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Larry Bauer has once again posed questions to a group of us “Family Medicine Bloggers.” I find them interesting questions because, as someone who trains family Physicians, I often get asked about training philosophy. In addition, because of changes in accreditation requirements and work hours, there is often a question among educators as to whether we are leaving out the best part of medical training. Larry has posed two questions:

In your training, what 3 things (maximum) were stressed/emphasized to you regarding how to take good care of people?

In your experience, what 3 (maximum) lessons have you learned about taking good care of people? (if you had just three suggestions to pass on to students and residents regarding how to take good care of people, what would you say?)

My medical school training was at Tulane and my clinical training was mostly at Charity Hospital (also known as “The Big Free”) in the mid 1980s. It was a different time and a different place. There were no work hour restrictions, there was very little contact with attending physicians in conjunction with patient care, and as a student you had the distinct impression that you were an important part of the health care team (and occasionally the only thing standing between your patient and death).Everyone, from the dean down to the intern on the serviced stressed one thing:

“Know Your Patient!”

In a place like Charity, this could not be overemphasized as to call the “health care team” stressed would be a generous understatement. Although the health care environment our resident learn in today is quite different, I still cannot overemphasize the importance of this.

The hospital had open bay wards where everyone could see everything. I still have a distinct memory of me as a 3rd year medical student watching a gangly white medicine resident trying to describe in very technical terms (using the barium enema image as a teaching tool) what Crohn’s Disease was to an impoverished African-American patient who clearly did not believe that the image was of his insides, much less that his insides were defective in some way. It was clear to me from that day forward that I had to:

“Speak the patient’s language.”

It may be through a translator or to the patient and a parent, or to the child of an elderly patient, but it is less important for me to be accurate than it is for me to be understood.

I did my first year of residency at Portsmouth Naval Hospital in Internal Medicine and stayed on working the Emergency Department for a year waiting to become a Diving Medical Officer. As a ED doc walking in with one year of post-graduate experience, I could not be accused of being over-confident in my abilities. Many of the residents who had been with me throughout my PGY1 year were still in training and I interacted with them on a regular basis. I was functionally the “admit resident” and they were my consultants. The ED staff and my colleagues  hammered home to me the lesson that:

“Medicine is a team sport.”

Never be afraid to ask for help. Always accept criticism and try to improve. Know what your role is in the health care team and hope that everyone else does as well. Put a good team in place and good care follows.

After I finished dive school, I was stationed in the clinic in Kaneohe, Hawaii. I got the job because no one else wanted it, based on rumors of what the job might entail.  At the end of three years I had made a bit of money on a condo, seen almost everything to see in Hawaii, made friends for lifetime, learned I wanted to do Family Medicine, and had a wealth of experience in leadership positions. In other words:

“Make the best of the hand you are dealt.”

Admittedly, raising your hand to volunteer to go to Hawaii isn’t like agreeing to fight “a land war in Asia” but it might have turned out badly.

I did my residency in Family Medicine at South Alabama. Ellen Sakornbut knew that I wanted to do Academics and challenged me to acquire and maintain OB skills (I still take OB call 20 years later). In her words:

“OB keeps your practice young.”

As I find myself caring for an increasingly aging patient base (despite miraculously not aging myself!), I am grateful for that piece of advice  when I see a pregnant patient in my practice (often, these days, the child of one of my older patients).

The last lesson that I learned in medical school and had emphasized in my internship, Navy career, and residency is this one:

“Always do the right thing.”

Of course, trying to figuring out what that is can be tricky!

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As I have said before, I don’t like selecting colleagues through the Match. The process was established to allow students to get the best opportunity available and I feel that our program (and our patients who rely on our trainees to provide care) is in jeopardy every year. It always turns out better than I anticipate, so I shouldn’t complain. However, we have to interview 60 prospective residents to fill our six slots so I have a lot of conversations with prospective applicants. Our interviews are about 20 minutes (we have each applicant have a discussion with about 6 faculty, staff, and residents). Most of these interviews are very pleasant and informative to me (and I hope to the applicant). Others, not so much. In order to give you, the applicant, more “bang for your buck,”here is some unsolicited advice to those interested in a Family Medicine position in our program:

1) Avoid the “If it’s Tuesday, this must be Belgium” phenomena – I know that you are under a lot of pressure to obtain a position and have applied to a number of programs but it isn’t like we are one big program. Just a little time on Google and you can find out some information regarding Mobile, Alabama, the South, and even more specific information about our program. This way, when I ask the question “Why our program?” we can have a conversation and not just stare silently across the desk at each other.

