My friends Lloyd Michener at Duke, Janice Benson in Chicago, Josh Freeman in Kansas, and I have a running conversation that is about 15 years old and only occurs when we get together at national meetings. The conversation runs something as follows: Janice will argue that the role of the physician is to be immersed in the community and the role of the medical education infrastructure is to develop instructional modalities which, although limited in scope, will lead to physicians doing great things in the community in which they eventually find themselves. Josh will argue that all physicians ought to be governed by a higher purpose and we should develop our community outreach to allow learners to develop that sense of purpose while in the educational environment. Lloyd will argue (or at least as best I can explain Lloyd’s very complex arguments) that physician need to partner with agencies doing activities which benefit the broader public and our educational efforts should be in making learners see the value of this truth. For the most part I entered the discussion about 5 years into it so I mostly sit and watch.

I find that each of these arguments have merit. It is clear that the current effective primary care delivery system is built on the backs of primary care “providers” who are pillars of their communities and at great personal expense deliver patient centered care (to a greater or lesser extent) to a pool of patients who choose to use these practices as an entryway into a very complex care system. These physicians (and others) are the ones described in the FOFM literature.  They believed so much in what they were doing and wanted so much to do it better that they volunteered for the National Demonstration Project. Their patients enjoy better outcomes than those who access the system through the ‘ologist route, get less stuff done to them, and result in less cost to whomever pays the bills. It is important to acknowledge that they are underpaid, are spending personal money on personnel to facilitate unreimbursable activities, and in general it turns out are the glue that holds the current system together. As much as some in Academic medicine would like to believe, this service will not be replaced by non-physician providers any time soon if ever. The services will be augmented by non-physicians and we in the Academic medicine need to determine the educational needs of those folks. Community Medicine curricula at the residency training level (as championed by Janice) clearly informs these physicians’ practices in a good way. Unfortunately,  if additional money doesn’t follow as a consequence of the reform effort it may be a moot point.

On the other hand, Lloyd often speaks of a different reality. He speaks of ” patients who are not well-connected to a practice.” He points out that much of the avoidable cost is with these patients, the ones who are not plugged into the health system, and that caring for them often takes a different skill set and as well as a different tool box. The primary care system, with its office based emphasis, can only go so far, as Lloyd says, “especially for folks who are struggling with chaotic lives, difficult behavioral change, and psychiatric comorbidity.” For these folks, traditional community medicine interventions associated with Family Medicine (and other clinical specialty training curricula) have been ineffective. Duke has shown that linked office and community programs seem to have better outcomes. Partnering with community agencies, focusing on community outcomes, outreaching to those folks using disease specific information will almost certainly improve these patient’s (and the communities) health outcomes. As I described before, Duke is doing some incredible things as they train learners in the community.

The Academic Heath Centers have proposed the Healthcare Innovation Zone  as the fundable and scalable fix for how learners and academic physicians should fit into the community. Unfortunately, we in Academic Health Centers have accrued a lot of healthcare dollars and yet have been incredibly ineffective at population definition, needs assessment, and assessment of intervention effectiveness (the skill set associated with Community Medicine). We have tried Academic-o-centric interventions (look at the GCRC /CTU model) to little improvement in the health of the population. NIH tried to impose some higher level thinking through the Roadmap process but it is unclear how many of the AHCs have fully embraced it. Large care delivery groups who have no vested interest in population clearly do not value this type of care. The exceptional groups, Kaiser, Group Health, and some other groups, are showing that this system is cost-effective but on a “shared savings” measure to which I’m afraid the average Academic Health Centers will be a cost to be jettisoned. Academic Health Centers with rare exception have not proposed improving community health markers as an outcome for which they should be held accountable.

Those of us in Academic Departments of Family Medicine like to believe that we can offer different perspective to Academic Health Centers. We bridge both of these worlds and we are more successful than other academic departments at training learners for (little c) community practice. The problem is that no one has yet asked us to do so and so the question continues to be can an ant move a rubber tree plant?

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