Are primary care physicians the future? (Cross-published in The Temple News, 8/27/13)

Philadelphia is a city of “firsts.” It is where colonists first declared independence from England. It was the first planned city in the New World. It is also the location of the first American hospital and medical school. I take special pride in having served the underserved communities of Philadelphia – a city to which American medicine owes so much – as a medical student at Temple.

During my recent time there, Temple Health was spending more than $100 million a year on charity care, much of it on an uninsured or underinsured population in a turbulent surrounding community. Many uninsured Philadelphians end up in Temple’s Emergency Department; in fact, applicants to the medical school and ER residency are lured by the prospect of seeing one penetration wound – that is, a gunshot injury or stabbing – per day. Dr. Amy Goldberg leads a robust program caring for trauma patients, and is one of the most brilliant educators that I encountered while at Temple.

While caring for that population and spending $100 million annually to do it is a noble cause, I don’t look at that as a statistic to be especially proud of.

From a business perspective, any health system that gives away that much free care is shooting itself in the foot. More importantly, from a patient care perspective, that number shows that our health care system is failing in its medical duties, no matter how good we are at robotic surgery, trauma care or research.

The United States spends 17.9 percent of its yearly gross domestic product on health care, far more than the second-most developed country – the Netherlands – spends per year.  However, according to the most recent numbers from the Centers for Disease Control and Prevention, the U.S. ranks 30th in infant mortality, one of the World Health Organization’s primary indicators of health.

How can Temple and other communities in the United States avoid growing debt from health care spending while actually improving the health of the populations they serve? In my opinion, giving that population a relationship with a primary care physician is the answer.

Insurance companies are increasingly realizing the cost-savings and quality that primary care physicians bring to a health care system, especially through the Patient-Centered Medical Home model of care, which advocates for comprehensive, coordinated and accessible primary care for patients and their families.

According to the nonprofit Patient Centered Primary Care Collaborative, a collective of insurance companies, employers, doctors, nurses and patients, some of the benefits of patient-centered care include lower costs of care, improved outcomes for conditions like cancer and heart disease, improved life expectancy, decreased mortality rate and reduced impact of socioeconomic disparities.

Family physicians also decrease the mortality rate more than other primary care physicians. Why? As a family physician now working in a PCMH in Billings, Mont., a city with remarkably similar problems to Philadelphia, I have realized firsthand what a family physician provides: a window into the major health determinants in the families and community that I serve.

For example, I recently saw a child brought in for care by his depressed mother whose husband was battling alcoholism, and who was also struggling to care for her diabetic mother. While these relatives may never have seen a physician otherwise, at this same visit I can treat what might be the most important factor in the child’s health: his family. More importantly, working in a PCMH, I can refer this family to in-house services including behavioral health for the mother, home health for the grandmother and substance dependence treatment for the father.

If Temple and other academic health systems in Philadelphia and the U.S. want to improve outcomes while reducing astronomical spending on emergency and charity care, let them serve as role models to other health systems and prevent those costs by investing in the PCMH model.

This transition can start with medical schools and their affiliated health systems acknowledging that approximately 90 percent of graduates going into internal medicine and 40 percent of graduates going into pediatrics will eventually specialize. They must also recruit more family physician faculty, increase the number of family physicians in their administrations, invest in partnerships with local community health centers to provide students and patients the opportunity to experience effective primary care and lobby at the national level for payment reforms to increase valuation for primary care services.

Targeted investment in primary care is a long-term strategy to combat the continued rise of costs and to improve wellness. Just maybe, with a sustained investment in preventive and primary care, we will eventually see charity care costs and bullet wound numbers decrease. No hard feelings to Dr. Goldberg, but I’m hopeful that we can decrease the need for doctors in her profession in the coming decades if we appropriately prioritize medical education.

If Philadelphia medical schools are to “create the next generation of health care leaders,” let them look toward primary care. Philadelphia has been at the forefront  of medicine in the United States in the past, and it can be again if its academic medical centers lead the way by investing in patient-centered primary care.