2) Understand the specialty of Family Medicine and our unique training environment – We are the only specialty that offers extensive training in the outpatient setting. We offer experiences in the broader community. This means that the broader community is important ot our programs. While you may ask about the hospital, PLEASE ask about the community, the population we serve, and the unique activities our residents have the privilege to participate in.

3) Be able to articulate a vision for 3 years in the future – A three year training program is very concentrated. You will be expected to enter into training with an understanding of what the future will hold for you upon completion as that will help us. If you know what experiences you may want, I can tell you if we can provide the training environment. “I want to go to a third world country and do surgery as well as primary care” requires different training than “I want to work with patients with chronic illness in a suburban practice.” I am happy to have this discussion but ask that you be able to initiate it when I ask “Where do you see yourself three years from now?”

4) Understand Family Medicine “Fellowships” – We are different than Internal Medicine. Our “fellowships” are intended to enhance our generalist skill set, not limit our practice. More importantly, you can’t get into an Internal Medicine fellowship such as Cardiology from a Family Medicine training program. If you tell me you want to be a cardiologist, I have trouble believing you really want to be in my program.

5) If you don’t want to be here, don’t come – There are over 2700 Family Medicine entry level positions. Almost everyone that wants one has gotten one in their top three for the last 10 years. Pick three places and programs you REALLY want to be at and work on impressing those program directors. Applying to and interviewing at 30 programs makes you tired and makes me tired as well.

When I was growing up the economy was terrible. The recession of the 1970s (with effects lasting until 1983) was characterized by both high unemployment and high inflation, leading to the presidency of Jimmy Carter and subsequently the presidency of Ronald Reagan. The last 30 years have been characterized by economic growth but at the expense of an increase in the wealth of the top 10% of the population and a concomitant decrease in the incomes of the bottom 50%. When this trend began, those who were the recipients of the increase were unapologetic in the display of their wealth, with Madonna’s Material Girl becoming an anthem of sorts. Acquiring wealth and displaying it was encouraged.

When I entered medical school in the 1980s, although it was understood that we would do well financially, financial incentives were not supposed to influence our decision making. Doctors made money but making money was not what being a doctor was about. We were told by our mentors to do the right thing by the patient and the money would follow. We were not guaranteed entry into the top 1%.

Today the top 1% of American households make more than $380,000 (US). As you can see from this survey, this level  income is easily within the reach of most non-primary care specialists. As chronicled by Atul Gwande, in ways subtle and not -so-subtle, physicians are able to influence patients (consumers?) to purchase health care such that today THEY ARE THE 1 PERCENT.

I have my own set of thoughts regarding the discussions of wealth redistribution, progressive taxation, and the value to society of certain types of work as measured by income. I (probably selfishly) believe that physicians deserve to be valued by society. I worry that physicians (like Wall Street executives) confuse income with value to society. I discussed the spectacle of Michael Jackson’s life previously but really had convinced myself that this was a “one-of” episode. Conrad Murray and his obsession with money and willingness to (allegedly) commit murder to maintain a client was an aberration, right?

Today’s news brings more evidence that physicians are willing to be participants in harming people in exchange for money. Reported by Bloomberg and picked up by the AP, the market for stealing solid organs for transplant has moved from an urban legend status to reality:

[B]rokers use deception, violence and coercion to buy kidneys from impoverished people, mainly in underdeveloped countries, and then sell them to critically ill patients in more-affluent nations. The middlemen form alliances with doctors in leading hospitals who do these transplants for a fee, no questions asked.

Although the real bad guys are the gangs who kidnap the potential donors, the article lets the doctors off VERY EASY. In describing one transplant evaluation:

They took him to Metropolitano Hospital, where kidney specialist Gustavo Salvador sat down with Yafimau. Salvador, who did his medical training at Central University of Ecuador, says Yafimau showed him the document saying he wanted to donate a kidney.

“If someone comes to me and says, ‘I come to voluntarily say that I want to donate,’ then that’s as far as we go,” says Salvador, sitting in an office adorned with Salvador Dali prints. “I can’t investigate the life of the person. That’s not my job.”

Salvador says he was paid $800, his normal fee for referring a patient to a surgeon.

