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I was asked to prepare for a discussion on what the role of primary care in our Academic Health Center should be. This will happen tomorrow. I have spent the better of 2 days trying to decide exactly what that role is.

I’ve decided to begin with the definition that the American Academy of Family Physicians uses:

  • Primary care providers offer a wide range of services including diagnosis and treatment of acute and chronic illnesses, disease prevention services and patient education.
  • A primary care practice serves as the patient’s first point of entry into the health care system.
  • A primary care practice is the continuing access point for all needed health care services

I decided to start here because I don’t know that my bosses have ever thought of primary care as other than another service line.

I plan to emphasize the second bullet point. We, like many other Academic Health Centers, have not taken the role of the primary care doctor in “entry into the health center” seriously. That has resulted in under-utilization of some of our specialty services and when I have conversations about care delivery they tend to go along these lines:

Surgeon: Why don’t you send me more patients.

Me: Only so many people need their gallbladders out.

Surgeon: You need to work harder.

I plan to spend the bulk of my time, though. not on where we’ve been but on where we are going.

My plan is to make the following points and let the discussion ensue:

  • Although the Affordable Care Act (Obamacare to some in the audience) will increase the number of “covered lives” through the exchanges, increased Medicaid coverage, and allowing parents to keep their children on their insurance policy, there will be less money in health care in aggregate. There is no way we can justify spending over 17% of the gross domestic product on health care, especially given the outcomes the system produces.
  • The Affordable Care Act has made system based approaches workable. Accountable Care Organizations and other forms of shared savings are being developed thanks to changes in CMS and in particular the Center for Medicare and Medicaid Innovation
  • Good primary care decreases costs and improves care.  The way that primary care doctors are going to be paid is going to be different, though. We are not going to be paid on fee-for-service but instead on managing chronic illness and keeping people out of the hospital.

Decreasing costs is not necessarily a good thing for an Academic Health Center. AHCs tend to rely on high margin services to offset training costs.It may be that we decide not to invest in primary care, relying instead on traditional appeals to “local medical doctors” and developing high margin profit lines. If we elect to develop primary care, it will need to be with an eye to improving care, increasing quality and improving safety. I hope we don’t do it with an eye to putting patients into my specialty colleagues’ exam rooms.

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The New England Journal of Medicine has a very good series on the implementation of the ACA (Affordable Care Act) or imminent arrival  of socialism as ushered in by  PPACA (Affordable Care Act)  depending on your politics. In the  article this week, John Kastor details the potential impact (or lack thereof) of Accountable Care Organizations (ACO)  on the Academic Health Center (AHC). As a physician who has spent almost his entire career in academics, I have seen how change happens (slowly) and how difficult the transition is for some. As the new law is being implemented despite some controversy, it is important that we in academics prepare for the changes as best we can.

Dr Kastor points out that the concept of the ACO is completely contrary to the way medicine is practiced in the AHC. AHCs tend to be rather top heavy with sub-sub specialists. In contrast

The ACO concept is predicated on the primacy of primary care, with doctors, nurse practitioners, nurses, and other health care providers working together to supply the most efficient, successful, and economical care for their patients.

He also points out that the AHC administrative structure may not be conducive to an ACO infrastructure. The tradition is for colleges of medicine to be a part of a larger university. The university is typically composed of many colleges, each of which is headed by a Dean. While this works for arts and sciences, it can be problematic if the college is expected to generate excess revenue in some manner such as patient care:

…the dean, who is often responsible for the practice plan, reports to a senior university official, whereas the hospital’s chief executive officer (CEO) reports to an independent board of trustees, as is the case at the University of Maryland, where I work. Conflict among deans, among chairs of clinical departments, and between directors of practices and directors of hospitals, particularly over the distribution of resources, can be endemic in institutions structured in this manner.

The organization of the AHC will be challenged in another way as well. The structure of the clinical department is based on the university model developed in the 16th century. In this model faculty members who share a common knowledge are gathered in a department. This department is headed by a Chairperson. These departments are tasked with offering instruction in the unique content that the department faculty represent.

Chairs tend to be jealous of their prerogatives and are not naturally inclined to transfer the administration of their clinical services to a central authority whose aims may not coincide with their own. The effectiveness of ACOs will depend on the centralization of the administration of medical care, whereas clinical departments in medical schools operate on a decentralized model. At least currently, department chairs have few incentives to change from their traditional method of operating. Without such coordination, it will be difficult for academic medical centers to reduce the costs of practicing medicine — one of the principal aims of ACOs.

