Does AAMC have an answer for the primary care shortage? No.

The December 5, 2012 issue of JAMA is its annual “medical education” issue, and contains a number of interesting studies and commentaries for those interested in the topic. In terms of increasing the number of primary care physicians, an issue which I have often addressed, the “original contribution” is “General medicine vs. subspecialty career plans among internal medicine residents”[1] by West and Dupras. This study discovered that only 21.5% of third-year internal medicine residents were planning careers in general medicine (which might be primary care), while 9.3% planned careers as “hospitalists” and 65.3% planned to be sub-specialists (cardiologists, gastroenterologists, pulmonologists, endocrinologists, etc.), with 4% undecided.

This is not a significantly different result from that found by Garibaldi, et al., in “Career plans for trainees in internal medicine residency programs[2] published in 2005 in Academic Medicine, and first discussed by me in “A Quality Health System Needs More Primary Care Physicians” 4 years ago, December 11, 2008. Garibaldi’s number was 27% of 3^rd (final) year residents and 19% of first years. What West and Dupras add is that only 39.5% of graduates of specifically-designated “primary care” internal medicine residencies are actually planning to become primary care physicians.  Apparently all of the discussion about the need for more primary care doctors has not swayed the decisions of these residents, who, at the conclusion of their initial 3 years of training can “go either way”; the way that they are going is to subspecialization.

Commenting on this article, Mark Schwartz (“The US primary care workforce and graduate medical education policy"[3]) notes that, in contrast to internal medicine, a larger percent of pediatric residency graduates, 45%, were planning to enter primary care, which is actually a decrease because of pressures in the discipline to create more pediatric subspecialists. Only family medicine, at over 90%, remains a reliable specialty for producing primary care physicians. Schwartz notes that the Council on Graduate Medical Education (COGME) has recommended a minimum of 40% primary care for an optimally-functioning health system (increased from the 32% at the time of its 20^th report, in 2010), but obviously the movement is in the opposite direction. Moreover, he talks about a 40% “rate” of entry into primary care; however, a 40% entry rate is only a sustaining percent once we are at 40% --an entry rate of 40% will take an entire generation, about 30 years, to yield a 40% primary care workforce. And, indeed, many, including many on COGME, believe that 40% is too low and the actual goal should be 50-60%. Nonetheless, it is all academic when the current rate of entry into primary care will not even replace the current under-30%.

Schwartz also looks at the fact that Medicare supports the majority of graduate medical education through two related programs, Direct Graduate Medical Education (DGME) funding, about $3B, which is to support resident salaries and teaching costs, and Indirect Medical Education (IME) funding, about $6.5B, which is intended to compensate hospitals, the primary sponsors of residency programs, for the increased costs involved in providing patient care in a training environment. Unfortunately for these hospitals (and other program sponsors), the Medicare Payment Advisory Commission (MedPAC), which advises Congress on Medicare policy, has indicated that IME payments exceed the cost differential by $3.5B. There are various proposals for what to do with this money; while MedPAC advocated using it for a pay-for-performance program for GME, both Simpson-Bowles and the administration have advocated using it to pay down the national debt (i.e., chopping it). The Association of American Medical Colleges (AAMC) wants to use it to increase the supporting number of residency positions, currently capped by the balanced budget amendment at 98,000, correctly noting that although the number of graduates from US medical schools is increasing (through class size expansion and opening new schools), this will not increase the number of physicians if the number of residency slot is constant.

Darrell Kirch, President of AAMC, avoids discussion of GME in his editorial in this issue (“Transforming admissions: the gateway to medicine”)[4] choosing instead to comment on an article by Kevin Eva and colleagues from McMaster University in Canada [5]  about using a technique called the multiple mini-interview (MMI) to increase the admission of students with desirable non-cognitive characteristics (i.e., those not well measured by grades and standardized examination scores) to medical school. Kirch says that “…medical schools are moving toward a broader view of medical school readiness that emphasizes the competencies applicants have demonstrated in addition to their academic credentials,” and that “This change is essential to identify future physicians with the skills and knowledge to manage illness in the 21^st century.”

So what do we have. Not enough internal medicine residents entering primary care. Not enough students entering the only true primary care specialty, family medicine. Expansion of medical school classes to produce more US graduates, but no expansion of residency positions, which will largely mean US grads will replace international medical graduates (IMGs) in residency positions (which may in itself not be entirely positive, as described in yet another article in this issue [6]). On the front end, we have increasing recognition that characteristics other than standardized test performance are the most important for future doctors, but only tepid experiments at changing the selection process.

