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)