The social mission of medical education: Admit different students

In his JAMA “Viewpoint” article, “Social Mission in Health Professions Education: Beyond Flexner”,[1] June 17, 2017, Fitzhugh Mullan makes a convincing case for medical schools to be committed to their social mission. He takes his definition from the “Beyond Flexner” website (www.beyondflexner.org), which says “Social mission is about making health not only better but fairer—more just, reliable, and universal”. He details what this means in terms of commitment to reducing health disparities, increasing access to healthcare in both rural and urban underserved communities, increasing diversity within the health professions. These serious issues have been identified for decades, but in fact the trend may be toward getting worse instead of better.

Mullan cites some examples of medical schools, primarily newer and “community based” schools, that are working toward these goals. These include Morehouse and Mercer (founded in an earlier wave of medical school expansion in 1975 and 1982 respectively), those of a more recent expansion in the 2000s (Florida International University and the AT Still Mesa Campus), and those yet to come (the merger of Geisinger Health System and Commonwealth University, Kaiser Permanente School). But he also talks about “mainstreaming”, the need for consciousness about, and implementation of, social mission to be a characteristic of all medical schools.

I believe that the most important measures of a health professions school’s social mission are its outputs. Using the 3 criteria identified by Mullan and colleagues in their seminal 2010 Annals of Internal Medicine article “The social mission of medical education: ranking the schools”,[2] we need to look at whether its graduates are more diverse, whether they practice in underserved areas, and whether they are more likely to be in primary care specialties. The 2010 article showed that some schools do better -- more often those that are public, newer, and not in the Northeast -- but the fact is that none is doing all that well.

The number of students entering primary care is a critical indicator because, based on national and international comparisons, a well-functioning health system should have 40-50% of physicians should be in primary care; the US is well below 30% and going down. Family medicine match rates are the most sensitive indicators of primary care production, because unlike internal medicine virtually all family physicians practice primary care, so a choice of this specialty means a commitment to primary care. In addition, it is the specialty most suited for practice in rural areas. Even if all schools consistently produced 50% primary care physicians, it would take at least a generation to get to that number for all physicians in practice, and we are far, far from this.

In 2012 John Delzell and I looked at 10 years of data (2002-2011) published annually on the family medicine match by the American Academy of Family Physicians (AAFP) documenting the number and percent of students from each medical school entering family medicine.[3] We found only a few schools that were relatively high in both number and percent, with the University of Minnesota and the University of Kansas far ahead of the rest. And yet even those schools do not produce primary care physicians at the 50% rate. In the most recent AAFP report, on 2015 graduates,[4] even the “socially conscious” schools cited by Mullan did not have very high numbers matching in family medicine:  Morehouse 8 (12.9%), Mercer 13 (13.8%), FIU 4 (5%). Minnesota, at 42 (18.2%) had the largest number in the nation, but still had 20 fewer than it did in 1999! In 1994, the Association of American Medical Colleges (AAMC) announced Project 3000 by 2000, aiming for 3000 minority medical students into US schools by the year 2000[5]. It failed. Today, in 2016-17, we are not only far from that number, but the percent of many minorities (especially African-American men) continues to drop.[6]

As in any process, the results of medical (and all health professions) education are affected by 3 sets of variables. Input variables are the students enrolled, process variables include the curriculum and overall experience of students during their education, and output variables are the expectations of what the income and life experience of a graduate is likely to be. While the last is probably the most important determinant, especially given the degree of debt with which students are graduating and the fact that many specialists can earn 2-3 (or more) times as much as a primary care physician, it is also the area that schools have the least ability to influence. As Mullan and colleagues have emphasized, medical schools can influence the process variables, including the school’s vision and mission, the teaching of social mission, determinants of health, disparities, and other areas in their classrooms and clinics, experiences for students to serve such as free clinics, and mentoring and role modeling by faculty. However, making these changes seem to be insufficient to overcome the negative influence of the output variables in terms of students choosing primary care and practice in underserved areas. At least for most of the students currently in medical school.

