Ideal Medical Practices

What Makes for a ‘Top’ Medical School: the disconnect between medical schools and national priorities

“So doctor,” she said as I pulled my stethoscope out to listen to her heart, “where did you go to medical school?”

via www.nytimes.com

Terrific piece by Pauline Chen describing the stark disconnect between our national health care workforce needs and what our medical schools produce.

Our nation desperately needs a larger and more effective primary care workforce.  This need is driven by the decades of research linking high performing health systems to good primary care.  People who have more access to good primary care (easy access, good relationship, comprehensive services, care coordination) are less apt to end up the hospital or emergency department - an outcome we can all agree is in our personal as well as collective best interest. 

Even better, people who receive good primary care are more apt to have preventive care needs met and those with chronic conditions are more likely to have those conditions under better control.  Adding to the benefits: people with good primary care are less likely to miss days from school or work and their total costs of care are lower.

Populations served by high concentrations of intensivists/proceduralists/specialists have increased cost with no demonstrable (and sometimes worse) overall outcome improvement.*

U.S. medical schools are pumping out ever increasing proportions of intensivist/proceduralist/specialist that our country does not need while the pipeline of primary care dries up.

One root cause of this problem is the way the NIH funds medical schools.  Inside the industry, medical school rank is a pissing contest to see who gets the biggest NIH check.  The bulk of NIH funding goes to highly specialized research while very little supports the core issue plaguing our nation today: ineffective, over stretched, over burdened primary care unable to meet the needs of America. (And I suspect almost nothing is spend to study how to better support solo and small practices that still make up the majority of practices in the U.S.)

Our national culture equates dollars with value.  The low dollar flow to primary care research implies low value and predicts the culture of medical school faculty who systematically belittle primary care as a career choice and berate those who admit an interest in primary care.** An expressed interest in primary care can turn the back-to-back specialty rotations of third and fourth year of medical school into a prolonged hazing incident.

Nothing short of a major funding shift will change this culture.  The occasional rotation with a PCP, the extra lecture or two from a community primary care physician, the extra residency slots for primary care are all nice but all fail to address the root cause: money.

It is time to stop this misadventure in funding that supports systematic bias against our urgent needs as a nation.  Washington must send a clear signal that the status quo is unacceptable with a major shift in funding to support research in effective primary care.  This federal signal would force medical schools to stop considering primary care orphan step-child of medicine and consider its rightful place as the foundation of a high performing health system.

* Starfield, B:  Threads and Yarns: Weaving the Tapestry of Co-morbidity Ann Fam Med 2006;4:101-103

See also the Dartmouth Atlas

** Hauer KE, Durning SJ, Kernan WN; et al. Factors associated with medical students' career choices regarding internal medicine. JAMA. 2008;300(10):1154-1164.

Fixing the primary care shortage: Doctor shortage in Miss. about to worsen

"With more people covered, access is certainly going to be a problem,"

via www.clarionledger.com

Access to good primary care is the cornerstone of high performing health systems.  Good primary care leads to better health outcomes and that leads to less cost since we catch problems before they get out of hand. 

(This is opposed to what we do now - we hamstring primary care with inadequate funding to do the work & crush the primary care workforce with paperwork and wonder why we're unable to spend the time people need to do our work really well.  This results in missed opportunities and very high cost catch-up care in 'centers of excellence' for heart disease, cancer and the like.  Hey, why be satisfied with $50 to find and fix a small problem when you can milk the system for $50,000 through your center for excellence?)

So what are we going to do with a shortage of good primary care?  First we need to reflect on root cause.  From a study of medical student career choice* we see that medical students avoid primary care because it is an unattractive career:  doctors on hamster wheels bearing the brunt of administrative trivia while being denied the time and tools they need to do their work well.

The solution to the root cause is then relatively obvious: 

• make primary care an attractive career choice by empowering them to get off the hamster wheel
• provide the funding and tools they need to do their work well
• eliminate the administrative trivia that has nothing to do with good patient care

There are very few environments that provide the full support for excellent primary care.  Group Health Cooperative, maybe Geisinger, some Kaiser practices, and a smattering of 'other.'  If you're Mississippi or Massachusetts (and soon the rest of the U.S.) you might therefore conclude that you need to bring Group Health or Kaiser to town, but then you may not be attracted to Big Box Medicine or it might not fit your rural environment, and what about all the solo and small practices that already exist in your region - you going to Walmart them out of existence?  I hope not.

Solo and small practices make up almost two thirds (depending on the survey) of the practices in the U.S.  Because we've demonstrated that solo and small practices can indeed deliver very high quality care that improves outcomes and lowers costs there is no reason to crush them with a big box.

