The Medical Education Futures Study Blog

Last month I wrote about our country’s specialty focused culture and last week as I listened to a medical student describe his cardiology rotation - how the cardiologist showed off his tools as if they were toys – and I watched as the medical student’s eyes lit up describing his experience, I realized it’s time to write about the specialty culture of medical education.  And while it would be easy to write about how medical schools and teaching hospitals, due to funding streams and priorities, have created a specialty focused culture in which medical students are subjected to comments like, “You’re too smart to go into primary care,” I’d like to talk about the need for primary care doctors to do a better job marketing themselves.

First, I’d like to address the issue of being “too smart to go into primary care.”  To get at this issue, I think it’s worthwhile to examine why physicians spend so long in training and studying things like pathophysiology or pharmacology.  Ultimately, what this training does is build brain power.  The most difficult thing that a physician does is to take a constellation of patients’ symptoms, ask the critical questions, order the key tests to figure out what the problem is and treat the patient using the best interventions.  This is at the core of a primary care physician’s job.  Procedures can be done by technicians, but accurate diagnosis and appropriate treatment are the most important and difficult parts of any physician’s job.

The second piece at the core of being a primary care physician is relationships.  Patients benefit from this relationship by receiving more consistent, coordinated and preventative care.  But as physicians, we also benefit.  Patients allow us into their lives, into their families, and whether we experience moments of heartbreak or moments of joy, it’s a privilege and a rare opportunity in society.  As a pediatrician, I look at children, remember when I held them as babies and can’t believe that they’re telling me about what they’re doing in school.  I get to share in the joy of my teenagers when they talk about which colleges they’re interested in.  And sometimes, all I can do is put my arm around a parent when I have bad news for them and assure them that we’ll move forward as partners.

Brain power and relationships – this is what being a primary care doctor is all about.  And this is what we need to help medical students see and understand.  As I mentioned last month, there are a number of factors that affect medical students’ career decisions – payment, practice, culture – but if we can do a better job showing medical students the joys of primary care, then we will be better poised to take advantage of other reforms.  And ultimately we’ll get the brightest and most compassionate students entering primary care.

The total number of PGY-1 residency positions offered and filled increased again this year, with 400 (1.9%) more PGY-1 positions filled.  However, despite a promising increase in family medicine position filled last year, the number of positions offered and filled is down again this year - 100 fewer positions were offered and there were 75 fewer positions filled (Figure).

Figure. Results of the NRMP, 1997-2009, for Family Medicine Positions Offered and Filled (Source: AAFP)

The number of internal medicine and pediatric positions offered and filled rose incrementally, but increases in these PGY-1 positions will not necessarily equate to more primary care as more and more of these residents are choosing to further specialize after their initial “primary care” residencies.

Congress is increasingly recognizing the physician workforce and medical student specialty choices as critical components to developing a health care system in the U.S. that is equitable, accessible and cost-effective.  But the 2009 Match is another step in the wrong direction and hopefully it sends a message.  The time to act is now.  

While much of the primary care stimulus funding was cut out in the Senate version of the Stimulus package, it was restored in a modified form in conference and signed into law by President Obama on February 17.  The final law gives a significant boost to community health centers - $500 million for services provided at CHCs and $1.5 billion for construction, renovation, equipment, and health information technology systems - and to the National Health Service Corps - $300 million for recruitment and field activities.  Primary care training funding received a modest boost of $200 million for Title VII and Title VIII of the Public Health Service Act and grants to training programs for equipment.

While increased support for CHCs and the NHSC are critical steps towards increasing care and access to underserved / uninsured communities, the relative levels of funding for these programs in comparison to the funding levels of the primary care training programs indicates a denial of what is and will be a core problem in providing health care to these communities and the nation.  Ultimately the question is - who will provide the health care that is funded through these programs?

CHCs and the NHSC rely heavily on primary care physicians to staff health centers and provide care in underserved areas.  But primary care is in crisis.  Medical students are entering primary care fields at all time low rates.  Yet the National Association of Community Health Centers (NACHC) report health centers currently need over 1,843 primary care providers and if they are to increase their reach, they will need over 15,000 additional primary care providers by 2015.

Solving the primary care problem in the U.S. will require changes in the physician payment system to reduce the income gap between primary care and specialist physicians and changes in the physician practice to maximize evidence based, quality care.  However, changes also need to happen in the primary care pipeline to ensure future medical students will choose to enter primary care fields and be ready to practice in the changing health system.  Many factors have been shown to promote primary care field choices - such as recruitment of students who intend to practice primary care, positive primary care experiences during medical school and strong primary care faculty - all of which are currently supported by Title VII grants.