Another potential problem is the use of faculty physicians to supervise and deliver care. Faculty members in academic departments see their role, at least in part, as furthering global knowledge. The way this is traditionally assessed is  when the faculty members receive grant funding and publish papers in peer reviewed journals. For faculty who teach history, this means going to the library and researching in the stacks then perhaps going out into the field. To some medical school faculty, this means treating patients in a unique manner. Unfortunately, for ACOs to work, the care, where possible, must be standardized.

Such standardization is not characteristic of the work of many clinical faculty members, who may have their own ways of diagnosing and treating patients who have similar diseases. Furthermore, doctors must accustom themselves to working with teams of auxiliary personnel to optimize their patients’ care, particularly for chronic conditions.

The traditional mission of AHC—teaching learners the nuts and bolts of clinical medicine—doesn’t pay very well. As ACOs proliferate, the anticipated efficiencies will eliminate some of the fee-for-service excess revenue that was being used by AHCs to accomplish this mission. Unfortunately, there doesn’t seem to be any obvious replacement for this revenue at this time. Additionally, the ACO is intended to change the balance in the health care world. As opposed to other industrialized countries, America has a health care system that is specialist dominated.  Many have speculated that this is a contributor to the well documented high cost and poor quality of care. This will be a problem for AHCs.

It is the specialists, not the primary care providers, who dominate academic medical centers and order the expensive tests that increase hospital charges. Moreover, many patients are referred to academic centers for single-encounter diagnosis and treatment of one particular medical problem and not for long-term care, which is a key focus of ACOs. The requirement for robust primary care programs will present a problem for many, perhaps most, academic medical centers that propose to become ACOs. Centers that do not have large primary care programs staffed by full-time faculty or that decide not to develop such units will need to form alliances with off-campus groups of primary care providers, many of whom may be self-employed — an undertaking with which many centers will be unfamiliar.

Ultimately, AHCs may find that they have a niche that doesn’t require affiliation with an ACO to take advantage of the ACA (PPACA). Their hyperspecialization may be useful to patients on a contracted basis for care such as transplants or treatment of rare illnesses. However, if AHCs remain tasked with training physicians-to-be with learning bread and butter medicine, they had better find a way to bring learners and these types of patients together. ACOs are potentially one such way to do that but it will require the AHC to change, not the other way around.

An article about geographic distribution regarding primary care for children was published in Pediatrics over the break. The investigators found the following

Between 1996 and 2006, the general pediatrician and family physician workforces expanded by 51% and 35%, respectively, whereas the child population increased by only 9%. The 2006 per-capita supply varied by >600% across local primary care markets. Nearly 15 million children (20% of the US child population) lived in local markets with <710 children per child physician (average of 141 child physicians per 100 000 children), whereas another 15 million lived in areas with >4400 children per child physician (average of 22 child physicians per 100 000 children). In addition, almost 1 million children lived in areas with no local child physician. Nearly all 50 states had evidence of similar extremes of physician maldistribution.

Once again, the data from Alabama are telling. There is a large disparity in distribution of primary care providers for children when Alabama’s performance as a whole (44th) and performance in rural areas (42nd) is compared to our performance in highly populated urban areas (13th – reflects Mobile, Montgomery, Jefferson, and Madison). There are three take home messages from these and similar data that I see

  1. In Alabama the market works just as you would expect. In urban areas where physicians who see a high volume low acuity practice can make a good living, there are a lot of physicians. In rural areas it almost certainly won’t happen, and this is a consequence of our current payment structure (discussed here and here). In Alabama where 45% of all births are funded through Medicaid, not changing Medicaid means not improving the system. The system is perfectly designed to achieve the results it achieves.
  2. Letting more people from urban areas into our medical schools (as we’ve done with the class expansions at USA and UAB) to turn out more docs in hopes that they will move into rural areas by bribing them with loan repayment or threatening them with inability to make a living in urban areas will not work, either. It turns out that physicians can generate their own business regardless of the “need” under the currently structured system and patients will play along (need an imaging study? Additional labs? An operation?) as discussed here and here. The combination of lifestyle and need to generate volume will ensure a continued maldistribution in Alabama under the current payment structure for the next 20 years. In 1956 Kerr White published a study of how healthcare money was spent entitled the “ecology of medicine” which was updated in 2001 by Larry Greene. If such a study were done in Alabama it would be interesting to see what our citizens get for the money. I only hope Governor Bentley understands this.
  3. Although money makes everything better (or allows for the purchase of better antidepressants), even if we altered the payment structure we will not get happy, fulfilled docs in rural Alabama. The other aspects of the infrastructure needed (discussed here, here, and here) are adequate professional support, availability of technology, access to tertiary care,and a team based approach that includes non-physician providers. Particularly, to care for children requires accessibility for the patients as well as physician accessibility to information and tertiary care.

