that recommends payment values for doctors. McDermott tells PULSE he is considering legislation to beef up the analytic abilities of CMS to sort through pay data that the AMA committee, known as the RUC, recommends to CMS. Rep. Tom Price, a Georgia Republican and orthopedic surgeon, also complained during a Ways and Means health subcommittee hearing Tuesday that primary care specialists are underrepresented on the RUC and that data used to set Medicare pay for the services they perform most often – office exams, emergency room visits etc. – is nearly 21 years old.

Is it possible to avoid such legislation?  Can the RUC be reformed so it accurately represents the viewpoints of all those involved with the care of our patients? The following recommendations are those that have been produced by many.

1: Never forget our patients!
Of the voting members, 40-50% should be primary care physicians, practicing and billing for primary care services. The RUC recognizes the need for cognitive care by attempting to give a slight majority to those who bill a majority of E/M services. A nice try - take it a step further, put your money where your mouth is, and embrace primary care as the foundation of the RUC. This would represent the workforce we need to serve the growing demands of our patients. I repeat, never forget our patients!

2: Never forget our future! Include medical student and resident presence with possible input +/- votes on the RUC. We may be naive, but we're not naive about the number of years and money we sacrifice to gain the knowledge and experience of those already in practice (we do recognize the gap in pay when choosing specialties). We also may be doing a lot of the scut work that our more experienced physicians and hospital networks are getting paid for, so it may be worthwhile to help increase representation to those in the trenches.

3: Never forget our teammates!
One non-MD/DO (a podiatrist) is not enough in proportion to the amount that our teammates help us in our care for our patients as well as the work we must get done to get compensated. Emphasize more inclusion, input, and voting members from non-MD/DOs in the appropriate primary care proportion who are key-players in physician payment. As we move forward with collaborative and patient-centered care, the RUC needs to include more of these important health-care team members in the process. By doing so, the RUC puts their money where their mouth is in regards to their support for the patient-centered medical home and collaborative/team-based care.

The RUC does a lot of time-intensive, budget-neutral work to help our profession get the credit it deserves.  A physician-only panel is optimal to help get physicians the payments they deserve.  However, these physicians cannot play well together... and that is a shame.

There were efforts in the past to increase primary care seats.  Unfortunately, efforts to increase primary care seats and proper representation has failed.  Even if we were to increase primary care representation by one seat, it still would not be reflective of an appropriate primary care workforce.  I have no confidence that this will change anytime soon.

Has the RUC really done as much as they could have over the years, or did they do just enough to say they helped primary care... could they have "sacrificed" more to help improve cost/quality/access for patients or was it an effort to minimize the losses in the interests of specialist/proceduralist physicians. We can say we kept the patient in the center of our decisions to help health care delivery in this great nation... but have we really kept the patient in the center of the RUC since 1992?  Have we kept to containment of rising healthcare costs in the forefront of RUC recommendations since 1992?

The 20th Report by COGME - Advancing Primary Care - outlines the parameters that must be accomplished to increase student interest - achieve primary care payment to 70% of specialists (rather than < 50%).  I do not believe that the RUC will make the appropriate and necessary changes quickly enough to help produce the balanced health care workforce that our country so desperately needs.  It has not only produced the contrary but may be a main factor in the current decreased medical student interest in primary care.

Which leads to the final question... what should happen next?  My prediction - it will not be left for physicians to decide and it will be of no one else's fault but our own.

How do international electives fit into medical education?

Last summer, I traveled to Vietnam with a family doctor on faculty in my school's family medicine department. The first thing he taught me when I got there was how to drive a motorcycle. Not exactly what I expected from an international health experience, but undeniably cool!

I then used my newly-founded motorcycle driving abilities (I didn't have a license, but, really, it didn't matter) as we traveled to different health communes in rural Vietnam screening local residents for diabetes and hypertension in the morning and managing more complicated long-term patients of his in the afternoon. I diagnosed and treated my own patients in the morning - dispensing new meds, modulating medication doses and talking to patients about prevention. In the afternoons, I learned about managing complicated rheumatoid arthritis, cleft palate, congenital heart defects and more - all without the help of subspecialists and generally without labs or radiology.

When I returned home later that summer, not only had I developed a solid fund of clinical knowledge but I also had developed a solid relationship with a family doctor who breathes and lives primary care, the commitment to the underserved and compassion for patients.

The AAMC Graduation Survey, which all medical students complete before graduation, found that 38% of students participated in an international experience in 2000. Most of these experiences occurred either in the summer between their 1st and 2nd years of medical school or as an elective during 4th year.

