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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.
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Dale Quinney, Executive Director of the Alabama Rural Health Association, sent me the following assorted random facts that point to just how dire the needs are (or just how great the opportunities are) in rural Alabama.

51 of Alabama’s 55 rural counties are currently classified as having a shortage of primary care physicians.  Only Coffee, Dallas, Marion, and Pike counties are not currently considered shortage areas.  (This classification measures the provision of MINIMAL rather than OPTIMAL care.) 

 

To eliminate all shortage designations, Alabama needs an additional 128 primary care physicians.  402 additional primary care physicians are needed to provide optimal care. 

 

All 55 rural counties are currently classified as having a shortage of dental care providers.    To eliminate all shortage designations, Alabama needs an additional 288 dentists.  348 additional dentists are needed to provide optimal care.  Alabama’s only dental school currently admits only 55 students each year. 

 

All 55 rural counties are currently classified as having a shortage of mental health care providers.    To eliminate all shortage designations, Alabama needs an additional 44 psychiatrists.  185 additional psychiatrists are needed to provide optimal care. 

 

More than one half of all actively practicing primary care physicians in Alabama are aged 50 years or more. 

 

It is estimated that the number of annual office visits to primary care physicians in Alabama will increase by more than 1,785,000 by the year 2025 – primarily due to the aging of Alabama’s population.  Over 904,000 of these additional office visits will involve rural physicians.  This increase does not consider such adverse factors as obesity with nearly one third of all adult Alabamians currently being obese, not simply overweight. 

 

Only 20 of Alabama’s 55 rural counties have hospitals that perform obstetrics.  In 1980, 46 of these counties had hospitals performing obstetrics. 

 

More than one in every five (22.1 percent) rural Alabamians are eligible for Medicaid services.  This is nearly one half ((44.5 percent) for rural Alabama’s children. 

 

The per capita personal income for rural Alabama residents is $29,170 which is over 21 percent lower than the per capita income of $37,109 for urban residents and over 27 percent below the figure of $40,166 for the nation.  Five rural Alabama counties (Wilcox, Bullock, Barbour, Sumter, and Bibb) are among the 250 poorest counties in the nation. 

 

The motor vehicle accident death rate in Alabama’s rural counties is 25.1 deaths per 100,000 population.  This rate is only 14.6 for the nation.  30 rural counties have motor vehicle accident death rates that are more than double the national rate with eight having rates that are more than triple the national rate.  While there are a number of reasons for this disparity, the great variation in  emergency medical service among the counties must be recognized as a contributing factor. 

 

Nearly one in every ten (8.5 percent in 2000) rural Alabama households have no vehicle for transportation.  This percentage is in double digits for 22 rural counties.

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…

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.

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