Christopher Baumert, MD; Family Medicine Resident Physician and 2011 Graduate of Temple University School of Medicine.

Family Medicine Residents Adopt Resolution to End Falsification of Primary Care Workforce Production by Medical Schools and Residency Programs

Change through disruption (check)

Change through creating policy (check)

Change through educating the media, legislators, and the public (pending)

All of the above are the reasons for continuing efforts to ensure that medical schools are held accountable for the primary care workforce numbers it publicizes and promotes to medical students, federal/state/local legislators, and the public. All of the aforementioned stakeholders deserve the right to know how many of its medical school and residency graduates ACTUALLY practice primary care.  

We have used this blog to call out medical schools that lie to the media and ultimately lie to themselves.  These blogs have served as references for a number of articles in the media to help explain what "the Dean's Lie" actually is. Over the past year, a number of media outlets have caught on to and have called out medical schools that, despite being shown the data, continue to publicize primary care percentages that cannot be proven until at least 3-5 years after graduation from medical school.

An article by Medical Economics ("How Medical Schools consistently cover up their primary care failures") focuses on an interview with Primary Care Progress CEO and primary care change agent, Dr. Andrew Morris-Singer. The article does an exceptional job in trying to relay this information to the media. By utilizing the media for these numbers, they may be more likely to show how many of the "primary care institutions" are actually performing at the bottom of all medical schools in the entire country.  In fact, this is already being evaluated in our internal medicine residency programs by the Graham Center and resulted in several media pieces, including the "20 worst" residency programs for contributing to the primary care workforce. 

Now that our efforts are finally starting to show promise, it is now important to continue this momentum and accumulate organizational support. Since medical schools and residencies refuse to face the truth and provide the correct data proving their inability to produce primary care physicians, we must now do the work ourselves in finding this objective data and distributing it via multiple large-scale organizations to legislators and the public. 

The opportunity to provide guidance and create policy outlining the specifics of this initiative presented itself this past weekend at the 2013 American Academy of Family Physicians (AAFP) National Conference of Family Medicine Residents and Medical Students. The Resident Congress provided a forum to present a resolution that, upon approval by the Resident Congress, a specific action and policy could be put into place to task an organization that represents over 110,000 Family Medicine physician, resident, and medical student members with advocating and collaborating with others in amplifying these efforts.

The following resolution was submitted and approved by the AAFP Resident Congress:

RESOLUTION NO. R1-407

Rebuilding Trust In and Accountability for Primary Care Workforce Production Reporting

WHEREAS, The United States (U.S.) educational system is currently doing a woefully inadequate job of producing enough primary care physicians to satisfy future demand, and

WHEREAS, medical school deans and residency programs consistently cover up their primary care failures, regularly exaggerating the number of medical school students and residents they report graduating into “primary care residencies” and practicing in “primary care fields,” also known as “The Dean’s Lie,” and  

WHEREAS, publicizing misleading data of primary care workforce production gives the taxpaying community and politicians a false sense that the primary care workforce shortage is being fixed, and

WHEREAS, after factoring in the specialization rate of pediatrics (66%), internal medicine (80-98%), and other “primary care” residencies (e.g. IM/Peds, etc.), a much lower number of medical students actually end up practicing primary care, and

WHEREAS, medical schools utilize other non-primary care specialties when reporting their primary care production numbers (e.g. obstetrics and gynecology), and

WHEREAS, the institutions touted at producing primary care physicians have recently been found to be among the worst at producing primary care workforce when looking at graduating classes from five years prior, and

WHEREAS, it costs $500,000 of taxpayer dollars to train the average resident and as part of the Affordable Care Act, provisional funding will be given to “primary care” residencies including internal medicine, pediatrics, etc., now, therefore, be it

RESOLVED, That the American Academy of Family Physicians (AAFP) advocate for accurate reporting by medical schools and residencies of primary care workforce production measuring the type of practice five years following medical school graduation, and be it further

RESOLVED, That the American Academy of Family Physicians (AAFP) explore the feasibility of working with other organizations and news outlets to collaborate in advocacy for more accurate reporting of primary care workforce production to politicians and the public.