A literature review completed in 2003 of International Health Experiences of Medical Students suggested an association between international experiences and career choices in primary care specialties and in underserved populations. The article and others published suggest that students develop soft skills in empathy, compassion and others while completing an international health elective - skills that are essential for doctors but often not taught in the medical school setting.

Offering more international health electives may draw more medical students to primary care and family medicine - not a silver bullet but one strategy among many in this multifaceted cause-and-effect of student specialty choice.

What can family medicine and primary care departments do? One significant barrier to a student's participation in an international health elective is the financial burden. We need to offer more scholarships and funding for students interested in international experiences - not just our strongest students but students who are on the margin about their interest in primary care and underserved care.

Another barrier is the timing - if students miss out on an international health elective between their first and second year of medical school, they may not have another chance to participate in one until well into their fourth year... beyond when specialty decisions are made. Could medical school curricula be redesigned to allow elective time in 3rd year and the potential of international electives then?

For those interested in an international health elective, the AAFP student website offers resources in finding electives.

I personally will never forget the time I spent in Vietnam and one day I hope to return as a physician to serve there. I hope that other students will have the opportunity to pursue international health electives - not only so that we can serve those abroad but also so that we can develop ourselves into better and more compassionate clinicians.


References:
Thompson MJ et al. "Educational Effects of International Health Electives on U.S. and Canadian Medical Students and Residents: A Literature Review." Academic Medicine 2003;78:342-7.

Godkin M and J Savageau. "The Effect of Medical Students' International Experiences on Attitudes Toward Serving Underserved Multicultural Populations." Fam Med 2003;35:273-8.

What's wrong with the way I look!?

Several weeks ago, one of the docs on a committee that I serve on sent out a link to the group to an article titled "Primary care's image problem," which you can find by clicking here.

The question to the group: tell me what you think? First let me give you some background. The article's author came across another blog by medical student SS (oddly enough by a friend of mine who attends Columbia) that was cross posted on KevinMD. In her blog, SS describes her experience working in an outpatient VA clinic. Rather than paraphrase, here is what she said:

It was awesome because I was the “doctor.” I essentially had full responsibility for each patient. From calling him in from the waiting room to deciding what medications he needed and at what dose, and everything in between, he was my responsibility. After I saw the patient, I’d present the case to my attending for a few minutes, we’d discuss and he’d teach for a minute and modify my plan a little if necessary, then the real doctor would go in and say hello and sign the orders I had suggested. I was my patient’s health care provider – a phenomenal feeling and an awesome transition in that I now think of myself as a capable clinician-in-training.

But that’s why I found primary care to be boring. I could do it. As a 3rd-year medical student. The cases I saw were by and large obesity, hypertension, diabetes and hyperlipidemia. A little tweaking of drug doses here and there, lots of education about lifestyle changes, plenty of questioning to assess for target organ damage, referrals for specialist followups… and far too much of “staying the course.” And if this is what most of family medicine/primary care is like… I don’t want to do it for the rest of my life.

The blog's author uses this rather short excerpt to make her point that we in primary care have an "image problem." To quote the article's author:

If you spend much time reading blogs and online discussions among medical students, however, the attitude that primary care is unexciting is far from unusual. And it’s not clear how much of this is based on reality and how much is perception.

She continues later:

But the article also hits on another factor: the high expectations of many medical students for a career that’s both intellectually and financially rewarding. These students, after all, are quite elite – very bright, very hard-working, competitive and achievement-oriented, with high aspirations for their future – and this sometimes leads to feelings of entitlement. When this is the mindset, primary care often simply can’t compete, especially if students perceive (mistakenly) that it’s easy enough for any rookie to do.

So, then the question to our small group of 2 family docs, 1 resident, 1 student (me!), and 1 chapter executive: Tell me what you think and what we can do to fix this at National Conference?

Well, here is what I think:

You have to start by looking at the background of how SS came to form her opinion. She was doing a 5 week, outpatient internal medicine rotation at a VA clinic. This tells me a lot about her experience. First, since its IM and not Family, that means no kids. No kids in my office alone would make it very boring for me. Beyond that, she's working at a VA clinic, which at least in my experience is predominately older men. So few women if any and certainly no OB or GYN. Last, and also because of it being a VA clinic, I would argue that all she saw in 5 weeks there were chronic care follow ups and med checks. Again, speaking from my experience, most of the older vets that use the VA system go there once or twice a year to have lab work and get their prescriptions at a lower cost, but then see their own physician for more acute problems.

