The Medical Education Futures Study Blog

In 1954, Darrell Huff wrote a book entitled, “How to Lie with Statistics” which suggests the way statistical analyses are chosen and presented can bend the truth.  This month’s Health Affairs web exclusive suggests we could all use a review of this lesson.

On Dec. 4, Health Affairs released a package of web exclusives - a sort of point-counterpoint examining the relationship between physician supply, workforce composition and health care quality.  Buz Cooper’s article: States with More Physicians Have Better Quality of Health.  Baiker and Chandra’s response: Cooper’s Analysis is Incorrect.

For the non-statistician, Baiker and Chandra’s arguments are at times confusing and Cooper’s graphics appear compelling.  Cooper finds that states with more physicians per capita generally rank higher in state health care quality rankings.  He also finds that states with more specialists are associated with higher state incomes per capita. 

But, does this mean that more specialists result in better quality (Figure A) or does it mean that higher income results in better quality and incidentally more specialists (Figure B)?  Where is the true causal relationship?  Are more specialists only a representation of higher income and otherwise unrelated to quality?

In this case, income might be considered a “confounding factor” – in other words, income is related to both quality and the number of specialists, and the failure to control for income in the analysis may lead to an inaccurate conclusion that more specialists equals better quality.  These are hypothetical arguments.  I have not done the analysis either to support or negate Cooper’s arguments.  However, Baiker and Chandra find that when they compare areas with the same number of total physicians, areas with higher generalist to specialist ratios have better quality and lower costs.

State by state a health care service crisis has emerged. There are not enough primary care physicians to care for the people in our communities. Providing health insurance to all will not address the problem. Insurance will not suffice when there are not enough primary care physicians to provide the needed care.

The short supply of primary care physicians has been caused by a long term decline in the numbers of students choosing careers in primary care. The primary care specialties of Family Medicine, general Internal Medicine and general Pediatrics have each experienced a decline. The deans of most medical school hide this issue by telling the public that they graduate sufficient numbers of graduates to the primary care specialties. By counting all students who choose careers in Family Medicine, Internal Medicine and Pediatrics (some even include students choosing OB/GYN) to their primary care head count, the deans and the organizations that represent them have misled the public.

For decades, a growing percentage of those entering Internal Medicine and Pediatric residency programs have added fellowship training to their preparation so they can practice in a sub-specialty field when they enter practice. Currently, only 10% of those choosing Internal Medicine residency training will practice as a primary care physician. In Pediatrics 65% of the graduates of a residency programs will practice in primary care

The deans respond to their critics by claiming that they are not responsible for the choices of their graduates. They argue that it is the marketplace and not the medical school that is responsible. Their graduates choose sub-specialties because they will earn a substantially higher income as a sub-specialist.

No doubt the marketplace plays a role but so do the deans and the leadership of their medical schools. At a recent meeting of the Society of Teachers of Family Medicine: NorthEast Region in Baltimore, MD, a series of speakers addressed these issues. Representatives from Jefferson Medical Center, Boston University, the National Association of Community Health Centers and others provided a compelling response to the deans. In sum their data indicates that when a medical school creates a program that selects and supports students with an interest in primary care and practice in a rural community, substantial numbers of graduates will choose to practice in primary care following their residency training. This approach has been demonstrated in a number of medical schools across the country.

The deans wish to attract the best and brightest students to their schools. The problem is how they measure the students’ suitability and the people they choose to rank the candidates. High grade scores and high MCAT scores are insufficient measures of future performance. In addition, a selection process overwhelmingly dominated by basic science and sub-specialty faculty members is also problematic. The first principle of selection is that people have a strong tendency to pick candidates who “look like” themselves. If you want to select a pool of students who will later choose sub-specialist careers, ask a group of sub-specialists to interview and rank the candidates.

It is time for the deans to take responsibility for who they select as students and how they support their students’ career development. The programs that select students who are likely to practice as primary care physicians actually deliver the goods. Every medical school is capable of producing the students needed to serve through careers in primary care and as future physician investigators.

