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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.

What it the purpose of a medical school? Seems like a dumb question but it turns out there is not an easy answer. Is the purpose to function as a regional economic engine? University of Alabama, Birmingham College of Medicine certainly does. Is it to provide care for the indigent of the region? Up until recently the indigent in New Orleans would not have had any health care were it not for the presence of LSU and Tulane at Charity Hospital. Is it to assure adequate physician manpower for the region? Clearly the presence of 2 medical schools accepting almost 300 students per year has not accomplished that for rural Alabama.

The American Academy of Family Physicians announced a new tool for those of us who are interested in whether the physician output is the purpose or the byproduct of medical education.

The AAFP’s Robert Graham Center has unveiled a medical school mapping program that allows users to gauge the role of medical schools in promoting and sustaining primary care access within states, regions and localities.

The free Med School Mapper tool can be used to identify counties in which a school’s graduates currently practice, the number of physicians in each county who have graduated from a particular school, medical schools that provide the most graduates to each county, and the percentage of graduates who are practicing in rural or underserved areas.

Using it has led to some interesting discussions around the office.

I’m back in Mobile from the Alabama Academy of Family Physicians meeting in Sandestin Florida (why an Alabama meeting is in Florida is a story for another day) and I was struck by three separate observations. The first was the participation of students in the meeting. The Alabama Academy Foundation has recently begun sponsoring students at the meeting and this year there were 20 students who had enough of an interest in primary care and Family Medicine to come to the meeting. You might say “So what, how tough can a trip to Sandestin be.”  I can assure you that Dr Coleman made sure these students were at more meetings than beaches. They all seemed engaged and eager to learn about and participate in the delivery of primary care upon graduation. Here’s hoping we get the payment structure improved before the students graduate so they will not be actively discouraged from going into primary care due to income potential.

The second observation was regarding the visit of gubernatorial candidate Robert Bentley. These meetings do not usually take on the tone of a political rally, but because Dr Bentley is a physician I suppose it was felt by the leadership to be okay. Dr Bentley stated that having a physician in the governor’s mansion would help Family Physicians to succeed (because we all have medical school in common). He then outlined his platform of fighting against “certain provisions” of the Patient Protection and Affordability act throughout his governorship. His belief is that we can delay long enough to allow the Obama administration and the Democratic Congress to be replaced, then the entire bill can be repealed. He favors replacing the coverage provision with Health Savings Accounts, tort reform, tax breaks, and the traditional doctor goodwill. It will be this goodwill that physicians draw upon when asked to see an uninsured patient. I would like for Dr Bentley to come and speak to some of the specialists in Mobile who seem to have lost the goodwill aspect of their practice and let’s see if we can create a more collegial atmosphere down here. In particular, I would like to draw his attention to the dermatology situation.

The last observation is regarding the update from the Academy. Every year the national Academy sends a representative to fill in the membership on the ongoing activities and upcoming plans. The update this year included the details of the Patient Protection and Affordability Act. In particular, it included information regarding the Medicare Pilot Programs. The law requires that these programs be developed, evaluated by CMS (not by Congress), and if shown to save money be rapidly replicated. The Accountable Care Organization (2012) and Bundling Payments (2013) are going to be rapidly piloted, evaluated, and replicated. It is clear that this will happen because CMS wants to be out of the business of paying for fee-for-service medicine and sees this as a huge opportunity.

So my advice to the students (and folks already in Family Medicine) is this: The wave of payment reform is going to happen. Primary care in general and Family Medicine specifically is being positioned to be in the driver’s seat of a changed healthcare system. The battle to keep government out of health care delivery was lost 60 years ago. Rather than working to negate the law, I encourage all of us to work to make advanced primary care techniques a part our practice and to work to make our medical neighborhood a place where safe, effective, and efficient medicine takes place. Rather than wait to see if another wave comes along, I would suggest we paddle as hard as we can to get in front of this one.

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.

University of Alabama, Birmingham is in the process of selecting a new Dean for its medical school. I have worked in academic medicine for almost 20 years and my father was in academics throughout the period that I was growing up so I understand the ebb and flow of the academic setting. In fact, Wallace Sayre summed up the problems very succinctly by saying “Academic politics is the most vicious and bitter form of politics, because the stakes are so low.”

This is never more apparent when it is time to hire a high-ranking executive in an academic setting. Universities typically use a “Search Committee”  to develop a list of candidates that the Provost (in this case) might choose from. Here is a quote from the University of New Mexico policy on hiring such people:

An effective search committee strategy will do much to facilitate, rather than undermine, an effective search. Keep in mind that the goal when using a search committee is to optimize the effectiveness of the search process from the perspective of all parties concerned-the hiring authority, members of the search committee, colleagues, and in particular, the applicants. Since the search process sets the stage for the future employment relationship, careful attention should be paid in effectively managing this very important phase of the staffing process.” (emphasis mine)

Imagine if  all HR departments had to run potential executives in front of a group of disgruntled folks with their own axes to grind. It would be a wonder if anybody got hired.