To sum all of that up, she spent 5 weeks outpatient seeing virtually only older men with chronic problems who needed their blood pressure checked and their medicines refilled. And when you put it like that - hell yes is that boring. The problem is that Family Medicine is so much more than that. Acute problems mixed with chronic follow up mixed with procedures mixed with starting people on their chronic meds mixed with babies, kids, young adults, older folks, and for those in a rural practice the occasional pet or two. But did she see any of that in her five weeks. No. Do most students see even half of that? No. With not every school requiring a family medicine rotation and some not even an outpatient general medicine rotation, how could you expect any student to get exposed to all that family medicine has to offer by simply going through their rotations?

The author of the article says that we have an "image problem." I would say that the problem is that our image is so large, when viewed through the tiny view hole of medical school you only see a small part of it. And unfortunately far too often all students see is that boring little corner of chronic care follow ups or viral sinusitis. I dont think there is anything we have to do differently at NC to help fix this. The great thing about NC is how diverse the programming is - all the different realms of family medicine that are put on display through workshops, seminars, and even the diversity of the residency programs. We just need to get people to COME AND SEE THAT. (see below)

And for those that can't, we need to make sure that we are reaching out to departments and sharing resources so that they can reach out to their own students (one on one if they have to) to show them all that family medicine has to offer them. We need to make sure that schools have good preceptors available to them for rotations in all practice settings so that they aren't stuck sending drones of people to clinics like the VA (not to say that the VA isnt a valuable experience). And lastly, we need to reach out to those students that are even marginally interested in what we do and be sure to fill in the missing pieces of the bigger FM image so that they can walk away from their rotations saying "gee that was the tip of the iceberg" rather than "gee, if that's all there is, I sure dont want to do it"

For all you students out there reading this: COME TO NATIONAL CONFERENCE!

www.aafp.org/nc

Death of the S.O.A.P. Note?

While shadowing a local family doctor in high school, I was given my first instructions in the art and importance of a good history and physical and the classic documentation of a S.O.A.P. note. At the time, he explained to me how powerful, yet simple and elegant this note could be – no more than a few dozen words to define the impression of an entire patient visit. For the uninitiated:

S = Subjective (What the patient tells you)
O = Objective (What you gather from inspection and exam)
A = Assessment (What is likely going on)
P = Plan (What is to be done for the patient)

In many ways, this format allowed physicians to distill the extent of an office visit into a focused assessment of pertinent positives and goals. It was quick, efficient, and most importantly – it worked.

The irony for me? I haven't seen a single S.O.A.P. note in nearly three years of medical school.

Sure, physicians will comment that modern documentation is an extension of the format of the classic S.O.A.P. note. That, we still rely on the subjective and objective examination to formulate an assessment and plan. But medicine has moved away from the quick and distanced itself from the intuitive. The risk of error is too great.

In no way am I supporting shortcuts in medicine, or worse, decrying technological advancement. This couldn't be further from the truth. In fact, I am currently working on a future blog post in which I hope to extol the value of EMRs and the medical community's embrace of such technologies. Rather, I'm attempting to paint a picture of swift progress – of how quickly we are shifting the function and duty of the physician.

Think of it this way – can you imagine another profession in which the field of practice differs so drastically from the time one decides to enter, to the point in which one actually begins? Modern medicine may see the greatest such shift of nearly any profession in the history of man.

To illustrate my point, take my path along the road to medicine for example:

1995 - age 11 – First inspired by my uncle, who was a family doc, to dream of following his footsteps
2000 - age 16 – First shadowed local physicians
2002 - age 18 - Declared pre-med intentions
2004 - age 20 – Took the MCAT exams
2008 - age 24 - Entered medical school
2012 - age 28 - Graduate from medical school
2015 - age 31 – Begin practicing as a family physician

How much medicine will have changed in those 20 years! I could go on and on about the politics and policy of medicine in the intervening period, but think of the sweeping technological innovations! I used the hand written S.O.A.P. note as an illustrative mechanism for these changes. Today, as I am engaged in a clinical rotation at a modern health system, I have instantaneous access to any patient's every clinical note, lab value, and imaging test at the touch of a button. The system is designed to remind me of best practice initiatives when a patient is due for a health maintenance test and built in redundancies prevent me from ordering conflicting medications. If I wanted to be bold, I could forget how to use a pen entirely, and still excel in the care of my patients.

This all begs the question of what awaits us in the coming years? Thinklabs and 3M are designing “smart” stethoscopes that can interpret heart sounds digitally, GE has developed a hand-held ultrasound, and genetic testing is targeting the most precise variables of disease. As we move away from the era of intuitive medicine and the likes of the S.O.A.P. note, where does the family doctor fit into all of this?