Given the deans efforts to increase their class sizes it would make sense that they designate a portion of the growth to a program that selects and supports students interested in primary care. It’s time to stop pretending they have no options. The deans can satisfy both their inner yearnings to produce sub-specialists and physician investigators and the public’s need for physicians who will care for the people. Acting as though this is an either/or issue when it is a both/and issue, reveals a lack of imagination. Our medical schools can do better.

Laurence Bauer, MSW, MEd is Chief Executive Officer of the Family Medicine Education Consortium (www.fmec.net) a not-for profit organization that supports the growth of academic family medicine in the northeast region of the US. He can be contacted at laurence.bauer@sbcglobal.net

Yesterday the House passed HR 2583 which would provide loans to hospitals to establish residency training programs with a preference for family medicine, internal medicine, emergency medicine, OB-gyn, and general surgery programs.  The loans would also favor hospitals in rural areas or small cities.

I applaud this action.  Developing a thoughtful physician workforce will be a critical component to a cost-effective quality health care system for all Americans.  However, this new piece of legislation adds urgency to the need to also address the other factors that contribute to how the physician workforce develops - namely, physician payment systems and medical school policies and programs.

The trend is for medical students to increasingly choose specialties over primary care.  Adding more primary care residency positions to the current system of graduate medical education (GME) without addressing the market forces and medical school factors that influence student choices, at best, will not fix the problem.  At worst, it will exacerbate the problem.

GME is largely funded by the federal government through Medicare payments to teaching hospitals.  However, teaching hospitals currently determine their residency compliments with no guidelines.  The last major legislation affecting Medicare GME came with the 1997 Balanced Budget Act which capped the total number of residents that existing teaching hospitals could receive Medicare payments for.  Again, no requirements were set for the types of residents trained and increasingly those limited residency program positions have been converted from primary care to specialty positions.

Some of this shift is due to hospitals choosing the more lucrative specialties over the primary care specialties.  But medical students are making the same choices and when there aren’t enough students to fill the primary care residency positions available, hospitals will eventually cut those positions.  Without addressing the factors that are influencing student choices, adding more primary care positions in the current GME system will only shift the few students choosing primary care into different residency programs while the positions they vacate are slowly converted into specialty positions paid for by Medicare.

HR 2583 is a step in the right direction.  But it’s only step 1 and to build the physician workforce needed by Americans, the market forces pulling physicians to specialty practices need to be fixed and medical school programs to promote primary care need to be expanded.

In the past week, both the House Ways and Means Subcommittee on Health and the Senate Finance Committee have held hearings to examine the Medicare physician payment system. Both hearings quickly evolved to discuss:

Source: JAMA Annual Graduate Medical Education data

1. The pending primary care crisis – medical students are increasingly choosing medical subspecialties over primary care.

2. Primary care’s role in developing a more cost-effective quality health care system – analysis of Medicare claims indicates regional differences in Medicare spending.  Higher spending regions are largely explained by more specialty-oriented practice but have no increase in quality or access to care (Goodman, 2003).

But what about the presidential candidates? In her Sept. 16 Good Morning America interview, former candidate Hillary Clinton encourages Americans to re-focus on the issues and she tells us from her experiences traveling America, “concerns about healthcare, that’s what’s on the minds of Americans.”  But if primary care is a key leg to cost-effective quality health care for all Americans, what do Barack Obama and John McCain’s health plans say about primary care?

The answer is – not much. Barack Obama at least recognizes the problem and the need to address it.

WORKFORCE. Primary care providers and public health practitioners have and will continue to lead efforts to protect and promote the nation’s health. Yet, the numbers of both are dwindling, and the existing workforce is further challenged by inadequate training about new health threats such as bioterrorism and avian flu, antiquated funding and reimbursement mechanisms, and limited access to real-time information and technical support. Barack Obama and Joe Biden will expand funding—including loan repayment, adequate reimbursement, grants for training curricula, and infrastructure support to improve working conditions— to ensure a strong workforce that will champion prevention and public health activities (excerpt from Obama/Biden Health Plan).

John McCain’s plan never mentions it.