Which brings us to the input variable: who is admitted? Clearly, from the data cited above, medical schools are not taking appreciable numbers of students from underrepresented minority groups, from rural areas, or from lower socioeconomic groups, at least not in anything close to the proportion in the population. They take, on the whole, white (and Asian) students from well-to-do suburbs of large cities who, not coincidentally, went to the “best” public and private schools and have the highest grades and Medical College Admissions Test (MCAT) scores. The problem for the health of the American people is that the strongest predictor of where a medical student will practice is where they come from; minority students are far more likely to practice in minority neighborhoods, rural students are far more likely to practice in rural areas, and white upper middle class students from the suburbs are more likely to practice in the suburbs. These are the areas that already have enough physicians (and sometimes too many). In a real sense, a physician who enters practice in a non-underserved area in a non-shortage specialty is contributing little marginal benefit to the health of the American people. The imbalance of physicians practicing in health professions shortage areas (HPSAs) vs other areas is demonstrated in the attached table from Zhang, et al.[7]

Yes, our society must urgently address the “output variables” to ensure that students who choose primary care can earn a reasonable proportion of what other specialists do (some studies indicate that 70% of mean specialist income would be sufficient to eliminate that as a reason for not choosing primary care). Indeed, medical schools need to address the “process variables” by having explicit curricula on health disparities, social determinants of health, and community and preventive health, and ensure there is not a “hidden curriculum” mitigating against primary care. But they also urgently need to ensure that most of their admissions, not a token number, are students whose characteristics mean they are more likely to meet America’s healthcare needs. These include demographic characteristics, such as rural or minority origin and lower socioeconomic status of their family, and individual characteristics identified by past performance (not sentiments in an essay). This is primarily significant volunteer service, especially major commitments like the Peace Corps, Americorps, Teach for America, etc.

And, most importantly, these changes and programs must happen at all medical schools and for the bulk of the classes. The time for experiments and pilot programs is done. These efforts must be scaled up, to be, in Mullan’s word, “mainstreamed”. And now is not too soon.

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[1] Mullan, F, Social Mission in Health Professions Education: Beyond Flexner, JAMA published online June 26, 2017. doi:10.1001/jama.2017.7286

[2] Mullan  F, Chen  C, Petterson  S, Kolsky  G, Spagnola  M.  The social mission of medical education: ranking the schools.  Ann Intern Med. 2010;152(12):804-811

[3]  Freeman J, Delzell J, Medical School Graduates Entering Family Medicine: Increasing the Overall Number, Fam Med 2012;44(9):613-4.

[4] Kozakowski S, Travis A, Bentley A, Fetter G, Entry of US Medical School Graduates Into Family Medicine Residencies: 2015–2016, Fam Med 2016;48(9):688-95, (online Table A).

[5] Nickens HW, Ready TP, Petersdorf RG, Project 3000 by 2000 -- Racial and Ethnic Diversity in U.S. Medical School, N Engl J Med 1994; 331:472-476August 18, 1994DOI: 10.1056/NEJM199408183310712

[6] https://www.aamc.org/data/facts/

[7] Zhang X, Phillips RL, Bazemore AW, Dodoo MS, Petterson SM, Xierall I, Green LA, Physician Distribution and Access: Workforce Priorities, Am Fam Physician. 2008 May 15;77(10):1378.

Helping primary care help the health of all of us

I recently described how primary care can improve the health of our population – proven by dozens of studies – as well as save significant money.  Recently, the distinguished family physician George Rust, MD, co-director of the National Center for Primary Care at Morehouse School of Medicine in Atlanta, made many of the same points in his testimony in front of the Senate HELP Committee’s Subcommittee on Primary Health and Aging (Dr. Rust is pictured here with Subcommittee Chair Sen. Bernie Sanders, I-VT). Rust specifically asked for significantly increased funding for Title VII and Title VIII, the sections of the Public Health Service law that provide grant funding for, respectively, primary care medicine and nursing programs, saying that they would represent "solid investments in the primary care workforce."

Rust also called for separating the funding for residency training provided by Medicare for primary care from hospital training of subspecialists, arguing that the current system has resulted in  "absurd proportions of subspecialists and hospitalists." I have often argued this (for example in GME funding must be targeted to Primary Care, December 10, 2011), noting that hospitals have an interest in training specialists and subspecialists who do things (usually procedures, given our current reimbursement system) that make money for hospitals, and much less for training the primary care doctors that are needed in the community. The problem is that, because academic medical centers provide a great deal of tertiary (and quarternary) care, the mix of primary care and subspecialist and super-subspecialists may be appropriate there, but not for the overall community. However, since these are the places where new physicians are minted and trained, providing the right mix for the community, for the rest of the state and country, means having a very different mix of specialists in training from those working there. This is hard; it is a very common reaction to want to replicate yourself, to want the “best” students to enter training in your specialty, so for an academic medical center which looks like the upside-down pyramid to train doctors in proportion to the right-side-up pyramid is a major challenge! Rust then suggests moving primary care training “back to its community roots”, and says "Instead, let's create direct, sustainable funding for community-based outpatient residency programs that train doctors to keep people out of the hospital”.