This scandal is not, for the most part, American in origin in the traditional sense. I do believe we have some culpability. First, in the same way those who trained the pilots who flew on 9/11 should have asked about the purpose of the training, our Graduate Medical Education system trains physicians with little to no discussion of manpower needs and ultimate outcome of training. If we train an excess of transplant surgeons they are going to have to practice somewhere and their skill set is limited. Our training should reflect manpower needs. Second, medicine as a commodity leads to poor decision making on the part of the physician and on the part of the patient. Third, physicians apparently need a set of rules imposed to prevent them from behaving badly. It was the Nazi atrocities that led to the reform of research ethics. What is it going to take to reform the ethics of clinical practice?

As a family physician I still supervise residents who perform deliveries and do deliveries myself. This weekend was one of those where I found myself at the hospital a lot more than I’m used to.

To get the point of this story you need to know the following:

1) A lot of teaching is done in the Socratic method where the teacher (that’s me) asks the resident (Andres in this case) questions to which the teacher  knows the answer.  In theory the teacher is trying to get the resident to remember the answer because of the active learning required to retrieve the answer from distant memory cell.  Many residents suspect that often the teacher is asking  something to which only he or she knows the answer and the resident will never answer correctly. This makes makes the teacher (me) look really smart and is known as “pimping the resident.”

2)  Pitocin is a medicine which is given in small doses to women who are in need of delivery to cause contractions and hasten labor and in large doses to those already delivered to clamp down the uterus

3) A twin pregnancy occurs naturally in about 1 in every 100 pregnancies

4) Evidence-based medicine is the practice of medicine using empirically derived evidence as opposed to anecdotes and clinical experience. The Cochrane database is an accepted place to go for evidence based medicine. The evidence for the use of Pitocin prior to the placenta coming out is that bleeding associated with childbirth might be reduced but other risks might outweigh the benefit…

The Anecdote:

Andres to nurse: Placenta is out!

Nurse: Pitocin is going!

Me (pimping): Andres, do you know why we wait until after the placenta is out to hang the pitocin at this hospital?

Andres: No

Me: The evidence is that if you give it before the placenta is out you will reduce bleeding. Because of the theoretical risk to an undiagnosed twin, we wait. If you give such a large dose of Pitocin you could kill a twin. Now that everyone gets ultrasounds I suspect it isn’t a concern and is a holdover from when you never knew how many babies were coming until the last placenta was out.The risk of undiagnosed twins today is probably overrated. I do remember when I was a medical student at Charity…

Nurse (clearly wanting to stop the story): We’ve had 3 undiagnosed twins this year that I know of. Some folks just don’t get prenatal care…

All my deliveries this weekend were singletons….

There is an interesting article in the New York Times (found here) about sleep deprivation and physicians-in-training. A new set of work rules for doctors in training (residents) took effect on July 1st of this year. There was one rather odd requirements  where the 1st year resident can work up to 16 hours but must then get 10 hours off, causing those of us involved with training to do a little head scratching about how to make that work. Did that mean residents come in 2 hours later every day? Talk about a screwed up circadian rhythm.

The article in the Times pointed out that despite severe reductions in work hours over the past 10 years, care related errors have not decreased and have in fact increased. The implication was that perhaps the hours, themselves, were not to blame. The comments accompanying the article were predictable. Many were from older doctors (likely my age) relating how they were able to resurrect folks from the dead but only after working for 35 hours straight. Some were from physicians who are currently in training (and thus only know the work-limited training model) talking either talking about how they would never learn resurrection without being allowed to work 30 hours straight or conversely how they disbelieved the older doctors stories. I trained in a time and setting where the hours were unlimited. I do not recall any specific abilities granted me by virtue of working long hours. I do recall being bone-tired after a day in the office, a night of working to fix some very sick people, followed by a day in the office. I certainly never felt I was doing my best at hour number 36.

The real story is not about one young woman (Libby Zion) who died in New York and her dad’s efforts to affix blame and correct a common sense problem (working for 36 hours straight can never be good). It is about system change:

But all of these hospital reforms ignore what may be the biggest problem in physician training today: the yawning chasm between what most doctors learn during the 80 hours a week they spend training in hospitals and what they actually do after leaving their residencies. Defenders of the old-school way argue that the demands of medical practice justify the brutal hours. But after their residencies, most doctors practice in outpatient settings and work regular daytime hours as members of large groups. They treat chronic problems that need weeks or months of periodic outpatient follow-up, not high-intensity hospital-based care lasting only a few days.