Things are about to get very interesting....

Highlight on interesting comments:

A comment left by Sylvia Kronstadt: 

On Sunday, June 2, the dean of the University of Utah School of Medicine had a cozy sit-down with our local “spokesmodel” news anchor and made several remarks that she knew to be false.

Dean Vivian Lee recently seduced the Utah Legislature into giving the medical school yet another $10 million (on top of the hundreds of millions it already receives) in order, she said, to train more primary care doctors. She implied that the U. is dedicated to resolving the shortage — which is rapidly becoming a crisis — especially since Utah is fourth from the bottom nationally in primary care doctors per capita. She ardently made her case for what seemed like a moral as well as a practical cause.

She referred to this victory during her interview on KUTV Channel 2 in Salt Lake City.

What she failed to disclose is that the U. is 75th nationally in recruiting students who express a desire to practice primary care.

Last year, there was NOT ONE TAKER for a scholarship that offered a $5,000 reward to any medical student willing to practice primary care medicine for just three years. That is a shocking indicator of how little interest the U. has inspired in this vital field of medicine.

Although the need for more primary care doctors has been a critical issue nationally for years, the U. has blithely ignored it.

The school glamorizes the specialties — paying professors in those disciplines hundreds of thousands of dollars more than those who teach primary care and family medicine (a professor of orthopedic surgery, for example, was paid $1.3 million in taxpayer funds last year. A professor of family medicine got $125,000).

Primary care has always been the “stepchild” of the U’s medical school, while the glamorous, high-status, high-paid, high-tech specialties are made ever more alluring.

Apparently it’s not just University of Utah officials who misrepresent their dedication to mobilizing an infusion of devoted primary care doctors into the health-care system. A shocking article, “The Dean’s Lie” (http://www.healthnewsreview.org/2013/04/the-deans-lie-about-new-docs-going-into-primary-care/), describes how medical-school deans all over the country are making the same urgent appeals to their legislatures for more money, brazenly fabricating the percentage of their graduates who are committed to serving in primary care, and then continuing to relegate primary care to the sidelines. The “dean’s lie” expression was coined by Dr. Reid Blackwelder, president-elect of the American Academy of Family Physicians.

(When I posted “The Dean’s Lie” on Lee’s University of Utah blog, it was promptly removed. Freedom of speech is so overrated, don’t you find? It just upsets people!)

Only Stanford University, according to one survey, was honest about how many of its medical school graduates actually established primary-care practices after their residencies: two percent (http://futureoffamilymedicine.blogspot.com/2011/04/deans-lie-about-medical-school-primary.html)

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

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

Hello, Fellow Downstaters!

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

***************************************************************

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

            There.  The title of this memo-to-all-med-students says it all.  But we’d like to elaborate!  First of all, our title might be, well, over the top, some might say--but we’re excited about where we’re headed (!), and we’ll tell you why in a second.  Plus, we felt it was that important to catch your attention, especially since in 1940, three-quarters of all doctors were general practitioners(1), but with the subsequent proliferation and dominance of specialist fields in American medicine, by 2010, less than one-third of practicing physicians were focused on providing primary care.(2) Moreover, the need for primary care physicians will continue to increase with the aging of our population and the millions more Americans who will soon be able to acquire health insurance, as a result of the Affordable Care Act.(3)  

            What does our opinion matter to you?  We don’t claim to be the end-all-be-all, or the know-it-alls, but among us, we have a good number of accumulated experiences as MS1-MS4 medical students during the years 2008-2013.  To be sure, our experiences in primary care have spanned providing care within an efficient team-based care model at a top-tier Patient-Centered Medical Home in Portland, Oregon; to staying after-clinic-hours to join in Zumba and nutrition classes with patients, led by the spirit-rich community of caregivers at Lefferts Family Health Clinic in the resource-poor community in Crown Heights; to working on public health studies of disparities in cancer screening; to experiencing successful integrative medicine practices that are helping patients to achieve better outcomes in Brooklyn Heights; to providing primary health care for uninsured patients at free clinics; to helping determine goals of care for patients and families faced with terminal cancer.  