The AAMC could be at the center of advocating for, and in their member institutions, implementing, some solutions to these problems, but currently the solutions they have proposed are far from adequate. Students will be more interested in primary care if they are selected based on the characteristics that are associated with choosing primary care, not mainly on grades and test performance (which are often inversely associated). This is not what Dr. Kirch is advocating. They will continue to be interested in primary care careers if their faculty and overall medical school experience support and encourage them. Most medical schools do not. Increasing the number of residency positions will not increase the proportion of primary care physicians if the expansion is in all specialties, but only if it is limited to primary care. The AAMC has not backed this idea. Finally, the decision to pursue a primary care career by entering family medicine training, or by opting for primary care on completing internal medicine or pediatric training, will only be achieved if the anticipated income differential is addressed, which will require decreased income for the currently most highly paid subspecialists at least as much as increasing that of primary care doctors. The AAMC does not have a position advocating this.

A wonderful “Piece of My Mind” in this issue of JAMA, “Not born in the USA” by Vijay Rajput [7] addresses many of these issues, including how the increased competition for US residency slots by IMGs will drive their test scores even higher, but how these scores do not really prepare someone to be a “humanistic” physician. The strategies mentioned above, including recruiting and matriculating students concerned about people and interested in primary care and care of the underserved, supporting them through their education, offering increases in residency slots only for primary care, and reducing the income differentials for primary care, will address the problems.

Medical schools, the AAMC, and the various agencies of the federal government (especially the Center for Medicare and Medicaid services) need to fully commit to these strategies. It is time for the talk to lead to real action.

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[1] West CP, Dupras DM, General medicine vs subspecialty career plans among internal medicine residents. JAMA. 2012 Dec 5;308(21):2241-7. doi: 10.1001/jama.2012.47535

[2] Garibaldi, RA, Popkave C, Bylsma W, “Career plans for trainees in internal medicine residency programs”, Acad Med 2005 May;80(5):507-12

[3] Schwartz, MD. “The US primary care workforce and graduate medical education policy”. JAMA 2012 Dec5;208(21):2252-3.

[4] Kirch, DG. Transforming admissions: the gateway to medicine. JAMA 2012 Dec5;308(21):2250-1.

[5] Eva KW et al., “Association between a medical school admission process using the multiple min-interview and national licensing examination scores”. JAMA 2012; 308(21):2233-40.

[6] Traverso G and McMahon GT, “Residency training and international medical graduates: coming to America no more”, JAMA 2012; 308(21):2193-94.

[7] Rajput, V. “Not born in the USA”. JAMA 2012; 308(21):2197-98.

Health Workers and Our Wars

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This guest column is by Seiji Yamada, MD, a family physician, Associate Professor of Complementary and Alternative Medicine at the University of Hawai’i John A. Burns School of Medicine, and one of my mentors. This essay is an expansion of the one that was published in the AAMC journal Academic Medicine, chosen as one of the five best responses to the question put forth by editor Steven Kanter “How can academic medicine respond to peace-building efforts worldwide?”. Dr. Yamada’s original essay, “Academic medicine should start at home”, is at http://journals.lww.com/academicmedicine/Fulltext/2009/11000/Academic_Medicine_Should_Start_at_Home.18.aspx

Health Workers and Our Wars

What is the responsibility of American health workers with regard to our nation’s wars in Iraq, Afghanistan, and Pakistan? As Americans, our primary responsibility should be to influence the actions of our own government. As health workers, our expertise is in the realm of morbidity and mortality, encompassing the direct effects of violence as well as the indirect effects arising from the collapse of health services, poor access to water and food, and damage to infrastructure, economies, and societies. Thus, we should monitor our government’s actions, apply the scientific methods at our disposal, apply the moral and ethical principles to which we subscribe, formulate and recommend policy, and disseminate our findings to the people. In a democracy, the citizenry would then determine the course of action.