Change needs to happen across the spectrum of the physician workforce - from practice and payment to recruitment and education.  It’s time to prioritize this issue and recognize the quick fix of funding CHCs and NHSC, without building the primary care workforce, will only lead to a future collapse of the system… to bright shiny health centers without the people to provide the health care within.

In the past I’ve written about what government and the presidential candidates are doing in terms of developing a health care workforce to meet the needs of the nation.  This week the Macy Foundation convened a working group to look at medical education’s role in this critical health care issue during this period of medical school expansion.  Participants included medical school deans and leaders from the Association of American Medical Colleges, the American Association of Colleges of Osteopathic Medicine and the Association of Academic Health Centers.

I sat in on this meeting as an observer and I was reassured to know that medical education leadership is taking on this issue seriously, recognizing the opportunity to shape America’s future physician workforce.  I was also impressed at the level of consensus on the responsibility of medical education to produce not only quality physicians, but physicians that meet the social mission of medical education - that is the production of a diverse workforce equitably distributed both geographically and across medical specialties.

The working group’s recommendations included:

1. Re-evaluating increasingly arcane admission policies in order to align those policies with factors that truly correlate with the desired characteristics of future physicians (another issue recently discussed on the MEFS blog).
2. Evaluating the full effect of student debt on medical education’s mission and working to substantially reduce debt as a barrier to the mission.
3. Promoting educational innovations such as moving away from traditional 2+2 year models, increasing longitudinal clinical training, evaluating new sites for clinical education, and promoting inter-professional team models.
4. Calling on foundations and government to support innovation and the social mission both at the education level and at the national workforce level, specifically calling on the federal government to expand the Title VII and the National Health Service Corps and to develop a national institute for health workforce research and policy.

Last week the Medicare Payment Advisory Commission (MedPAC) held a panel discussion on medical education’s role in training physicians for the 21st century.  Thomas Dean, a family practitioner and MedPAC commissioner, noted that minorities and individuals from rural areas have a greater likelihood of returning to and serving those communities after their medical training and stressed the need to recruit more primary care doctors and doctors interested in practicing in rural areas.  Also last week, the Urban Institute held a forum on Medical Homelessness and the Role of the Academic Medical Center.  The panelists emphasized the need for greater numbers of and value on primary care physicians, and that a robust primary care workforce is critical to the success of the medical home model.

When asked for solutions to address the impact of who is admitted to medical school, the panelists stressed the importance of incentivizing family practice and sending a clearer message that primary care doctors are valued.  While these are necessary fixes to the current problem, they do not constitute the whole of what needs to be done.  Medical schools play a pivotal and influential role as well.

Two clear messages emerged from the recent briefings.  One, primary care and rural medicine are in great need of attention.  Two, now is the time to examine how we can address these issues at the undergraduate and graduate medical education level, specifically at the point of admission.

Robert Bowman of A T Still School of Osteopathic Medicine pointed out in a recent blog discussion that the MCAT fails to predict who will perform better or worse in medical school and that greater attention needs to be paid to more comprehensive admissions processes.  Innovative programs give hope that there are solutions to this dilemma. The Northern Ontario School of Medicine (NOSM), established in 2005, is committed to engaging the surrounding communities in the education process, and medical students spend time studying in Aboriginal, small rural as well as larger urban communities.  Furthermore, their admissions requirements part from the traditional model – they do not require the MCAT and they aim for a class profile that reflects the demographics of the Northern Ontario population.  Sophie Davis is a U.S. school with another innovative model – they offer a combined BS/MD degree, recruit from underserved areas and they also have no MCAT requirement.

With the recent forums and briefings, it is encouraging to see attention being paid to these important issues facing the health care system, primary care and rural medicine.  But attention is not enough – now is the time for action and change in undergraduate and graduate medical education.  True, admissions processes have been successful in selecting and producing top quality physicians for our nation’s workforce for decades.  But as Robert Sternberg recently pointed out in a recent article in Academic Medicine, U.S. medical school admissions methods are archaic.  The dearth of primary care physicians and the large numbers of medically underserved areas are issues quickly gaining attention in the public and with legislators.  While payment reform and a shift in values are important first steps, it is time to update school admissions policies to produce the physicians needed for the 21st century.