As strong as Dr. Rust’s arguments are, primary care will still have problems. One of the comments on the posting at the “AAFP News Brief” that covered this testimony  said “I must be missing something. Can anyone explain how creating more residency slots will increase med student interest in family medicine?” I believe that this is an excellent point – if we cannot fill the slots that exist today for family medicine, particularly with excellent medical students, how will increasing the number of slots improve things? One of the answers, certainly involves reimbursement, dramatically decreasing the difference between what primary care doctors earn and what more highly-paid subspecialists earn; work by the Altarum Institute cited by Jerry Kruse, MD MSPH in his article “Income Ratio and Medical Student Specialty Choice: The Primary Importance of the Ratio of Mean Primary Care Physician Income to Mean Consulting Specialist Income”, suggest that the ratio should be about 80%.

However, there are other factors at work. Sometimes they are referred to as “lifestyle” (perhaps defined as hours of work needed to generate a certain income, or what I have called the income/work hours ratio) but they are more profound than that. In the May/June issue of the Annals of Family Medicine, Christine Sinsky and her colleagues refer to it as “the joy of practice”. “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices” [1] identifies the “deep dissatisfaction” experienced by primary care physicians who care for adults (general internists and family physicians) demonstrated by the many reports of high “burnout” rates. The authors relate this to the extraordinary amount of time that physicians spend doing paperwork and administrative functions, and the pressure by employers to generate high numbers of visits; doctors experience this as alienating and not the reason that they became physicians.

“We propose joy in practice as a deliberately provocative concept to describe what we believe is missing in the physician experience of primary care. The concept of physician satisfaction suggests innovations that are limited to tweaking compensation or panel size. If, however, as the literature suggests, physicians seek out the arduous field of medicine, and primary care in particular, as a calling because of their desire to create healing relationships with patients, then interventions must go far deeper. Joy in practice implies a fundamental redesign of the medical encounter to restore the healing relationship of patients with their physicians and health care systems. Joy in practice includes a high level of physician work life satisfaction, a low level of burnout, and a feeling that medical practice is fulfilling.”

The authors go on to list a number of common problems, and solutions that have been found by one or more of the 23 practices that they visited and analyzed in detail. They included:

·       Reducing work through pre-visit planning and pre-appointment laboratory tests;

·        Adding capacity by sharing the care among the team;

·         Eliminating time-consuming documentation through in-visit scribing and assistant order entry;

·         Saving time by re-engineering prescription renewal work out of the practice;

·         Reducing unnecessary physician work through in-box management;

·         Improving team communication through co-location, huddles and team meetings;

·         Improving team functioning through systems planning and workflow mapping.

These are all good ideas, and the solutions are sometimes creative, sometimes painfully obvious, and sometimes obstructed by our bizarre health system. One of my favorites, the second, is an example of the latter:

“We observed that team development must often overcome an anti–team culture. Institutional policies (only the doctor can perform order entry), regulatory constraints (only the physician can sign paperwork for hearing aid batteries, meals delivery, or durable medical equipment), technology limitations (electronic health record work flows are designed around physician data entry), and payment policies that only reimburse physician activity constrain teams in their efforts to share the care. An extended care team of a social worker, nutritionist, and pharmacist may be affordable only in practices with external funding or global budgeting.”

Thus is illustrated the tie-in between innovations that can make practice again joyful and the payment reform and re-working of our entire non-system which we desperately need! There is a long way to go; as the authors point out, no single practice has solved every problem. But the linkage is clear – a medical care system designed to reward expensive interventions for a relatively small number of people has created an inappropriate mixture of physicians as well as an incentive for hospitals to focus mainly on such procedures, as it has increased the burden on, and in many cases taken the joy out of, being a primary care physician. It is important to remember that it is not just about the doctors (I try to remind my students and residents, precious as each of them are to themselves and their families and often to me, that ultimately it is not about them). The authors put it this way:

“The current practice model in primary care is unsustainable. We question why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training. Likewise, we question whether patients benefit when their physicians spend most of their work effort on such tasks. Primary care physician burnout threatens the quality of patient care, access, and cost-containment within the US health care system.”

Both the macro-structural changes in the structure of the system as identified by Dr. Rust and the more micro-level changes in the practices of primary care clinicians identified by Dr. Sinsky and colleagues need to occur to make us have a sustainable, healthful, system of health care. And they need to happen soon.

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[1] Sinsky, C, et al.,, “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices”, Ann Fam Med May/June 2013 vol. 11 no. 3 272-278, doi: 10.1370/afm.1531