The investigators reached the following conclusion:

The status quo has resulted in a primary care workforce for children that has grown tremendously without elimination of major variations in primary care supply. As demonstrated by the dramatic variation in local child physician supplies across the United States in the face of robust expansion in the child physician workforce, current calls for expansion in medical schools and lifting of the graduate medical education cap should be viewed critically. Unless expansion is targeted explicitly toward serving populations with the greatest needs, it may lead to greater health care inequities, with little improvement in the quality or outcomes of care. Accountability for the public funds that support medical training should start with concerted, transparent efforts to develop, to use, and to evaluate policies aimed at reducing disparities in geographic access to care caused by extremes of physician maldistribution.

With this conclusion I heartily agree.

I interview approximately 60 prospective physicians for medical school over the course of the year and 40 physicians who are applying for the residency program. The pre-med students (almost all of whom are the age of my children) tend to have pretty good interview skills and are trying very hard to get into medical school (“I’ve wanted to be a doctor for as long as I can remember”) so the interviews tend to be somewhat predictable. Every so often I’ll get one who considers ObamaCare to be the devil’s work but for the most part they are good but non-controversial interviews.

The resident interviews are more fun for me. These are physicians-to-be who want to be in Family Medicine, want to see what our program has to offer, and have at least a passing understanding of the advantages our program might have over our competition. These are interviews with much more substance. The three on Friday were especially enjoyable.

One of the candidates was from Louisiana and grew up in a part of the state that my family is from as well. After a discussion regarding Cajun territory, the conversation veered towards Family Medicine and why he wanted to become a Family Physician. The candidate had done most of his clinical work in Lafayette, a regional clinical site where Family Medicine is taught. Like all good clinicians-to-be, on every clinical rotation the instructors not only focused on his clinical learning but also on his career choice. “Why Family Medicine” they would ask. He worried about the prestige factor as he was choosing a specialty. His decision was cemented, though, by a decision LSU made to place him with a rural Family Physician for an extended period. He saw this physician as a mentor and it was this relationship that cemented his decision to go into Family Medicine. He said “At the (teaching) hospital in Lafayette, the Family Medicine team is down here and the specialists are up here. Out in the community it is completely reversed.”

The second candidate was a student who had come for an interview the previous year. I remember the interview from last year very well. I was very surprised when I heard that this student selected Pediatrics instead of Family Medicine. She came back to re-interview because she said she had discovered her mistake and wanted to be a “Family Doc.” She said she was admitting a very young patient to the inpatient service for failure-to-thrive. It is uncommon for infants to fail to thrive and it is almost always a parenting problem and not an infant problem. In this case the mother seemed to the resident to be suffering from post-partum depression. Unfortunately, she was told that it was not her place to treat the depression, only the poorly fed infant. She said to me “I want to be able to treat the whole family.”

The third was a non-traditional candidate who was originally from Mobile. He left Mobile almost 18 years ago and after a roundabout life course ended up in medical school. He told me “I want to take care of people who are underserved in a holistic way and I want to do it here at home.” The fact that he was of African-American descent was meaningful. Traditionally we have had trouble attracting African-American candidates from Mobile into primary care, as have others, in part because there is a tradition in the community to encourage minority medical students to pursue limited specialty choices. I suspect this is a reminder of our racist past in this region, where African-American physicians were excluded from specialty training. Having Family Medicine seen as a “specialty” by this student is clearly a victory.

So three candidates and three conversations that give me hope for our specialty and the future of medicine.

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.

The faculty at the college of medicine were asked along by the College of Medicine “blogger” to share what we thought were the top three advances in medicine. I named two drugs (H2 blockers like Tagamet because they practically eliminated a type of surgery and statin drugs like Zocor because they have altered the course of heart disease dramatically) and one process (outcomes measurement because it forces physicians to consider how they are in aggregate and look at an individual patient’s improvement or lack thereof). I was not asked what has changed Family Medicine training for the worse but I am certain in my top three would be the “Teaching Rules”.