            In primary care, the patient--and your relationship with that patient--comes first.  If this excites you, and you haven’t considered going into primary care yet, then we recommend that you start doing some considering.  Primary care is not defined by one organ system or illness category, but by whatever it is that brought that patient to you, and keeps bringing her or him back to you, in illness and/or in health.(4)  The person, their significant other, their family, their psychology, their context, their home, their community, their daily struggles, their life’s joys, their life’s tragedies, their health, illness, growth, journey to death--they all matter, and you get to be there with them, for them and their families, when they need.  The buzzword these days is “continuity” of care.  That is what primary care does and is.

            Asfuture primary care physicians, we are excited by the chance to hone and master diverse clinical, interpersonal, research, and policy skills, depending on our interests and our patients’ needs.  One of the greatest assets of being a primary care doctor is that you truly are a lifelong learner, with your patients at the center of the learning process.  Additionally, we work with other providers including specialists, psychologists, integrative medicine providers, nurses, and home health aides--not to mention teachers,not-for-profits, and policy makers--to provide care that best fits our patients’ needs, values, and life circumstances.  As “frontline providers,” we are in a unique position to work with communities--e.g. organizing community health efforts or contributing our voices to healthcare policy--as advocates for our patients.  We are incorporated into their lives and communities, and, from this unique vantage point, have initiated the development of many social initiatives and advocacy efforts; we have been pioneers of social justice and pushers of public health policy initiatives, from vaccination to improved access to care.  In all of these endeavors, primary care doctors have led the way.

            There is also an abundance of dynamic opportunities in primary care research, from improving preventive medicine to management of chronic diseases; from the hospital-to-outpatient transition to the complex needs of our aging population; and from end of life care to ending racial/ethnic health disparities.  As just one example, take the recent changes in the U.S. Preventive Task Force recommendations for mammography, prostate cancer screening, and HIV testing: primary care doctors not only help navigate their patients through these complexities, we are the ones formulating and conducting the vital research that ultimately improves our national guidelines!  As primary care becomes the centerpiece of health care reform, the opportunities to be involved in research are becoming endless.

            If there wasn’t enough respect for and investment in primary care in our country from the mid-20th century through 2010, then at least you can be sure that in the coming months, years and decades, primary care will be the main focus of healthcare investment and reform.  Who, by now, has not heard of the “chronic care model” or the more recent Patient-Centered Medical Home (PCMH)?  While there are a number of components to understand regarding these models(5), including continuity/coordination of care and patient access, at their roots, they recognize the evolutionary shift that has occurred in modern industrialized society--that people are living longer and predominance of acute morbidity has shifted now to an overwhelming burden of chronic disease in our country.  

            The 2001 national assessment by the Institute of Medicine, Crossing the Quality Chasm(6), called for transforming a “fundamentally flawed” US health care system; this report helped to propel the momentum that has led to the first serious attempt now at implementing health care reform in our country’s recent history.  With this, is a growing focus on primary care: in the words of the Institute of Medicine, “primary care is the logical basis of an effective health care system... [and] is essential to reaching the objectives that constitute value in health care.”(7)  This recognition has led to increased reimbursement rates and medical school grants for those going into primary care (contrary to popular belief, a recent study has proven that medical students with median loans are able to pay it off on a primary care physician salary(8), and there are many federal, state and private scholarships targeted to attract brilliant and compassionate future-physicians--like yourself!--to the field), which have paralleled the overall shift ingovernmental priorities to strengthen our health care workforce through support of its frontline providers.  This growing emphasis on primary care has crescendoed over recent years and is now evident in restructured health systems and practices in many parts of the country, federal and state policy, and is even beginning to take hold in medical education(9).  There has been no better time, as a medical student, to choose primary care as your match and future career.

