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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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The rules for creating a Teaching Health Center (which I discussed before here and here) have been posted. If you are thinking about applying, note that the deadline for submission is December 30, 2010 at 8:00 pm ET.  Here is a link to the application page. Below are some excerpts from their announcement with my commentary. 

The government is willing to pay for direct expenses associated with sponsoring an approved graduate medical education training program and indirect expenses associated with the additional costs relating to teaching residents in such programs out of this money. This money will go directly to the THC instead of being filtered through a hospital. Although the program period is one year, it is HRSA’s intent to fund qualified THCs for the entire five year THCGME program period pending satisfactory performance of awardees and availability of federal funds (putting the THC at risk if congress changes its mind but also putting the THC on notice that they may not take advantage of this progrma to continue to create traditional residency training programs). Funding can only be used for the costs of new residents in a newly-established THC or an expanded number of residents in a pre-existing THC (this is not to pay for residency slots currently being paid for but to try and create new slots which is a problem because many current slots are underfunded). These payments will be as much as $150,000 per resident per year (which shows you how much it costs to train residents).

Payments must directly support the THC ambulatory training site (to try to keep hospitals from taking the money and re-purposing it). If a THC-affiliated teaching hospital receives GME funding from Medicare or other sources for the new THC residents, the THC cannot claim that portion of the time for HRSA GME payments (you can’t double dip).

 Corporate Eligibility

Eligible entities include community-based ambulatory patient care centers that operate a primary care residency program in high-need, underserved communities. (This will move training into the community where it belongs).  

 Training Program Eligibility

Only specific residency training programs program (family medicine, internal medicine, pediatrics, internal medicine-pediatrics, obstetrics and gynecology, psychiatry, general dentistry, pediatric dentistry, and geriatrics) are eligible (Hospitals can’t use it to create radiology residencies).

 Funding Limitations

Successful THCs have common elements, foremost of which is an institutional commitment to a dual mission of medical education and service to an underserved patient population, including underrepresented minority and other high risk populations.  In addition, there is significant patient- and community-based input into THC operation and management; and THCs have also demonstrated progress toward innovative models of patient care delivery such as the patient-centered medical home, implementation of electronic health records, population-based care management, and use of interdisciplinary team-based care (HRSA is not interested in funding the same old stuff)

Measureable outcomes

Measureable outcomes will include practice patterns of graduates such as whether they are providing primary care, and whether they are serving in safety net settings one and five years after completion.  It may also include outcomes such as creation of interprofessional teams that provide person-centered care, improvement in quality parameters, improvement in patient outcomes, and improvement in use of electronic medical technology. Not only does the successful applicant have to say they are going to do good things, they have to actually do them.

I look forward to seeing the applicants and how they propose to change our training…

As I have written before, the Teaching Health Center is seen as a way to move education into the community (using Community Health Centers as a training resource) and out of the Academic Health Center. Currently, 20 million Americans receive care in a CHC. They serve Americans who are unable to obtain access through more traditional means, either because of location (the community will not support traditional healthcare) or socioeconomic barriers. They provide primary medical care but also provide dental, mental health and substance abuse, pharmacy, health education, and other services that facilitate access to care, such as translation, transportation, and case management. In an expansion begun by President George W. Bush and continued by President Obama, they are receiving a huge increase in funding and are poised to work with academicians such as myself to help train the physician manpower necessary to succeed in this expansion.

This is good news, right? For those of you who have been following the health care debate, this is the worst nightmare of some. Americans like to be able to pay money for a perceived increase in value. If you don’t believe me, just look at the number of different cigarette brands that were used to sell a product that only does two things (deliver nicotine and shorten life expectancy). If we were to treat health care as a utility such as electricity then we would all get the same thing. After all, rich people seem happy with the same electricity and fire coverage as poor people so they ought to be satisfied with the same health care as well.

I don’t see all Americans queuing up (as the Brits do) for health care at the local community health center. My clinical practice is in a location that serves all types of patients and I can report that my patients are willing to come to my office and sit next to others who are there regardless of their ability to pay. I can also report that there are some who would prefer a less egalitarian environment.

Joe Sherger has described a tiered system that I believe is how primary care will break as well. He sees two distinct types of primary care practices:

Organized Team Model – Each PCP covers a large panel of patients (2000 or more) with one or more mid-level providers and others on site such a care manager, care coordinators, pharmacist and others.

