Tuesday, November 20, 2012

Recipe for a vital primary care workforce

Thanksgiving is just around the corner, and so it seems appropriate to share a recipe:

Recipe for a vital primary care workforce

1. Accept more students into medical schools who are likely to choose primary care.
2. Validate medical students' interest in primary care.
3. Provide adequate Family Medicine and General Internal Medicine training opportunities.
4. Enact meaningful payment reform.

Now, a sub-par cook such as myself needs a little more detail than just the basics to pull off such a complicated recipe...

1. Accept more students into medical schools who are likely to choose primary care.

Studies show that medical students who choose primary care are more likely to:
    Live in a rural area and/or plan to return to work in a rural area (1)
    Live in a disadvantaged area and/or plan to work in a disadvantaged area (2)
    Have grown up in a low or middle socioeconomic neighborhood (1,2)
    Not plan a research career* (1)
    Believe primary care is important and plan to practice primary care (1,4)
    Be indifferent about earning a high income after residency (1)
    Be female, older, and/or married (3)

2. Validate medical students' interest in primary care.

It's not enough to accept the right students into medical school; schools must also support interest in primary care.  Here's what's been proven to increase the number of grads choosing primary care careers:
    Increase mandatory rotation time in Family Medicine and General Internal Medicine. (2)
    Rotate at two or more Family Medicine sites. (4)
    Require a longitudinal primary care experience.  (3)
    Expose students regularly to academically credible FM/GIM faculty. (3)

3. Provide adequate FM and GIM training opportunities.

Medical school graduate numbers are increasing as new schools open and existing schools expand their class size, but there are not enough residency slots for all of them. Some estimate that we will need 52,000 new primary care doctors by 2025, largely thanks to the Affordable Care Act, (6) and our capacity to train them is lacking.  Additionally, few Internal Medicine residency graduates are practicing primary care these days, so the bulk of those 52,000 will likely need to be Family Medicine docs.  Unfortunately, Family Medicine residencies are not growing in numbers and capacity but are instead closing at an alarming rate. (5)

One of the local health systems here closed a Family Medicine residency program to "rebalance" their budget and workforce needs.  Those GME slots are going to a vascular surgery residency.  Local pressures are leading health systems to make short-sighted choices about what kind of medical specialities we are training our future physician workforce for.

4. Enact meaningful payment reform.

Payors devalue primary care by paying more for procedures and specialist care than for comprehensive, preventive primary care.  Case in point - our residency program practice earns about twice as much for doing a circumcision (a simple procedure that takes about 10 minutes) than for admitting a patient with complicated problems to the hospital.  We earn more for snipping off a skin tag than providing 45 minutes of direct patient counseling about chronic disease.  

The current "Medicare physician payment formula...rewards volume over quality and that discourages growth of primary care." (7)  Systems produce what they are designed to produce, and right now our payment system disincentivizes primary care by better rewarding procedures and specialists. Unnecessarily expensive care does not produce better patient outcomes, and it certainly won't help the US balance its bloated budget. (8)

Shifting our nation's health emphasis back to quality primary care will take deliberate effort by many parties.  I would argue, however, that the payoff will be more than worth it.  US counties with more primary care docs have lower health costs and longer life expectancies compared to counties with a heavier emphasis on specialists. (9) Yes, we need our specialist colleagues.  

But I'd argue, at this point in US history, that we need Family Medicine more.

1 http://www.ncbi.nlm.nih.gov/pubmed/1985676
2 http://www.ncbi.nlm.nih.gov/pubmed/14963077
*  Not to say that research in primary care isn't vitally important...just citing the studies.
3 http://www.ncbi.nlm.nih.gov/pubmed/7612128
4 http://www.ncbi.nlm.nih.gov/pubmed/15057616
5 http://www.ncbi.nlm.nih.gov/pubmed/14603401, http://www.ncbi.nlm.nih.gov/pubmed/1544533
6 http://www.thefiscaltimes.com/Articles/2012/11/19/Wanted-52000-More-Primary-Doctors-by-2025.aspx#page1
7 http://www.aafp.org/online/en/home/publications/news/news-now/government-medicine/20121107electionresults.html, http://www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/twentiethreport.pdf
8 http://www.jsonline.com/business/looming-primary-care-shortage-starts-with-med-school-to39lu9-134971463.html
9 http://bostonreview.net/BR30.6/starfield.php

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