The old method of physician training is dead. We used to think we could put physicians in training and really sick poor people in the same building, and poor people would get at least some care and learners would get training. It was this model that Medicare put money into in the 1960s. This evolved into a different model. In the current model some (if not all in some teaching hospitals) of the inexpensive trainee labor is re-purposed to provide help for physicians providing complex care for paying patients. As we ratchet back the inexpensive labor, changes are going to have to happen.

As I have discussed here and here and as Dr Sanghavi discusses much more eloquently, the current training system does not prepare learners for practice and now is shown to contribute to fragmented, error prone care. It is time to re-think the entire process. In the words of the man who sets policy:

“For people who came out of the old training system, it may be hard to imagine one that works better,” says Donald Berwick, the director of the Centers for Medicare and Medicaid Services and former president of the Institute for Healthcare Improvement. “The point is, it’s all about design and coming up with optimizing models.”

Poor people need care other than in the hospital provided by over-tired trainees. Trainees need to learn about care delivery in settings that prepare them for a future of error free practice. Hospitals need to wean themselves from cheap labor provided in the name of training.

Also, I kind of think the resurrection stories were exaggerated.

It’s that time of the year…A resident who just graduated and went on to a faculty development fellowship sent me a thank you note. As a clinician educator, I will ask those of you who are or were learners to send such a note to a mentor, because it makes them feel like they’ve accomplished something. Mine says, in part:

As for Massachusetts, I think my study abroad on the Gulf Coast left me with a little Red State Glow – It’s hot here with not enough AC, to-go cups, or pink flowers, and there are RULES like even a good commie wouldn’t believe. I mean, at the gym, there’s a sign telling people to clean their own hair out of the drain (!!) and to consider bringing a latex glove for that purpose.

And they say that study abroad is overrated…

Match week was this week. That is the week when all of the student doctors find out where they are going for training. Once again, the University of South Alabama College of Medicine did not put as many students into “primary care” as did the rest of the nation, with only 42% of our graduates going into either Internal Medicine, Pediatrics, Family Medicine (6 total which is up from previous), and Medicine-Pediatrics. While this is a concern to me, it is not my topic for today. Today I want to focus on the trend regarding students (not) staying in Mobile.

Most medical schools keep about 50% or so of their students for residency training. This is typically because the inertia to stay is usually greater than the desire to move for a brief (3-5 year) training experience before taking a “real” job. Also, the students have typically put down roots in the area, have a support system, know the hospital, and in general are the school’s to lose. This year we managed to keep only 16 out of 70 students. As the match is a national exercise, we got students from outside of Mobile as did all of the other South Alabama programs but you have to wonder why more of these students didn’t stay.

I have noticed for a long time that Mobile, Alabama, is a tough sell to young, energetic student types. I have a lot more success selling it to students I do phone interviews with than when we bring them here in person. I know that our program offers good training, has an exceptional faculty, and our graduates get multiple job offers prior to graduation. So why don’t the students want to come? I’m afraid it might be in part, in the words of the real estate agent, location, location, location.

The Gallup polling group has partnered with Healthways to develop and administer a survey comparing various cities in the United States. It’s called the “Well-Being Index:

The Well-Being Index measures six domains of well-being. Each domain is determined based on scientific study of responses to the survey questions and include:

  • Life Evaluation
  • Emotional Health
  • Physical Health
  • Healthy Behavior
  • Work Environment
  • Basic Access

Each of these have a series of related questions regarding the category. For example, physical health asks questions to get at how healthy the population is. Basic access assesses not only access to health care but to community services as well. If you can’t see where this is going, Alabama ranked #46 (out of 50) and Mobile ranked 174 (out of 188). As a region our congressional district ranked #416 (out of 436). We lost students interested in Family Medicine to Huntsville (#59), Birmingham (#136), and Orlando (#116). Although they too have Family Medicine programs, we did not lose anyone to Shreveport LA (#178), Spartanberg SC (#182) or Port Author TX (#186).

Mobile, I need your help. It strikes me that Mobile has been engaged in “smoke-stack chasing” as a corporate strategy ever since the demise of the cotton plantation. We Mobilians have used coercion to try to recruit military dollars, tax abatements to  attract a chemical industry, and assistance to attract a steel industry. Unfortunately we have also found that each of these strategies comes with a downside. One of the major ones is pollution such that we have limited public access bay to our bay. I don’t know if our Well-Being Index rankings are a result of this strategy or are a coincidence. It really doesn’t matter.