The reason this came up is that the Search Committee for the Dean at UAB does not contain a Family Physician, General Internist, or a General Pediatrician. The leadership in Family Medicine asked whether a differently constituted search committee might select a Dean that would place more emphasis on primary care and rural medicine.

It is my opinion that it would not and here’s why. Academic medicine sees Family Medicine as one of a number of competing clinical concerns that they need to balance as they provide education for undifferentiated students.  Traditional academic deans are concerned with maintaining or building revenue streams (typically family medicine is not helpful in this regard), maintaining the educational programs (in which case they need Family Medicine as well as Surgery, Medicine, OB, Peds, and Psych and Pathology  known collectively as the educational “six-pack plus one”), and growing research programs (typically not a Family Medicine function except at the Dukes of the world). Academic medicine in my opinion, does not seen themselves as producers of the physician workforce anymore than Colleges of Arts and Sciences see themselves as producers of the Chaucer scholar workforce. Colleges of Education tend to understand this workforce issue better than most (probably due to the initial charters under which they were founded and state mandates) but now with the charter school movement that might change.

Those of us in academic Family Medicine might see ourselves as producing tomorrow’ s healers but Deans and Provosts see us as  most equal to the others in the “six-pack.”

Medical schools typically don’t care about shortages, workforce needs, unless required to by external pressure. The reason is multi-factorial. One is that there is a lot of give in the system. We graduate 17600 allopathic physicians in this country. There are another couple of thousand osteopathic graduates. We allow almost 10,000 folks from other countries or from Caribbean schools into this country EVERY YEAR to fill the remaining slots. That’s one reason that medical schools don’t worry because this allows US schools to say that the “market” will fix things. We have been unsuccessful in the last 10 years in trying to develop a primary care workforce using a majority non-US grads.

The other reason is that the pipeline following medical school graduation is in the training hospitals and this portion of the pipeline is divorced from the medical schools. Medical schools point to the residencies and claim protection from these types of issues. The residencies point to success in the match as proof that their clinical care is vital and necessary. The way the payment structure is set up all of the grads get jobs, so why should the residencies worry? Of course, when we all get leukemia from CT exposure it’ll be a problem but more business for Oncologists as well.

What makes Deans worry about students attitudes towards a career in primary care? Mandates work for state schools. If the governor or key legislatures say “you gotta make primary care docs”, it happens. As it stands now, some in the Alabama legislature are securing funding fo an osteopathic pipeline as a response to the “shortage” but there are still no mandates in place so it’ll likely fail in this regard as well. This pipeline may have more success because folks educated in rural areas are more likely to go into primary care, all other things being equal.

What else works? Selecting the right students, educating them in a nurturing environment, and paying them (or at least not making them take out and pay loans) for doing the right thing. Paying primary care docs for doing the right thing makes students want to go into primary care. Lastly, making the communities conducive to quality care delivery works (which is why I would like to see collaboration between Schools of Public Health and Colleges of Medicine).

In summary, I suspect that UAB will select a Dean based on the weight of his or her CV and the perceived possibility of extramural funding and/or prestige regardless of the search committee composition. If Alabama wants primary care docs, the Dean will probably not matter one way or another. In fact, one Dean would argue that the Dean’s job is more of a mediator than anything else.  The Governor, on the other hand, will be a different story.

I recently gave a “State of the Department”  report to the Executive Committee of the College of Medicine. I took over as Chair in 2005 and have attempted to create a training environment that would facilitate entry of students into a primary care practice with a focus on rural and underserved Alabama.  The template we are working off of is above.
We’ve not done very well in the 4 years since I became Chair.  Only 5% of the students have gone into Family Mediicne and those going into Internal Medicine and Pediatrics have mostly left the state. In the course of the discussion, the non-Family Physician faculty became very defensive and felt that they should not be asked to take responsibility for an outcome that they were unable to influence. In addition, they felt that test scores were an outcome that they should be able to influence and rural students would have trouble keeping up with our current students.
Fortunately, the National Rural Health Association is working on a position paper to counter this argument. In it, they point out that “Medical education programs that include a focus on attracting practitioners to rural settings offer both recruiting and retention benefits to rural communities. In one study, six medical schools that made an explicit commitment to increasing the rural physician supply, that had a defined cohort of students, and that offered a focused rural admissions process or an extended rural clinical curriculum placed an average of 57% of their graduates in rural areas (compared to a 3% of medical students who report intending to practice in rural areas and the 9% of physicians who currently work in rural areas) and, of the two schools for which statistics were available, 79% and 87% of these physicians were still practicing in rural communities from 1 to 20 years after graduation. Implementing similar strategies for 10 students a year in the 125 United States allopathic medical schools would conservatively create an estimated 1139 physicians in rural practice, more than double the numbers expected without these strategies in place.”
This study does not mention test scores but it has been my experience that the NBME exams measure one clinical competency (medical knowledge) and do it on a threshold basis (can you make the minimum on the exam). Maybe we need to assess medical schools differently…

