I was in a meeting today of the Alabama Family Practice Rural Health Board. Their primary charge is to improve health delivery in Alabama by targeting resources to improve health manpower, specifically by increasing the number of Family Physicians in rural Alabama. The conversation soon turned to Elba, Alabama. Elba was founded as a ferry crossing site on the Pea River. Health care delivery in Elba has been problematic at least since the turn of the last century. From the Elba website:
The story of “Little Noah Tucker” is one of the most often remembered and retold. Eleanor Talbot Tucker and her husband Ed Tucker became the parents of Noah at the Elba Hotel during the flood. The mother had to be moved from room to room during the birthing because room after room crumbled and fell into the swift water currents. The baby was named Noah since he lived through the flood like the biblical Noah.
While things may never get that bad again, there are problems on the horizon
The Board of Directors of the Health Care Authority of Elba, Alabama has announced that Elba General Hospital will close its Emergency Room and discontinue accepting new inpatients as of January 31, 2013. Officials say they’re working with area hospitals to transfer any patients who will need continued hospitalization.
The hospital completed a renovation exactly one year ago. The nearest hospital is appoximately 17 miles away.
The conversation at the meeting was about the closure and the story not told.
Rural hospitals are in trouble under the best of circumstances. The hospital in Elba provided limited services so many prospective patients did not even stop there, electing to go to Andalusia or Enterprise which provided a more comprehensive range of services. This had been going on for a while so was likely not the proximate cause. The reimbursement in Alabama is done in such a way that Critical Access designation, a lifeline for many rural hospitals in other state, is not a viable option for many hospital in Alabama. The fact that this hospital was less than 35 miles from its competitors may have precluded this option but, again, not a new problem
The death knell for this particular hospital was an older medical staff, unexpected illnesses, and no one in the pipeline set to return to Elba and practice Family Medicine, or any specialty for that matter.
The Office for Family Health, Education, and Research at the University of Alabama Birmingham, Huntsville Campus has just published an amazing study. They plotted out every rural Alabamian and every primary care doctor (87% are Family Docs). This report finds flaws in the current “pipeline” way of thinking, flaws that are exemplified by the situation in Elba. The report offers the following solution:
Its goal must be, at a minimum, to admit rural pipeline and BMSA awarded students to in-state family medicine residencies (Henderson et.al. 2003) and, during residency, promote resident/rural community relationships. Within the infrastructure of Alabama’s medical schools and current primary care pipeline initiatives, there is the potential to increase medical student selection of in-state family medicine residencies. However, there is no established method for directing graduated residents to rural communities other than the BMSA’s requirement of serving in an underserved community of less than 50,000 people and independent private based enterprises.
Nick Saban would never allow Alabama high schools to drop football in all but the largest cities. He knows that talent needs to be developed in many settings. The majority of medical students in state schools are from Jefferson, Mobile, and Madison Counties. The majority of Alabamians do not live in these counties. The pipeline has to start and end in the community.
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February 4, 2013 at 3:21 am
Robert C. Bowman, M.D.
Finally, someone who can do simple math. Rural pipelines, which I once promoted, are not the specific solution that can resolve massive and growing health access deficits. The only time that pipelines may have worked is 1965 – 1980 when health policy support was much better and made almost any health access intervention work. Since 1980 the pipelines have been dismal failures.
Studies only show rural origin plus family medicine as reasonable for significant rural workforce result. Rural origin is down to 6% of entering physicians and family medicine is about 8% in medical schools “serving” the 30 states that need rural workforce. Rural pipelines involve too few in number in a track, are too dilute in family medicine result, are not restricted to instate practice locations, have low rural location rates, and the result is diluted by increases in highest income, most urban children of professionals who dominate admissions ever more..
Nationwide the urban origin physicians are 8% rural in location and rural origin physicians are 18% rural. This may seem like a help, but the fact is that still 82% of rural origin physicians are found in urban areas. A few percentage points is not much help.
Rural origin plus FM is good for about 40% with Native American plus FM at 50% rural. Predominantly black county origin physicians are 25% found in predominantly black counties and this is over 44% when the career choices is FM.
Logistic regression controlling for origins and training indicates FM choice is a 3.3 times multiplier for rural locations and also for 30,000 zip codes with 200 million Americans left behind by design.
Rural origin matters little for physician career choices other than in family medicine as the choice to specialize or choose IM or PD results in a very limited distribution with 75% to 92% found in 3400 zip codes with higher to highest physician concentrations.
Rural origin specialists are found in rural areas – but the preferred locations are zip codes with 150 or more physicians. Even if you do have rural origin specialists, they find their way to top concentrations of workforce that happen to be in rural areas.
If you want primary care and primary care where needed, there is really only one choice – the family medicine medical school with an 8 year instate primary care where needed obligation.
The pathway is through family physician practices to gain admission – informed consent for a lifetime of such work. Admission comes with an 8 year instate primary care where needed obligation. The training for medical school and residency is integrated with family physician practices. This is the best of the legacy family medicine designs as demonstrated in RPAP in Minnesota, accelerated FM, rural training tracks, and other models that would work even better with 100% FM by design.