Turns out, young people want more than low taxes, low housing prices, and jobs (if available) that don’t pay very well. The students (and young faculty) that I need to attract into my program typically have a working spouse and small children. They are attracted by good schools and daycare, safe housing, safe opportunities to pursue athletic endeavors such as bicycling, windsurfing, and running, and professional opportunities for their spouse. Those that are single (or married but with no children) are attracted by a downtown with a vibrant night life and residential potential. Might I suggest that we have enough smokestacks. For Pete’s sake, we are on the water, something we have in common with Honolulu (#5) and Alexandria VA (#10). We have 102 days of sunshine a year which puts us ahead of Houston (#84) and Tallahassee (#45). We have a medical school which should put us above Gainesville (#8).

City leaders, let’s build on the industries we have, but now let’s work on making Mobile attractive for young professionals. Former Mayor Mike Dow has outlined one potential proactive move in today’s paper:

While GulfQwest, our new National Maritime Museum of the Gulf of Mexico is being constructed (to include  two high-speed ferries on Mobile Bay), let’s support our mayor to find investors and a world-class developer to knock down the civic center, realign the ugly overpasses from I-10, use the old CSX property we now own, and reuse the south end of the Convention Center to build one of the most competitive entertainment and retail districts in the country.

Might I also suggest the following taken from Mayor Sam Jones’ Transition Task Force (2006):

  • Encourage further tourism and residential development on or near the waterfront.
  • Create consulting group or a Maritime Advisory Council composed of various public and private waterfront interests to consider non-Port Authority maritime issues.
  • Essential to Downtown Redevelopment is a commitment from the City government. The Downtown Redevelopment Committee believes that the top priority of the Mayor’s office and City Council should be continued redevelopment of the downtown area.
  • Create a downtown cultural and entertainment district.
  • Work to promote residential development in the downtown area.
  • Recruit educational institutions and small businesses for the downtown area.
  • Expand waterfront access and commercial development along the waterfront.
  • Elevate the public’s awareness of the importance of the cultural and quality of life aspects of our community.
  • Address lighting, parking and safety for walking, jogging and bicycling at all City recreation areas.
  • We must address the fact that we do not have a City marina or fishing pier.
  • Increase City-wide awareness of tennis, golf and the fast-moving sport of disc.
  • Develop City-wide (or regional) plan for provision of primary/specialty/dental/mental health care to under-insured and uninsured citizens, bringing together educators, health care providers, health care insurers/financiers, government and other interests.
  • Enhance and improve public transportation and City recreation sites.

And let’s not forget the plan for downtown finished in 2008, either….

President Obama announced and defended his budget yesterday. Having studied the federal budgeting process in graduate school I know that the proposed budget by the executive branch is hardly ever what ends up on the President’s desk so I tend not to pay a lot of attention to it. The budget did get some press in Alabama, however. It seems that a program to train pediatric generalists and specialists has been listed for extinction in the President’s budget and that would cost the state of Alabama approximately $7,000,000 annually. Turns out the President wants to use the money differently

The money for training pediatricians is one of about 200 federal programs targeted by Obama to trim $33 billion starting in 2012. The White House wants to cut the program in favor of competitive grants “that create incentives for improved performance,” according to the president’s budget.

Who isn’t in favor of improving performance?  Maybe the feds see their role as a more global, pointing out to the states how they can deliver care better. Unfortunately, the $7,000,000 of federal money  coming into Alabama every year is not only used for training residents but it pays for a lot of care that gets delivered as a by-product of this training. The current thinking in Washington is that the health of Alabamians shouldn’t be  a federal problem as is the current thinking in Alabama. Maybe we need to find another source for the federal money we now use for care delivery.

Perhaps the state is responsible? Unfortunately, former Governor Riley spent his time avoiding increases in taxes and hence did not leave Alabama much wiggle room to pay for health care this year. In his recent testimony to the Alabama House, the new Medicaid Director points out that there is a projected $700,000,000 shortfall and I guess he’ll have to add the $7 million to that. Dr Mullins was fairly straightforward with the legislators

Mullins said he is reviewing the program looking for places to cut. “I have to be honest with you, even those trim backs are not going to make a difference in $700 million,” Mullins said.