I have discussed peripherally how we pay for physicians-in-training here and a little more detail about the agency that pays for them here and here, but I’ve not yet attempted to describe the disconnect between the payment process and the training process that currently exists. Partly that is because the story starts in 1965. It seems that from its inception, Medicare was expected to pay for some training but did not want to pay for all training. From testimony before the Practicing Physicians Advisory Council by the AAMC:

There is a 35 year history of Medicare requirements that a teaching physician is obligated to comply with when he or she submits a bill for a service in which a resident is involved. At issue over the years has been the extent to which a teaching physician must be present during a service in which a resident is involved, and the documentation that must be provided to support the level of a bill submitted to Medicare. Starting in 1967, The Centers for Medicare and Medicaid Services (CMS) and its predecessor organizations have issued a number of regulations, intermediary letters, memoranda and other documents that attempted to clarify the requirements. These efforts were not successful, and, in 1995, HCFA issued a new rule that superceded the old pronouncements. It became effective as of July 1, 1996.

Over the years, the Academic Health Centers had rationalized accepting payment for care provided by residents.  T he discussion around the development of this rule made it clear that Medicare felt that they were paying for the care delivered by the learner already and so the additional payment for care delivery seemed to be “double-dipping.” The 1996 “clarification” created a set of regulations which were well-intentioned but had several consequences, intended and unintended. First, it resulted in an immediate loss of revenue for the care of those patients who were insured through Medicare which was anticipated. Secondly, every other insurance followed Medicare’s lead (even though they do not pay us through any other method for training residents) resulting in additional loss of revenue which was unintended.

The response of Academic Medicine could have been to provide free care and charge learners tuition to make up the difference. Instead we decided to work within the new rules to maximize revenue generated as a consequence of patient care. For most hospital based specialties this meant the Teaching Physician needed to be present for certain aspects of care (such as a surgery performed by a resident, for example). The rules posed a particular challenge in Family Medicine, where most training took place in the office and involved thinking more often than the performance of a procedure. The thought process is more difficult to supervise than the removal of a gall bladder. Initially it looked like the rules would lead to the death of primary care training. The rules eventually  included an exception for primary care training to mitigate some of the potential difficulties. Unfortunately, as the rules were interpreted and reinterpreted, it seems that lost in the process was the intent of preserving primary care training.

As I said before, Family Medicine training tends to be different. Here at South Alabama we want our learners, by the time they finish their residency, to know how to take responsibility for patients over time. This includes caring for their acute illness, chronic illness, and facilitating their use of preventive services regardless of their insurance. The only way I know of to do this is to begin with heavy supervision and offer learners the opportunity to gradually practice independently over the course of the training program. We wish for our learners, when they graduate, to care for underserved populations so we would like to offer them the opportunity to provide care for patients with Medicare and other insurances while in training.

When the new rules were enacted we could (and did) request a “primary care exception” to allow us to not have to directly supervise the care delivered by every resident who had Medicare insurance. To obtain this we had to have one faculty for every four residents (which we were already doing) and the residents couldn’t bill for “higher level” codes. Although this sounds fairly simple, the rules have been interpreted and  re-interpreted.  So if a resident sees a patient who is “not complicated” but becomes complicated, what should the teaching physician do? Regarding the 1-4 ration, what if there are 7 residents and 2 teaching physicians? Under such circumstances, must each faculty member supervise a designated 3 or 4 of the 7 residents, or can they essentially provide “cross-coverage” of the entire 7 residents between them? If one of the teaching physicians takes a phone call, is he capable of supervising or does he have to call in a back-up supervisor while he’s on the phone? Each of these circumstances is open to interpretation, and unfortunately the audit is typically 2-3 years behind so we are required to keep records and detailed notes on what happened.

Part of the problem is that the rules are interpreted by intermediaries and are different in different locations and at different times.  What I can do is not what my colleagues in the northeast are able to do so we can’t offer best practices to our colleagues. Another problem is that the interpretations of the rules  are colored by “consultants” who have no more knowledge than most about the interpretation of the rules but as a consequence of their status can cause great disruption.  Because of the teaching rules we focus on style over substance, documentation over instruction, and worry all too much about payment for a particular activity. Our Family Medicine Center went from being marginally profitable prior to the Teaching Rules to being $700,000 in the red.