The state or primary care association or corporation sponsoring this effort can expect 90% instate within primary care where needed for 8 years. This already exceeds the best training efforts.
But the model continues with impact upon the remaining 25 years of a career as shaped by instate origins, instate training, and all connections instate and where needed. Long after obligations are gone, the connections remain.
The design that works for predominantly black counties, for border counties, for Native Americans, for frontier locations, and for all locations and populations left behind – is family medicine training integrated with practice.
For decades we have been training and retraining family physicians. For decades of class years family physicians have distributed 50% or greater where workforce is needed.
It is time we gave our future family physicians a real family medicine experience for a lifetime.
With a much better beginning, they will do more to enhance family medicine than most of us with very little FM experience before medical school, and maybe 3 months of generic primary care during medical school and a limited portion of FM residency.
We are already seeing what our SOMA students can do to enhance medical education where it needs enhancement – because they were not behind by design. Specific clinician focus has power from day 1 of training (clinical skills, OMM, integration of basic sciences within a clinical framework). Specific family physician focus before, during, and after training can do even more.
The only thing that limits primary care and family medicine is too few annual graduates and too few trained specifically in family medicine – limitations because of design.
February 4, 2013 at 4:14 am
Robert C. Bowman, M.D.
Working Simple Math
For 5.8 million people in 2050, Alabama will need about 5000 family physicians or their equivalent
Dividing by 30 class years is 166 annual FM graduates. But retention rates impact this result and the current design is only good for 40% instate retention. This moves the training number and training cost from a small medical school to two medical schools with 416 family medicine graduates. The actual requirement would be about 470 annual graduates to get this result.
But if you have an instate focus before admission and during training with an 8 year obligation instate you could get to 55% instate primary care and just 336 annual graduates.
If you move to family physician training right out of high school you can get more years and only 284 annual graduates a year required.
If you have this model in all states such that you get what your give (no theft) then you can suffice with 133 annual graduates. Sadly our US design results in about six states that benefit from the current design such that they can do well while contributing little. Only when more states force instate retention and obligations will all states have to ante up for the workforce required.
Yes you can figure on Alabama being able to get some workforce from other states, but I would only count on what you can produce and retain.
Why would you design for less? Also why would you design solutions for other states – especially states not investing in health access workforce?
How about the NP and PA solution?
Well it turns out that the NP or PA is only 4 Standard Primary Care Years per graduate. The requirement for NP and PA to be a primary care solution for all primary care for Alabama is 1000 annual graduates a year. And since about 30% stay instate, this would mean 3500 annual graduates a year for sufficient primary care by 2050.
The cost of sufficient primary care from NP and PA is 2 billion dollars a year or about $500,000 for each trainee in post high school education and training costs plus cost of living.
The cost of sufficient primary care from traditional FM at 1.2 million per graduate would be 500 million a year. For the family medicine specific model the cost would be lower at $900,000 with the higher primary care yield such that the cost is cut in half to about 270 million.
If the NP and PA designs were specific to employed family practice result for 90% of graduates instead of 25% and falling, the cost of training for the primary care result would be the same as in family medicine – but there is the problem of higher turnover, higher losses, and designers that do not want limitations – limitations that would result in specific primary care and primary care where needed.
When you have highest volume primary care that remains in primary care at highest activity for an entire career – and the instate retention is enhanced by design it is possible to meet sufficient primary care needs at about 86 per 100,000 for an entire state. It takes 40 years of work – 10 years to build it and 30 years of graduates. You can also meet needs with fewer graduates and lower costs with outstanding results.
If you do not design for success, why design at all?
February 4, 2013 at 4:30 pm
USAMedStudent
http://www.medschoolwatercooler.blogspot.com/2013/02/five-medical-students-match-early-in.html
It’s hard to get excited about family medicine when the school puts so much emphasis on celebrating students that get into the most prestigious, competitive, high-earning, procedure based specialties.
February 4, 2013 at 5:04 pm
Carol Motley
Carol Motley
As the Director of Medical Student Education for the Department of Family Medicine at USA, I find that I can only support the medical student’s comment rather than refute it. Although I will have to say that this problem is not unique to the University of South Alabama. Power follows the dollar as they say and the low reimbursement and limited recognition of the critical skills that primary care brings to the medical system has deterred many a student whose heart lies in primary care. I have been educating and supporting medical students who choose family medicine for almost 25 years and hope (sometimes desperately) that the changes in medicine address the respect and appropriate financial reimbursement primary care deserves.
Back to USA, it was originally established by the state to address the very shortages in Alabama that are described by Dr Perkins. The students have limited exposure to primary care at this time except for 6 weeks on the Family Medicine clerkship in the third year. With a 5 year HRSA grant, we have started placing first year students to primary care clinics for about 9 half days a year.
I do wish that USA would stop treating primary care (in general) as the red-headed step-child and value this critical specialty. Specialists are important to the system as well but do not provide the basis of a healthy health care system. If state medical schools do not see this as a mission, no wonder we are where we are. To my observant student I would say, hang in there, go where your heart tells you about the importance of being a primary care doctor and know that you have figured out something perhaps our leadership has missed.