Mullins urged lawmakers to remember that Medicaid is critical to the state’s health care systems. Medicaid pays for about half of all Alabama births and provides medical care to 40 percent of Alabama’s children,

“Without Medicaid, the rural hospital system would probably collapse,” Mullins said.

Seems like a problem that has a potential solution. Unfortunately, that solution (more money into the system in the short term and ultimately transforming the system to be more efficient)  is not politically viable at this time.

Rep. John Rogers, D-Birmingham, said the $700 million request will be difficult to meet.

“We’re in real trouble,” Rogers said.

Perhaps the answer is local. Maybe the health care providers in a local area should all get together and provide the services to those most in need, especially those that are vulnerable and can’t care for themselves. In 2001, the local newspaper looked at our community (Mobile Alabama) and here is what they found

[From 1995 – 2000], the levels of charity care at all three private hospitals have dropped significantly, according to hospital reports filed with the state. Providence, a 349-bed, tax-exempt, Roman Catholic-affiliated hospital in west Mobile, proclaims a mission to pay special attention to the poor. In the last five years, though, 10 percent of its patients were uninsured or on Medicaid, records show. The hospital showed a positive net income of almost $14 million in fiscal 2000 — an 8.5 percent profit margin — although a sister company lost $4 million. At Springhill, about 7 percent of the patients in the last five years did not pay their bills or were covered by Medicaid. Springhill’s profit level topped $2 million last year, financial records show. But 252-bed Springhill, some community leaders say, may have less of an obligation to provide charity care than other private hospitals: It is a private, for-profit company that pays taxes.

My employer, the University of South Alabama is the other care provider in Mobile and it has 40% of its adult beds taken up by medically indigent people at any given time. How do we do this?

The medical college’s faculty salaries are among the lowest in the country and it has fewer teachers per student than any public medical school in the Southeast.

In addition, we rely heavily on Medicaid money which, I’m afraid, is likely to go away.

My experience tells me that it is important to pool our money to provide access to health care for our neighbors. On what scale that happens, whether national state, local, or family, is currently up for debate. I know that here in Mobile it is me, my colleagues, and the USAMC who are not being paid like our peers in order to allow poor Mobilians to receive what care we can provide. I’m not sure that it should be our problem, but it is…

Should the Mayans have been wrong and we survive 2012, 2014 is approaching rapidly. Despite the belief among newspaper letter writers that providing healthcare is a form of communist income redistribution, the Affordable Care Act (or PPACA) is the law of the land, most of the provisions occur in 2014, and implementation will need to be planned. Unfortunately, suddenly providing health care to 30,000,000 Americans previously denied is not a simple as giving them an insurance card. The New England Journal of Medicine published an article that looks at America’s state of readiness for the impending increase in people who suddenly have access to healthcare. Not surprisingly, they found that America is not ready, southern states are less ready than most (Alabama is 41st out of 50 as it relates to readiness) and we have no plan for increasing readiness. They conclude:
Addressing the goals of health care reform will take a combined federal, state, and local strategy involving resource deployment and actions designed to expand the available short-term and long-term supply of well-trained primary care professionals who are ready and willing to serve the newly insured. Ensuring access to care will depend on our ability to achieve smart growth in both insurance coverage and primary care capacity.
There is one group that has looked beyond 2012. The Council on Graduate Medical Education has published a report entitled Advancing Primary Care, focusing on how physician training should be redeveloped given the new realities. The recommendations are as follows but I encourage you to read the report in its entirety:
1. The Number of Primary Care Physicians
Recommendation: Policies supporting physicians providing primary care should be implemented that raise the percentage of primary care physicians (general internists, general pediatricians, and family physicians) among all physicians to at least 40 percent from the current level of 32 percent, a percentage that is actively declining at the present time. The achievement of this goal should be measured by assessing physician specialty once in practice, rather than at the start of postgraduate medical training.
2. Mechanisms of Physician Payment and Practice Transformation for Primary Care
Recommendation: To achieve the desired ratio of practicing primary care physicians, the average incomes of these physicians must achieve at least 70 percent of median incomes of all other physicians (According to data from the Medical Group Management Association cited in the report, primary care physicians’ median annual compensation was $186,044 in 2008 versus $339,738 for physicians practicing in other specialties). Investment in primary care office practice infrastructure will also be needed to cope with the increasing burdens of chronic care and to provide comprehensive, coordinated care. Payment policies should be modified to support both of these goals.
3. The Premedical and Medical School Environment
Recommendation: Medical schools and academic health centers should develop an accountable mission statement and measures of social responsibility to improve the health of all Americans. This includes strategically focusing and changing the processes of medical student and resident selection and altering the design of educational environments to foster a physician workforce of at least 40 percent primary care physicians and a health system that meets societal needs.
4. Graduate Medical Education
Recommendation: Graduate Medical Education (GME) payment and accreditation policies and a significantly expanded Title VII program should support the goal of producing a physician workforce that is at least 40 percent primary care. This goal should be measured by assessing physician specialty in practice rather than at the start of postgraduate medical training. Achieving this goal will require a significant increase in current primary care production from residency training and major changes in resident physician training for the practice environment of the future.
5. The Geographic and Socioeconomic Maldistribution of Physicians
Recommendation: So long as inequities exist, policies should support, expand, and allow creative innovation in programs that have proven effective in improving the geographic distribution of physicians serving medically vulnerable populations in all areas of the country. This should be done through mechanisms such as the National Health Service Corps and Area Health Education Centers.
The Future of Family Medicine blog, found here, is created and maintained by medical students to support students who remain interested in Family Medicine despite all of the obstacles and hardships. They are excited. In the words of mdstudent31, these are exciting times
I do not know about you, but these are pretty bold recommendations and very exciting for the future of our great specialty.  Will these recommendations gain traction anywhere within the government?  While it is true that more primary care used appropriately and effectively decreases the amount spent on healthcare, will there actually be an increase in salary?  Or would we go as far as entering into the blasphemous territories of decreasing the median specialty salary?  ::GASP:: My guess is it would probably be a little bit of both.
I will concede that if we make it past 2012 we are in for exciting times.

