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Monday Jun 03, 2013

Family Medicine Wins … or Loses?

On the day before graduation at the University of Nevada School of Medicine, where I am Chairman of the Department of Family and Community Medicine, the school recognizes students who have performed well during an awards ceremony. The ceremony also offers an opportunity for students from both our Reno and Las Vegas campuses to recognize the faculty mentors who were important to them during their training through individual and departmental awards.

This year, I was honored to receive the Tow Humanism award and the Clinical Faculty Teacher of the Year award for Reno, while Kate Martin, M.D., assistant professor in family and community medicine, won the clinical teaching award for Las Vegas. Amanda Magrini, M.D., the chief resident in our family medicine residency, received the Resident Teacher of the Year award.

Not one clinical award was presented to a department other than family medicine, which also won Clinical Department of the Year awards for both Reno and Las Vegas.

You might think with this level of recognition that our family medicine program would be well on its way to recruiting more students into our specialty.

Not so fast. Only five of our 64 graduates this year chose family medicine. 

Our country has recognized the need for more physicians -- specifically, primary care physicians -- and our medical schools have responded by increasing enrollments. In 2009, there were 15,638 U.S. medical school graduates who participated in the National Resident Matching Program. This year, that number increased by nearly 2,000 to 17,487, an increase of almost 12 percent.

Meanwhile, family medicine residency training programs increased the number of available slots by almost 300 (from 2,764 in 2012 to 3,062 in 2013). The number of U.S. graduates going into family medicine also increased compared with last year's figure, but only by 39.

That slight increase in U.S. graduates filling family medicine positions combined with the much larger increase in the number of U.S. graduates overall means that the percentage of U.S. graduates choosing family medicine actually went down, from 48.4 percent in 2012 to 44.9 percent in 2013. 

The bottom line is that we have a need for more family physicians, and we have more available students to match to family medicine. And yet, a lower percentage of U.S. graduates are choosing our specialty. 

Five years ago, 20 percent of Nevada graduates chose family medicine. Now we are down to 7 percent.

Obviously, there is a huge disconnect. Our family medicine program is being recognized for excellence in patient care and teaching, so why aren't more of our graduates choosing family medicine? 

The Future of Family Medicine project pointed out two main reasons students don't choose family medicine: lifestyle and income. 

Students perceive family doctors as always being available for patients, working late hours, taking frequent phone calls and having our personal lives interrupted by patient care issues in the middle of the night, on holidays and weekends. To address this issue, a more patient-centered approach with an emphasis on prevention in the office might improve our lives outside of it.

Income is an even bigger issue. The disparities in income between specialties can be huge, with several hundred thousand dollar differences between the average primary care physician income and that of certain subspecialists. Narrowing that gap is definitely on the Academy's agenda.

We are looking to create primary care-specific evaluation and management codes that support the increased complexity of the family physician encounter.  In addition, we are advocating a CPT uplift for primary care physicians. As we move to a value-based system of payment, this should improve payment to primary care by paying for care coordination and population management of chronic disease.

In our department, we take exit surveys from our resident applicants who decide not to match our program. Three factors have emerged that touch on those issues of lifestyle and money: insufficient financial support for family medicine education, lack of an electronic health records (EHR) system and incomplete patient-centered medical home (PCMH) transformation.

The budget to support medical education in family medicine is lacking for both residents' and students' education. This shortfall relates to the income issue because our students see the faculty struggling to increase clinical revenue so they can carry out the mission of education.

      We have not yet implemented our EHR, and our PCMH is in its infancy. There are plenty of data that show the practice environment and physician and patient satisfaction improve dramatically when technology is used and a practice transforms into a PCMH. We are working toward that goal.

      So, what do we need to do, both at our local level and nationally, to attract more students into family medicine?

  • Continue to be great role models and teachers in family medicine.
  • Work to protect and increase graduate medical education funding so that students see that family medicine is valued.
  • Continue to move forward with information technology and the PCMH, and work to improve practice environments.
  • Move forward with the transition to a value-based system of payment. In the meantime, advocate that family physicians' income be increased and that the income gap between our specialty and others be closed.

Family physicians make great role models and teachers, but that isn't enough to encourage a sufficient number of students to go into family medicine. What else do you think could be done to draw more students to our specialty?

Daniel Spogen, M.D.is a member of the AAFP Board of Directors.