Relationship Centered Model – Each PCP is a personalized care physician and has a smaller panel size (600-1200) with an activated medical assistant as care coordinator and a “neighborhood” of team members helping to coordinate care.

Our practice looks a lot like the first and I’m very comfortable with that. We are in an area of high need and using this model we can deliver services to the largest number of patients.  Joe has a different type of practice based on the second model that works as well.

As we design training expereinces for physicians, we will need to keep in mind that one size does not fit all. All people need a good primary care doctor and all doctors need to be paid what they are worth. It is likely that the practice experience may be different for different people.

For those of you interested in graduate medical education (residency training) the news that how we pay for our trainees affects what they do for the rest of their life is not new. It may come as a surprise that we have been engaged in a broad-based discussion regarding the nature of payment for training and how that relates to who sets rules for training. This discussion is not a transparent policy discussion such as was the recent one on health insurance reform (despite the term “death panel” now being used as a verb). It is a much more subtle discussion between the Academic Health Centers (the folks who employ the medical school graduates for their first couple of years after graduation), the AAMC (the association of medical schools), the ACGME (the body who sets the rules for training after medical school), and CMS (the folks who pay for employment of RESIDENTS but not for training of MEDICAL STUDENTS.

To oversimplify, the medical schools take tuition from students. They are producing undifferentiated graduates to enter into the practice of medicine AFTER finishing a residency. Although some schools (mostly those funded by state legislatures) have the local health manpower needs as part of the mission, for the most part medical schools see manpower as a policy problem independent of the medical education process. It is their supposition that if the policy conforms with the desired outcomes, the students will follow.

There are 8,734 ACGME-accredited residency programs in 130 specialties and subspecialties. All told, there are many more slots than there are graduating US citizens. Each of these programs requires learners to choose them for training or they will cease to exist. The ACGME can dictate standards for training for each of these specialties based on input from volunteers from within the specialty. The specialties are PRECLUDED from limiting slots because of a Reagan era believe that if we had unlimited specialists prices would fall.

The teaching hospitals train most of our countries health professionals. The care they provide, although essential, is skewed towards high-tech care that requires inexpensive manpower (provided by resident physicians). They require a steady supply of inexpensive labor to continue to provide this high-tech care and in exchange offer resident physicians the opportunity to practice such high-tech care upon graduation. These graduates, though, may not have sufficient patient volume on which to practice the high-tech interventions that they have been trained in. The believe is that these procedures will translate into primary care practice such that upon completion the fully trained physician will practice the type of care needed by America.

The federal government has not had a clear sense of where they fit into the equation. Although they have been paying the salary of medical school graduates in the first several years of training for 40 years, the intent of this payment has become increasingly unclear. As I alluded to, the “market driven” changes of the 1980s led to policies that treated residency training as an educational process. Fueled by a believe in the power of the market, the believe was that learners would choose training activities based on projected need. After 12 years it became clear that this led to an increase in the numbers of non-primary care physicians (see above for reasons). The Clinton administration brought about a change in policy with significant improvement in attention to manpower needs and exerting rationality into the system through changes in policy. These changes were not necessarily welcomed by the medical schools, residencies, or teaching hospitals (see above for reasons). With the change in adminstration the policies changed again. Under GW Bush the regulators who I spoke with had several deeply held beliefs. They believed in the market approach to health care. They believed that the government should not be in the business of training physicians, much less dictating what type of medicine was practiced, and they remained puzzled as to why this approach led to a wasteful, bloated system.

Enter President Obama and the “new law” has ushered in another change in policy. It appears that primary care reimbursement will be improved and the environment will become much more favorable towards primary care. This does not change the training environment. One thing to watch as a potential game changer is the Teaching Health Center. These are enshrined in the “new law.” They are in training environments specific for primary care and the training dollars do not go to the hospital but instead go to primary care practice (usually on FQHC). Many of us are excited about this development. It should allow a decoupling of the training from the manpower needs of the Academic Health Center, an increase ion effective primary care training, and the provision of needed primary care services to a population that will likely remain underserved even as the “new law” goes into effect. Although the devil is in the details, watch this as it develops.

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