During this decade, our nation has been responsible for invading and occupying two countries halfway around the globe—Afghanistan since 2001 and Iraq since 2003. In the case of Iraq, the invasion of 2003 was preceded by comprehensive economic sanctions, which hampered the rebuilding of its infrastructure after the Gulf War of 1991. The consequences included childhood deaths, mental illness, juvenile delinquency, begging and prostitution, as well as cultural and scientific impoverishment.[1]

In 2002-03, the American people were not convinced by the Bush administration that war on Iraq was justified. However, despite massive demonstrations against the war prior to its launch, the intellectual classes, the corporate media, and our elected representatives went along with the administration. Democracy failed us in this respect. Prior to the war, we health workers should have been recounting the health toll of the First Gulf War and the sanctions regime. With its onset, we should have been disseminating the images and recounting the narratives of casualties of the war.[2] As it progressed, we should have been acutely interested in the number of casualties caused by the war. The best estimates for deaths among Iraqis are those of the July 2006 epidemiological survey that reported 655,000 deaths as a consequence of war.[3] This study did not distinguish among civilians, military, and irregular combatants. While its authors have been criticized for breaches in the non-identification of participants, the study is nevertheless considered the most accurate estimate.[4]

Insofar as we have failed to pay attention to such findings, American health workers have failed its constituents.

At the mention of history or political economy, many health workers groan. We are not interested in politics, they say. But unreflective citizens repeat the blather that they are fed by the corporate media. We need advocate for the cause of health—in particular for the health of those whose voices are otherwise unheard, whose deaths are otherwise uncounted, unmourned, unopposed, and unorganized against. In order to do so, our analysis must be geographically broad and historically deep, as Paul Farmer urges us.

As the United States pulls its troops out of Iraq and sends them to Afghanistan, as our military wields drones called Predator and Reaper in Pakistan, we should concern ourselves with whether the cause of peace is thereby served by such acts. Our commander-in-chief is apparently now reflecting upon whether to double down (again) in Afghanistan and pursue counterinsurgency, as urged upon him by his general in the theater.[5]

Apparently, “counterinsurgency” no longer connotes Vietnam or Central America.[6] But the “clear and hold” strategy utilized late in the Vietnam War was characterized by indiscriminate shelling and bombing of villages[7] and ran concurrently with the Phoenix program of torture and assassination.[8] Extrajudicial killings in the Federally Administered Tribal Areas of Pakistan are now being carried out by the CIA by missile attacks by drones, with the deaths of many innocents.[9] Of 701 people killed in 60 attacks in FATA between January 2008 and April 2009, fourteen were suspected militants.[10]

The British and the Soviets failed in their attempts to militarily control Afghanistan, while inflicting untold casualties on the populace. The Soviet Union’s invasion of Afghanistan proved to be its Vietnam. One would think that our own country would not repeat its mistakes in Vietnam, but our wars in Iraq and Afghanistan’s go on. As American health workers, we must concern ourselves with the morbidity and mortality caused by our own government’s actions. Let us get to work.

References

[1] Save the Children UK. Iraq sanctions: humanitarian implications and options for the future. Available at: (http://www.globalpolicy.org/component/content/article/170/41947.html). Accessed July 21, 2009
[2] Yamada S, Fawzi MC, Maskarinec GG, Farmer PE. Casualties: narrative and images of the war on Iraq. Int J Health Serv. 2006; 36(2):401-15
[3] Burnham G, Lafta R, Doocey S, Roberts L. Mortality after the 2003 invasion of Iraq: a cross-sectional cluster sample survey. Lancet 2006; 368: 1421–28.

[4] Tapp C, Burkle FM, Wilson K, et al. Iraq War mortality estimates. Conflict & Health 2008;2:1-13.

[5] Filkins D. Stanley McChrystal’s long war. New York Times Magazine, Oct 18, 2009.

[6] Parry R. Bush’s death squads. In These Times, Jan 17, 2005. Available at (http://www.inthesetimes.com/site/main/article/1872/). Accessed Jan 23, 2005.

[7] Steinglass M. Vietnam and victory. Boston Globe, Dec 18, 2005. Available at (http://www.boston.com/news/globe/ideas/articles/2005/12/18/vietnam_and_victory/). Accessed Sep 27, 2009.

[8] Chomsky N, Herman ES. The Washington connection and third world fascism. Boston, MA: South End Press, 1979.

[9] Mayer J. The predator war. New Yorker, Oct 26, 2009. Available at (http://www.newyorker.com/reporting/2009/10/26/091026fa_fact_mayer). Accessed Nov 15, 2009.

[10] Ahmad MI. Pakistan creates its own enemy. Le Monde Diplomatique. Nov 2009. Available at (http://mondediplo.com/2009/11/02pakistan). Accessed Nov 5, 2009.