Growing up in Baton Rouge in the 1960’s, I am genetically predisposed to be a fan of  LSU and Saints football. LSU is an easy team to declare one’s allegiance to as it has a proven winning track record, one Heisman Trophy winner, several national championships (both before and after the creation of the BCS) and a real tiger habitat to keep its tiger in. The Saints, are a different story. To be a fan of theirs, you have to be used to creative book-keeping. Some would say that since that opening kick-off in 1967 (run back for a touchdown) it has been downhill. In their 42 years of existence, they have had 14 head coaches, have never been to the Superbowl, have only been to one championship game (and lost), and have only been to the playoffs 7 times (including this season). They went 11 years before winning and losing an equal number of games and went another 10 years before posting a WINNING record. I travelled to the game last night and watched them lose knowing all along that they will find new and creative ways to disappoint me.

Also, as mentioned previously, I am training for a marathon. I have been running relatively long distances since I was 16. Not being very fast, I discovered I could outlast some people on street races and when I was 18 I decided to run the Mardi Gras Marathon. Being 18, I assumed training was optional. I ran it in about 4 hours which in hindsight was pretty good for someone who showed up to “gut it out”. I have now run about 5 or 6 marathons and know that for survival as a 49-year-old, training is an 18 week experience. I am now finished the last hard week but still have some miles to put in before the race on the 10th.

What does any of this have to do with health care reform? I chose to go into the military so that I could practice medicine without consideration of personal debt entering into my career choice. I chose the specialty of Family Medicine because it was the one that allowed me to deliver the care to my patients in a personal, cost-effective manner. Like selecting the Saints, my choice of specialty was not based on “winning” but on what was a good fit between me and my patients. When I chose the specialty, interest in the field was down. Specialty colleagues were convinced that Family Medicine was dead. I fell in with an outstanding group of Family Physicians (Ellen Sakornbut, Perry Dickenson, Frank deGruy) who felt otherwise. One of them (Perry Dickenson) had done some work for the young governor of Arkansas and felt like if he were elected President he might just be in a position to put the pyramid upright and place primary care at the base again.

Working on healthcare reform might seem like a sprint, but it has been much more of a distance run. We pick up a schedule and train, preparing for our time. We, like Saints fans, believe in what we are doing and even  the Cowboys are about to kick a field goal to put the game out of reach, we believe that they will miss (which happened). Bill Clinton blew it (as did Jimmy Carter, Richard Nixon, Lyndon Johnson, John Kennedy, and Harry Truman) but those of us who believe in the importance of primary care are ready once again. This time, we’re really close.

I have to give a presentation to the residents on “Clinical Decision Making” and this caused me to reflect on  “How Doctors Think” (Jerome Groopman’s book) and, more importantly to me, “How Should Primary Care Doctors Think?”. In an interview on NPR, Dr Groopman follows the story of a patient who lived with severe nausea, cramps, and weight loss ( mis-diagnosed  as anorexia for 15 years when in fact she suffered from a gluten intolerance) and who has seen approximately 30 physicians, none of whom are very helpful. The patient is saved when a physician (self-referred) sits down with her, elicits her entire story, then does the appropriate diagnostic test.

Dr Groopman feels that we in medicine are letting our patients down . He bemoans the fact that our training has become less apprentice like where we learn at the feet of the great clinicians. He suggests that the use of clinical algorithms  has led us to place patients in clinical “boxes” which benefit insurance companies, and pharmaceutical companies, but not patients. He feels (and I agree to an extent) that the solution isn’t following evidence based algorithms but lies in listening to the patients narrative. Where he and I differ is that where he thinks we need to focus more on critical clinical thinking in medical education and less on algorithms, I feel we need to teach folks when to rethink and how to put systems in place which limit the consequences of poor clinical thinking. The patient whose case he uses seems to me to have been let down by a system which encourages sloppy thinking, includes limited quality assurance, and rewards procedural efficiency.