Comments:

Our design for medical education and our design for payment prevents choice of family medicine. More of us and 30% revenue over the cost of delivering primary care are the requirements for efficient and effective primary care recovery for our nation.

We need entry of students committed to health access and health access training integrated with practice across the entire span of before, during, and after training.

We need family medicine medical schools. This involves a process of discovering commitment to health access prior to medical school.

We know that it takes many months if not years to understand who we are and what we do. There is not enough time and certainly not the resources expended to get medical students beyond "overwhelmed' (3 months exposure) to neutral (6 months) and to appreciation (9 months).

The current design will not allow this - so we must add sufficient preparation and training in front of our 3 year residency training to supply our needs - and the needs of half the nation behind in basic health access.

We are the only ones remaining who demonstrate commitment to primary care and to primary care where needed. It is this commitment that results in a lifetime of primary care, over 90,000 visits (2 to 7 times other sources), 2 to 4 times more primary care where needed, $12 training cost per visit (4 to 8 times less cost per visit over a career), and multiple times more instate primary care. Our optimized design is multiple times better than any other primary care source - by design.

Our clinicians must be committed to health access before training and they must train at health access sites during medical school and during FM residency.

Assessment as a suitable candidate for admission includes assessment as an employee, as a member of the health access team, and as a life-long learner. The academic progress evaluation should involve performance on course work sufficient to demonstrate the capacities required of a physician delivering the most complex health care - front line health access.

The curricular design should be continuity longitudinal in nature guided predominantly by clinicians who guide the development at the medical school and at the sites of practice. This is also a design that facilitates the delivery of health access where needed before, during, and after medical training.

Florida State, the Northern Ontario School, the Minnesota Rural Physician Associates Program, and the Accelerated FM designs represent a best future for health access for our nation with integration of training with practice. These designs have demonstrated not just adequate, but superior medical education with outcomes specific to the populations served by family physicians. This has required faculty development guided by a legacy design and by those such as Dennis Baker at Florida State. AAMC GQ, MedEdIQ, and residency director preferences confirm the outcomes of such design. LCME has approved such designs. The pathway to excellence leads through us and designs that optimize what we do.

We are the pathway to the fewest graduates needed for sufficient primary care for an entire nation with the least additional costs for distribution – another cost factor that grows rapidly with each passing year.

Flexner demonstrated the primary importance of preparation prior to admission. The preparation that emerged over the past 100 years has been in the wrong directions for health access.

The prerequisites of the health access design are local in application and specific to health access. We want health access workforce to develop and remain locally with care specific to the populations in need of care.

The pathway to FM must teach the language of health access, the technologies, and the applications. This can only occur in our practices prior to admission. The current admissions pathway of exclusive colleges, MCAT prep, shadowing specialists, and volunteering at hospitals is a design that suppresses us and health access for our nation.

The scheme presentation model (U of Calgary) and its application online to multiple distant sites (SOMA) offers substantial value for the new learner as a framework for organizing the learning as well as a framework for developing the decision-making of a clinician. Aspects of this design can also help us in cost-effective practice as well as in defense of our work in the case of legal action.

A design for health access must be specific to health access to recover health access for a nation – falling further behind over the past 30 years while we continue to limited to just 3000 annual graduates – by design.

Robert C. Bowman, M.D.
Professor of Family Medicine at ATSU-SOMA

Posted by Robert C. Bowman, M.D. on June 06, 2013 at 03:50 PM CDT #

I appreciate Dr Spogen's thoughtful self evaluation. I am increasingly convinced the income gap between family medicine and our surgical and disease care provider colleagues is THE huge elephant in room driving medical student choice for residency and it is time to stop beating around the bush about it. Payment parity at the physician median for location should be the norm for family physicians in the US, as it is in every other developed higher functioning lower cost medical system in the world where 50-60+% of physicians are generalists. We can not expect to attain the higher performing health care system our nation needs at an affordable and reasonable price with 7% of US students entering family medicine. Policymakers must be re-educated on the fact that they drive our physician workforce by physician payment policy. Large businesses, especially self insureds (since they shoulder a large share of the costs) also should informed on the consequences of their payment structures for physicians.

Posted by Scott R Dunn MD, President Idaho AFP on June 09, 2013 at 02:23 PM CDT #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.