Monday, April 5, 2010

Primary Care and the Medical Home, Today and Tomorrow

March 18, 2010 was “match day”, the day that the seniors at US allopathic medical schools, along with many from osteopathic (DO) schools and thousands of graduates of non-US schools (including many who are Americans) “open their envelopes” and find out where they will be doing their post-graduate residency training. Most have already chosen their specialty and are waiting only to find out with which program they have “matched”. This year, for the first time in many years, the number of US medical students matching in family medicine has risen from the prior year. Not by much – there were, according to the American Academy of Family Physicians (AAFP) report, 75 (2.1%) more positions offered, and 2,404 (91.4%) of the 2,630 positions offered were filled on match day, the highest percentage in history. 1,184 of these are US grads, which was 101 more than last year and the highest number since 2004. This is good because, as I have often indicated, we need more primary care physicians and family medicine is the only specialty where virtually all graduates practice primary care. However, more sobering, it also notes, “The majority of positions offered and filled in the NRMP, however, continue to be in nonprimary care subspecialties.”

The Association of American Medical Colleges (AAMC)’s “Reporter” for March, 2010, contains an article by Scott Harris (written before the current match results were in), “Primary care in medical education: the problems, the solutions”. He notes that
Primary care is generally defined as family medicine, internal medicine, and pediatrics, although it is the adult-oriented specialties for which the problem exists most pointedly, physician workforce experts say. In the 2009 Main Residency Match, 3,703 U.S. allopathic senior students matched to an internal or family medicine residency program, compared with 4,617 in 2000 and 5,020 in 1996. According to AAMC data, all primary care practitioners entering general practice after residency are down from 8,162 in 2000 to an estimated low of 6,757 in 2007. The Council on Graduate Medical Education (COGME) claims that all primary care physicians currently comprise 35 percent of practicing physicians, but that number is rapidly declining because of increased retirements and fewer new doctors to replace them. Recent COGME studies show that fewer than 20 percent of all U.S. medical students are choosing primary care specialties.”
This formulation recognizes the problem of most of the graduates entering internal medicine specialty training ending up as subspecialists. If we are currently at 30-35% primary care, 20% of new students won’t get us to the 50% we need. In fact, even if 50% of graduates enter primary care specialties, it will be a generation before that number is achieved.

Harris’ main focus, however, is on the “hidden curriculum” in medical schools, the influences outside the formal curriculum from teachers and peers that encourages students to enter non-primary care specialties. He quotes students and faculty members who identify the problem. One is David Deci, a family physician at the University of Wisconsin, who says "Modern medicine is enthralled with high-tech measures. We're all drawn to bells and whistles. The contribution that can be made through a long-term relationship with a patient needs to be shown as well. When you're working with an elderly patient with multiple conditions and diseases, and you manage to keep him out of the hospital for two years, you've made a great contribution. But it's harder to demonstrate that than it is to show the value of removing a tumor with gamma knife surgery." Another is Jeffrey Borkan, chair of Family Medicine at Brown and (now) past-president of the Association of Departments of Family Medicine (ADFM), who notes “Medical education is all about context. There can be an inherent bias because of who the trainers are and where the education happens. U.S. academic medical centers and medical schools tend to be in urban areas and have a predominance of specialist and subspecialist physicians, providing care in tertiary and quaternary hospital settings. Primary care and primary care physicians and educators can be underrepresented in these settings, even though present in the broader community and country." Most distressing is the student (planning to enter radiology) who tells of a family medicine program director discouraging him from entering the field. Harris’ article also has descriptions of programs at a number of medical schools, including new ones and those that have been around a long time, who have programs and plans for changing or modifying this “hidden curriculum”. How well they will work, however, especially against the financial pressure of greater reimbursement for narrower specialties, remains to be seen.

There are some hopeful trends on the horizon. The new health reform bill promises some increased reimbursement and other support for family medicine. At a recent private meeting with the President, a family medicine chair was told that Mr. Obama understood that family medicine was the crucial specialty for providing care for the American people. The ADFM and other primary care organizations are working with the Patient-Centered Primary Care Collaborative (PCPCC), a network of employers such as IBM, health insurers, providers and drug manufacturers who recognize that health systems built around primary care keep people healthier and save them money. Of course, the “save them money” part may be the most important part for many of the corporations. It is an important venture, although the family physicians in the collaborative will have to remain on guard that the health of people remains the most important focus. Merck’s slogan, for instance, may be “Where patients come first”, but the reality of their practice has been much more “Where profits come first” – $6 billion in one recent year, despite the Vioxx recall; some details can be found at

I certainly hope that all these efforts work. Goodness knows, we need them. And I hope that the many medical schools who are not on board, whose focus has never been primary care, who feel their main missions are biomedical research and quarternary care rather than training the doctors our country needs, will rethink their curricula – formal and hidden – as well.

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