First, the advantage primary care physicians have is that of time. We have done a poor job of teaching physicians how to utilize time as an aspect of disease management. In a separate interview, Dr Goopman identifies “anchoring” (when physicians latch onto a piece of information and do not change despite evidence to the contrary) as a problem which leads to missed diagnoses. If a patient such as this one is mislabeled as having a certain illness, multiple visits should offer the clinician a clue something else might need investigation. For example, abdominal cramps and intense nausea are not the diagnostic criteria for anorexia (see below) and in this patients care should have led to further investigation

Criteria for anorexia

  • Body weight < 85% of expected weight
  • Intense fear of gaining weight
  • Undue emphasis on body shape or weight
  • Amenorrhea (in girls and in women after menarche) for three consecutive months

    Secondly, in Advanced Primary Care involving the use of a high end electronic health record, algorithms can be used not to limit thinking but to confirm diagnostic labels. For example, if a diagnosis of diabetes is added to a patient’s medical record, the diagnositic criteria could be placed in front of the clinician to get confirmation that this is what was really meant and avoid mis-labeling. From a quality assurance standpoint, a diagnosis should be confirmed and the management should then be optimized based on accepted guidelines. Guidelines should be used to guide testing and therapy, not to limit thinking.

    Thirdly, we have lost critical thinking in all of medicine but it has been especially missed among subspecialists. Dr Groopman suggests that primary care docs, with only 12 minutes per visit, merely get a sketchy complaint from the patient and then route them to the appropriate “subspecialist”. In truth, the 12 minutes is a very loose average. The average primary care doc sees approximately 25 patients in an 8 hour day, resulting in approximately 20 useable minutes per patient. An ear infection takes approximately 3 minutes. We can (and do) use this extra 17 minutes to listen to and work with complex patients over the better part of an hour. What we (and patients) would benefit from in the way of subspecialty care are physicians who will listen to the patient’s story again, and work with us to help make a correct diagnosis and determine the appropriate treatment rather than calculating how to extract money from the patient’s insurance via invansive procedures. I was taught at Tulane by George Burch, C. Thorpe Ray, and others who prided themselves on being the good kind of consultant. What I try to encourage my learners to do is to find those types of consultants and latch onto them so that their patients will get complete care.

    One patient an hour and a nurse in go-go boots

    One patient an hour and a nurse in go-go boots

    There is an argument made about the “main stream media” that the information is influenced delivered by the bias of those screening the information. As someone who grew up with Vietnam at the dinner table (although not of draft age when the war ended), I will say that the pictures of the war and the pictures of the protesters seemed to a young me reflect reality rather than influence reality.

    I am, however,  a firm believer that popular culture influences student specialty selection rather than the other way around. Those admitted into medical school have little idea of what the average week of a person who chooses a given specialty will be like. In the case of Family Physicians, a week for one physician will not look like that of the person in the office across the street. Our beliefs of what we are getting into are colored, in fact, by popular media.

    When I was growing up the medical show was MASH. In actuality, an antiwar show disguised as a medical show, it demonstrated to us that one could be irreverent in the face of unreasonable authority and maintain ones compassion and (more importantly) sense of humor. Where Marcus Welby saw one patient an hour (and was really boring as he did it) the doctors on MASH were able to see dozens of patients, make time with nurses, pull the wool over the Colonel’s eyes, and be the good guy in the end. Let me be a surgeon…

    The students of 15 years ago were influenced by ER. Although if you analyze the practice, it was much more Family Medicine with bizarre trauma than a real ER, it allowed students to envision a life of non-stop excitement in a 12 hour shift followed by a torrid affair because “when you’re off, you’re off”. Having had the luxury of having 4 years in the military (very un-MASH like, it turns out) I worked in several ERs and discovered that seeing people on the worst day of their life every day wasn’t for me. Very difficult to convince students of that….after all, they’ve seen ER.

    The students of today seem to be influenced by a variety of media. The reality is that there is no dominate one. Some seem to be MASH aficionados. Others fans of “Nip/Tuck” on FX and enter medical school for the prestige and the power that they associate with being a doctor. Others are fans of “House”. They enter medical school not looking for the mundane but looking to solve the medical mystery.

    The popular media has never been good at portraying the mundane aspects of daily life. Family life in the 1960’s and 70’s was represented alternately as a walk in the park (The Adventures of Ozzie and Harriet) or as a “reality-based show”  (An American Family) that demonstrated a level of pathos not seen again until Jerry Springer. It may be a while until they get Doctoring right. I was given some media that explains what Family Doctors do (or will do as Patient Centered Primary Care physicians). The production values are not nearly as good as MASH, but here is a video about how good primary care allows people to take better care of themselves when they have diabetes. Here is one that describes exactly what that model will be. Here is our Academy’s take on it. Here is why women like good primary care. Unfortunately, here is a doctor who feels that delivering exceptional care ought to be reimbursed better.

    Maybe one day, a comedy….