            In fact, many are! Check out David Margolius, a resident physician at UCSF primary health track who is speaking at conventions across the country about reinventing primary care and improving access, continuity, and clinical outcomes . Take a secondto google David Katz, an internist at Yale, and his Huffington Post article titled “The Case for Caring About Primary Care” (as well as his other great food and exercise tools!).  While you’re at it, meet a few long-time primary care leaders who have, for years, inspired doctors starting their careers: go on Amazon or to the good ‘ol library and check out, Big Doctoring in America: Profiles in Primary Care.  Among the fascinating profiles turn to “Neil Calman, M.D.: Urban Warrior,” to read about the self-proclaimed “flag-waving family physician...warrior for urban health,” who founded the trailblazing Institute for Family Health in New York City.  Or, look no farther than our current U.S. Surgeon General, Dr. Regina Benjamin, who once founded a primary care clinic in a poor shrimp-fishing village on the coast of Alabama--and rebuilt it three times after two hurricanes and a fire; we are now nearing two years since the release of her unprecedented National Prevention Strategy, which has been the centerpiece of her tenure.  Its successes mirror the improved health outcomes seen across the country, in the places where there has been increased emphasis on primary care.

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

Sincerely,

-Abraham Young, soon-to-be resident in Family Medicine! atEinstein/Montefiore Hospital, Bronx, New York

-Jessica Bloome, soon-to-be resident in Primary Care Internal Medicine at UCSF Medical Center/San Francisco General Hospital, San Francisco, California

-Alinea Noronha, soon-to-be resident in Family Medicine at UC Davis leadership track, Sacramento, California

-Rachael Maciasz, soon-to-be-resident in Pediatrics atBrown, Providence, Rhode Island

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

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

---

(1) We recommend you see “Ch. 1: Primary Care Roots” inFitzhugh Mullan’s Big Doctoring in America: Profiles in Primary Care(University of California Press, 2002)

(2) See the Agency for Health Research and Quality (AHRQ) website for some more recent statistics. http://www.ahrq.gov/research/findings/factsheets/primary/pcwork1/index.html#

(3) Stephen M. Petterson, PhD, Winston R. Liaw, MD, MPH, Robert L. Phillips, Jr, MD, MSPH, David L. Rabin, MD, MPH, David S. Meyers, MD, Andrew W. Bazemore, MD, MPH. Projecting US Primary Care Physician Workforce Needs 2010-2025. Ann Fam Med. 2012;10(6):503-509

(4) We recommend you see “Ch. 2: Principles of FamilyMedicine” in Ian R. McWhinney and Thomas Freeman’s A Textbook of FamilyMedicine (Oxford University Press, 2009)

(5) For a helpful primer, we recommend browsing through the AHRQ's website, “Defining the PCMH”.

(6) Institute of Medicine. Committee on Quality of HealthCare in America.Crossing the Quality Chasm: A New Health System for the 21stCentury . Washington, DC: National Academy Press; 2001.

(7) Donaldson MS, Yordy KD, Lohr KN, Vanselow NA, eds.Primary Care: America’s Health in a New Era . Washington, DC: National AcademyPress; 1996;52.

(8) James A. Youngclaus, MS, Paul A. Koehler, PhD, LaurenceJ. Kotlikoff, PhD, John M. Wiecha, MD, MPH. Can Medical Students Afford to Choose Primary Care? An Economic Analysis of Physician Education debtRepayment. Academic Medicine. 2013;88(1):16-25.

(9) As examples, please see the articles, “FamilyMedicine Welcomes Mount Sinai Into the Fold,” and “Medical schools taking additional steps to highlight primary care,” published 6/20/2012 and 5/8/2013, respectively, on the AAFP’s blogs.