These are all wonderful and valued additions to a health care system that demands efficiency, precision, and cost-saving mechanisms. But, BOY – what a difference from the office of my uncle, or that of the family physician I first shadowed in high school! Just think about how the clinical setting in which I was first inspired will bear little resemblance to the one in which I begin my first practice. The classic S.O.A.P note may be a relic for historical medicine soon, but as long as the spirit of the family physician endures – I know I'll be overjoyed to enter the profession.

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.

The "Dean's Lie" About Medical School Primary Care Production

First, we want to congratulate all students who matched in family medicine!  Welcome to the Family Medicine Revolution!  (#FMRevolution)

We also want to congratulate all students who matched in primary care residencies AND who plan to stay in primary care!  We all need to work together to provide increased access to quality primary care to our future patients.

Over the past few weeks, I have had the pleasure to read summaries of match results from various schools and various national organizations.  Trust us, we are excited about the 11% increase in Family Medicine and the 94% fill rate - the most all time - for Family Medicine!  However, there are many misleading reports flying around from various sources touting their production of primary care.

These misleading reports are what some call "The Dean's Lie".  The Dean's Lie is commonly interpreted as the number of students that medical schools report that enter into residencies that eventually produce general internists, general pediatricians, and family physicians.  This seems like a good thing - though it is quite the contrary.

What is missing?  Consider how many of these future physicians choose to specialize into sub-specialties and never actually practice true primary care.  In many circles, the specialization rates vary between 80-90% for internal medicine and 60 -70% for pediatrics.

Would it be more appropriate for medical schools to publish how many of their graduates from 5 years ago currently contribute to our primary care workforce?  The problem is, most medical schools know about these specialization rates and publishing the results of retrospective graduates would most likely hurt the image of their medical school rather than boost them onto a pedestal.

How about some examples of the Dean's Lie from this year's match results.  Here we go!

Let's assume a 90% specialization rate in internal medicine and a 66% specialization rate in pediatrics (and some rounding).  Also, let's keep in mind that there are some that would consider these specialization rates on the lower side.

Remember, these are predictions according to current specialization rates and from taking into account historical numbers from the Med School Mapper tool. We would be more than happy if the specialization rates were lower and that all of these numbers were wrong!  We want them to be wrong!  Unfortunately, this is the current trend.

Some of these results may be disturbing (and some come from highly ranked schools, whatever that means) - viewer discretion advised.

Harvard’s Match Day stats bear out national trends -- in a good way

Claim:
42% of 167 seniors into primary care
35 IM (4 primary care), 13 Pediatrics (4 primary care), 3 IM-Peds (1 primary care) and 8 Family Medicine
8 out of 167 = 4.8% Family Medicine
17 out of 167 = 10% Corrected for 32% Dean's Lie

More Einstein Seniors Choose Primary Care Residencies at 2011 Match Day 

Claim: 43% of 187 seniors into primary care
47 internal medicine (5 primary care), 22 pediatrics (7 primary care), and 11 family medicine
11 out of 187 = 5.9% Family Medicine
23 out of 187 = 12.3 % - Corrected for 31% Dean's Lie

Sixty Percent of Meharry Students Match Into Critically Needed Primary Care Specialties

Claim: 60% of 89 seniors into primary care
Meharry does traditionally well with primary care production and, because of this fact, I am using a lower specialization rate.
17 internal medicine (4 primary care), 16 pediatrics (8 primary care), and 10 family medicine
10 out of 89 = 11% Family Medicine
22 out of 89 = 25% - Corrected for 35% Dean's Lie

UA Match Day: Nearly Half Will Stay in AZ for Residencies
Claim: 43% of 129 seniors into primary care
13 internal medicine (2 primary care), 23 pediatrics (8 primary care), and 20 family medicine
20 out of 129 =  15.5% Family Medicine
30 out of 129 = 23% - Corrected for 20% Dean's Lie

Robert Wood Johnson Medical School Sends 157 New Physicians to Hospitals Nationwide
Claim: 32% of 157 seniors into primary care
33 internal medicine (4 primary care), 11 pediatrics (4 primary care), and 7 "family practice"
7 out of 157 = 4.5% Family Medicine
15 out of 157 = 10%  - Corrected for 22% Dean's Lie

The 2011 Stanford University School of Medicine Match Results
I will give Stanford credit - they don't lie here.  After searching for "primary care" in this article, it is only found once.  Additionally, it is not in regards to their own primary care production.
2 out of 91 = 2% Family Medicine

Does your school participate in the "Dean's Lie"?  We would love to hear your feedback as well as other articles and commentary about the Dean's Lie from other schools that we may have missed.

What will you do to help keep those in primary care?

As a side note - we would like to thank everybody who checked out our blog for our Family Medicine Match Day 2011 Coverage!  It was an exciting day for all US Seniors participating in the NRMP Match and congratulations to all who found their perfect match!