When I was a student at Tulane, there was a story (possibly apocryphal) that illustrates how medical education used to occur. The Endocrine Clinic (a training clinic for Internal Medicine residents) at Tulane used to take care of a lot of patients with overactive thyroids. They would place them on medication (Propylthiouracil, expensive, had to take three times a day) and monitor them roughly every 2 months from signs of worsening or problems with the medication. One Christmas break, the surgery residents broke into the clinic, pulled the charts of all of the patients on this medication, and called them to ask if they were interested in having an operation that would eliminate the need for this medication (but possibly lead to the need for thyroid replacement therapy). After the clinics reopened, many of these patients came back for their follow-up with a fresh scar from their thyroidectomy. The chairman of Medicine, a clinical giant named C. Thorpe Ray, went into the Dean’s office and proceeded to rant loudly about the surgeons. The chairman of Surgery, called in special for the occasion, let Dr. Ray rant. When asked for his response, he answered simply: “The boys need thyroids.”

This had been the training philosophy in medicine since the model for modern medical training was established following the Flexner Report. Learners were placed in large hospitals and practiced on folks who needed care. Folks in need went to the large hospitals to get care. Some folks might get care they didn’t need or want but… the boys needed thyroids.

Medical training, though, is changing.

A new report from the AAMC provides the results of a 2010 survey of member institutions to determine how attributes of the patient-centered medical home are being incorporated into the clinical education environment.  While few studies have examined how medical homes have been integrated into teaching settings, “Moving the Medical Home Forward: Innovations in Primary Care Training and Delivery,” offers examples of seven medical schools successfully delivering patient-centered care to their communities.  The report also discusses the challenges and opportunities in the post-health care reform era for medical schools and teaching hospitals to develop new ways to train physicians and improve the health of the public.

And now Tulane offers community-based training at several Federally Qualified Community Health Centers across the city (from the AAMC report)

While training in an NCQA-recognized patient-centered medical home has profoundly affected the resident ambulatory experience, (there is currently a waiting list of residents who wish to train at Covenant House) their exposure to innovation extends outside the health center walls. The team has partnered with numerous local nonprofit civic and religious groups in efforts to “get our tentacles into the community,” and allow faculty, residents, and medical students to train community health workers through culturally sensitive care management programs. Faculty have noted the quick ability with which residents become “savvy” with the resources available to the community, and, as indicated by Dr. Price Haywood: “Residents play a key role in helping patients negotiate the community.”

A far cry from the boys needing thyroids.

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