Clearly there are competing demands on the system and even under the current oppressive set of rules it is cheaper to use residents than any other labor source for many types of care delivery in Academic Health Centers. In Family Medicine it is more expensive to provide such care in the context of training. I believe we continue to do so because we realize the importance of our training mission and understand that there are no alternative training methods. As a consequence we react to continual reinterpretation with coping (like the frog in the boiling water) rather than saying “to heck with it.” I hope that the value of high quality subsidized training for Family Physicians is understood by Dr Berwick and he will work with the leaders in Family Medicine training to make the rules less difficult to interpret and follow. On my wish list for the primary care exception as it relates to the Teaching Rules are the following:

  • Changing the direct  payment structure such that the money follows the trainee instead of going through the Academic Health Center. This would allow me to hire the appropriate team members to transform the Family Medicine Center into a true Patient Centered Medical Home
  • Changing the rules such that the resident can deliver care for his or her patient without having to with hold documentation so that he or she can remain in compliance with the teaching rules. This means eliminating the restrictions on the codes that can be billed in the residents name if the Primary Care exception is followed
  • Use the PQRI process as a method to document the reception of value for care rather than focus on how residents are supervised as a metric. If we are able to deliver good care, does the minutia of supervision matter?

Are there more? Maybe Dr Berwick is open to suggestions…

As I was driving back from a very nice long week-end with my extended family (fireworks, festivals, baseball, wings, and art in a gritty urban setting) in metro Atlanta, I heard an NPR story on “the July effect.”  This effect is a suspicion (now with some evidence behind it) that health care in teaching hospitals is worse in July because of the inexperience of the new learners (or as I tell my residents “You are moving from a very experienced physicians at one level to a very inexperienced physician at the next level”). The report cites an increase in deaths in counties with teaching hospitals and  lack of a similar effect in counties with non-teaching hospitals in July as evidence for this effect. It only finds the effect with medical errors. I am grateful to Dr Carol Motley who traded calls with me so I could be with my family and she could work with the newly promoted physicians on this worst weekend of the worst month of the year.

From experience I will agree that the learning curve for a newly promoted physician is steep. I unfortunately know of no better method of training physicians. The author of the study in his interview cited a lack of surgical effect as evidence that surgical training is superior. I would argue that this suggests a certain randomness to his findings and we probably need to look more closely before discarding the entire training process. It does point out the need for close supervision of neophyte learners and the importance of good processes coupled with an assessment of outcomes to determine if the desired effect is being achieved.

It also identifies a need for continuation of an extensively supervised period of learning prior to neophyte physicians being transitioned into the “real world”. This process (known as residency training) is labor intensive if done correctly. It involves ongoing assessment of the learners progress towards achieving  six types of competence which the prototypical physician is expected to demonstrate in practice. We do this in part through close supervision of the learner in hopes of detecting potential errors before they are made. We also do this by collating thousands of individual observations on each of our learners and using them to assess progress towards achieving these competencies. This process is time consuming and expensive.

The current way of paying for this instruction is for the payor (usually Medicare)  to give money to the hospitals and hope that they pass this money on to those of us providing the instruction. The hospitals tend to see the cost of training residents as including a lot of costs not involving direct supervision and assessment residents by attending physicians (in part because we can bill for the service which covers a small part of the total cost). Consequently, we don’t see much of that money. Perhaps if more people are aware of the “July problem” the allocation of money to pay  for supervision of neophyte residents will be seen as important.

Fitzhugh Mullins published an article this week in which he evaluates the ability of medical schools to respond to the “social mission.” In it, he uses a metric to measure the medical schools contribution to solving the following societal problems: an insufficient number of primary care physicians, geographic maldistribution of physicians, and the lack of a representative number of racial and ethnic minorities in medical schools and in practice. Using only physicians who have been in practice for 10 years, he determines which schools are good at this and which schools…um… not so good.

I bring this up not just because my school (the University of South Alabama) is the 8th best in our students doing the right thing, but also because it is an important story. As was pointed out on NPR’s healthcare blog

Medical schools, Chen explains, often claim whether students choose primary care has a lot more to do with financial worries – including paying off student loans – than with how the schools operate. “But the variation shows that some medical schools are obviously doing it better than others,” she says.  “It allows us to give credit to medical schools that are doing the hard work, the good work, the social mission work. Medical schools have traditionally not gotten a lot of credit for this work.”

We will debate the relative importance of the many missions of the Academic Health Center for several years yet but is is good to be in the top 10 of something.

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?

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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