I entered into a discussion regarding the potential impact of health care reform on the Medical School at the University of South Alabama. Being a Family Physician I find myself much less attuned to “saving someone’s life” as I become more attuned to “keeping them from getting that way in the first place”. A lot of medical education here in Mobile still takes place at the University of South Alabama Medical Center. I was surprised to learn that 1/3 of the admissions to this facility were almost certainly preventable. As I began pushing “advanced primary care” as a solution I was reminded that these are people who are poor, non-compliant, and really may not capable of participating in their health care to any greater extent than making their way to the hospital when in extremis.

I began a literature search to see whether a town such as Mobile, which has 18 different locations serving the poor and disenfranchised, could do any better than we are doing now. I know that North Carolina had shown a reduction in hospitalizations as well as costs by implementing this process over the state but that’s not the same as a years worth of diabetic admissions in an inner city hospital.

It turns out, folks have shown success in urban health centers. By working with this population, they “showed significant improvement on eight out of nine health status scales and showed statistically significant improvement for all nine diabetes clinical indicators evaluated through chart audits. One key finding was improvement in performance of quarterly HbA1c tests for each patient (control group 23% pre increased to 30% post and study group 0% pre increased to 46% post)”. Although outcomes are still sketchy, it is becoming clear that programs such as this reduce hospitalizations and other types of encounters with the care delivery system thus saving money.

What are the implications for medical student education? I would like to believe that if incented correctly the Community Health Centers could develop resources such as Community Mental Health Centers have done to outreach to patients who have barriers preventing them from obtaining care for their chronic diseases. Learners who need to learn about chronic illness will need to move out of the hospital setting and into the community health or private practice setting to do so. Won’t that be a change?

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