If you're Mississippi or Massachusetts or any other state you can make moves to support your local practices by providing adequate funding for the work, by eliminating the insane burden of paperwork that has nothing to do with good care or outcomes.

It's time to stop doing what we've always been doing and it's time to start following the evidence as we contemplate the PCP shortage.

*Hauer KE, Durning SJ, Kernan WN; et al. Factors associated with medical students' career choices regarding internal medicine. JAMA. 2008;300(10):1154-1164.

26% of Solo Practitioners Polled on Sermo Forced to Close Due to Financial Hardships | Sermo.com

Cambridge, MA, February 17, 2010 — Sermo (http://www.sermo.com), the world’s largest online community for physicians, today announced its weekly hot topic. Nearly 500 physicians from 40 specialties participated in a Sermo post “It’s 3am. I can’t keep my solo practice open anymore” from a Family Medicine physician. Over 26% of respondents admitted they too had been forced to close, or are considering closing, their solo practice. This new polling data confirms the seriousness of many forecasts predicting a shortage of primary care physicians and sheds light on the many reasons physicians are choosing to leave the profession.

via sermo.com

Primary care bears the brunt of the burden of managing costs in our current health system. We do this with the least resources (5% of total budget) and the broadest set of tasks: coordinate care for all patients across the continuum of the health system in spite of its fractured and non-communicative nature.
I love being a primary care physician. I'm particularly lucky that I've come across models of care that make it possible for me to practice medicine the way my patients deserve: unfettered access, no wasted time, focus on the patient and their needs instead of the insurance company policies.
The good news for the insurance companies is that when I focus on the needs of my patients I actually help them get better results and total costs go down.
The other good news is that more and more PCPs are throwing aside the learned helplessness and creating their own practice environments that support exemplary primary care.
Too many of my colleagues feel trapped in a system that sucks every last ounce of energy and professionalism from them as they attempt to do right by their patients. Too much of their energies are diverted into shoring up this dysfunctional and frankly harmful system.
If they stop trying to shore it up and spend that energy on their patient needs we may have more than enough primary care supply to meet the nation's needs.
Solo practice is not dead.  It's thriving in places where your colleagues have crafted supportive environments.
No one out there will do this for you - they are all tied up by their investment in the status quo or playing political chicken - so stop waiting for someone else to solve the problem.
Pull yourself out of the muck and join the swelling ranks of those who choose to focus on their patients and not insurance policies. Other have gone before and there's help (here is one example and here is another). You don't have to go it alone.

Medical school expansion = increase primary care is a specious argument. Reporters need to do more homework

Supporters of the expansion say that having more doctors will improve care, by getting doctors to urban and rural areas where they are needed, by shifting care to primary and family practice physicians rather than expensive specialists, and by reducing long waits for people to see a doctor and get the care they need. [emphasis added]

After Years of Quiet, Expecting a Boom in U.S. Medical Schools - NYTimes.com

It is just so American to see a special interest group wrangle hundreds of millions of dollars based on something that looks good on paper but doesn't bear up under scrutiny.

Medical schools and their national association must be just so thrilled at dollars they will reap through their expansion plans.  There may be a good case behind this expansion but this article like many cites the primary care shortage as one of the key arguments in favor of the expansion.

This is a specious argument and must be called out every time it appears.  The primary care shortage is not due to a deficiency in US Medical School students.  These students avoid primary care like the plague because their exploratory rotations with existing primary care practices expose them to professionals who have been degraded to hamster-wheel-running drones forced to suck up to insurance companies and hospital system masters who focus on dollars instead of care.

This issue has been heavily covered in blogs but the mainstream media keeps parroting the specious argument. (To be fair ANEMONA HARTOCOLLIS did find counter opinions, but that part of the article was anemic compared to the host of pro-med school quotations, and the counter position missed the issue I write about here completely.)

If medical students don't choose primary care because it is repugnant how in the world would building more medical school slots help solve the problem?  Some bright person out there is probably thinking "Well, if 2% choose primary care we'll see some increase if we build more medical schools.'

Yes of course that's true but the dollars spent on this strategy could go a long way to addressing the root cause & thus effect a much greater increase in primary care supply.

If health care payers shift an additional 5% of the overall health care budget to primary care we'd be adequately funded to:

• Get off the hamster wheel and actually spend the time out patients want and need
• Hire the multidisciplinary care team so that we'd really be able to manage care across the continuum 
• Purchase technology that really improves our ability to care for those we serve

It's possible.  We see it in employer delivery systems like QuadMed, we see it in the data of the IMP grant, we see it in the experience of consumers in direct practices.

It's possible if self funded employers stop buying crap from the usual suspects and start exploring exemplary primary care delivery coupled with catastrophic or high deductible plans.