Will physician shortage raise family medicine's profile?
■ Medical schools are working to fill gaps in primary care as more students express interest in becoming family physicians.
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The July opening of the Dept. of Family Medicine and Community Health at Mount Sinai School of Medicine in New York marked a change in perspective for the 44-year-old school.
Previously, it had been on a short list of U.S. medical schools without a family medicine department. But Mount Sinai officials say the new department represents the school's commitment to strengthening the primary care work force to help meet the nation's future health care needs.
“One of the provisions of the Affordable Care Act is lowering costs through prevention, and that starts with the primary care physician,” said Dennis Charney, MD, the Anne and Joel Ehrenkranz Dean at the medical school.
Leaders in family medicine have lauded the new department as evidence of increasing recognition of the importance of primary care. Since it was established as a board-certified specialty in the late 1960s, family medicine has faced numerous challenges, including low payment rates compared with other specialties and a lack of respect from some in the medical profession who associate higher clout with other specialties, said Perry Pugno, MD, MPH, vice president for education at the American Academy of Family Physicians.
He said evidence of those challenges remains. Ten medical schools don't have family medicine departments: Columbia University College of Physicians and Surgeons in New York; Weill Cornell Medical College in New York; George Washington University School of Medicine and Health Sciences in Washington; Harvard Medical School in Boston; Johns Hopkins University School of Medicine in Baltimore; New York University School of Medicine; Stanford University School of Medicine in California; Vanderbilt School of Medicine in Tennessee; Washington University School of Medicine in St. Louis; and Yale School of Medicine in Connecticut.
“We have a number of schools in this nation that are on the high-prestige list that still don't have family medicine, and, quite frankly, it is a tragic commentary on those schools that they don't, because the need is clear,” Dr. Pugno said.
Officials at some of those schools said they have a strong family medicine presence even without dedicated departments. Others said they don't have family medicine departments because primary care has never been integral to their schools' missions, and historically there has been limited student interest.
That is beginning to change, as schools report growing numbers of students pursuing careers in family medicine. The number of U.S. medical school graduates matched to first-year residency positions in family medicine increased 14.4%, from 1,156 in 2008 to 1,322 in 2012, according to the National Resident Matching Program.
Whether their schools have family medicine departments or not, medical educators agree that the prominence of the specialty is rising as the nation moves toward lowering costs and improving patient outcomes with preventive care and better management of chronic conditions.
“Family medicine should be the foundation of health reform if we ever expect to provide affordable, quality care for all,” said John P. Fogarty, MD, dean of Florida State University College of Medicine in Tallahassee.
The American Medical Association urges the Liaison Committee on Medical Education, which accredits the nation's allopathic medical schools, to strongly encourage every medical school to have a department of family medicine, according to AMA policy first adopted in 1990 and most recently reaffirmed in 2010.
Demand for more physicians
DID YOU KNOW:
10 medical schools do not have family medicine departments.
An appropriate supply of primary care physicians is needed to ensure the best health care outcomes with the best access for patients, said Jerry Kruse, MD, MSPH, president of the Society of Teachers of Family Medicine.
“In a nation with a good supply of physicians like the U.S., the appropriate proportion of primary care physicians — defined as usual sources of comprehensive, longitudinal care — is 40% to 50% of the total physician work force. We are now at 32% and declining rapidly,” Dr. Kruse said.
Nationwide physician shortages are projected to reach 91,500 by 2020, says the Assn. of American Medical Colleges' Center for Workforce Studies. About half of those shortages will be in primary care, said AAMC Chief Academic Officer John E. Prescott, MD.
“It is a sign of the times that schools like Mount Sinai have embraced family medicine,” he said. “I think they see this is an incredibly important way” of responding to that demand.
Development of Mount Sinai's Dept. of Family Medicine and Community Health was driven by three factors: the ACA's emphasis on primary care; the development of an accountable care organization there; and a groundswell of interest from students, said Dr. Charney, who also is president for academic affairs of Mount Sinai Medical Center.
The department is a collaboration between the medical school and the Institute for Family Health, a network of community health centers that offers primary medical and dental care to more than 80,000 patients annually at 26 New York locations.
Relationships between primary care physicians and specialists are becoming more collaborative, said Neil S. Calman, MD, who co-founded the institute in 1983 and serves as its president and CEO. He is professor and chair of the new department at Mount Sinai.
New quality mandates under the ACA require specialists to communicate with their patients' primary care physicians to prevent hospital readmissions.
“With ACOs developing, there is an increased interest in primary care and family medicine,” Dr. Calman said. “Without primary care, people will continue to see hospitals and emergency rooms as sort of a revolving door for people with chronic disease.”
Optimism about family medicine
Stanford University School of Medicine has never had a stand-alone family medicine department. Family medicine is housed in the Dept. of Medicine as part of the Division of General Medicine Disciplines, said Erika Schillinger, MD, clinical associate professor and director of predoctoral programs in family medicine.
“The medical school has never seen it as part of the mission of the school to train family medicine doctors,” Dr. Schillinger said.
Even so, there always has been a strong family medicine faculty presence, and there is optimism about a new emphasis on primary care both nationwide and at Stanford, she said. Ten Stanford students applied for family medicine residencies in 2012, compared with two or three in previous years.
Harvard Medical School also is seeing increased interest, with more students applying to family medicine residencies, said Russell S. Phillips, MD, director of the school's Center for Primary Care. The center launched in October 2010 with the goal of helping boost innovations in primary care.
In the past, Harvard has focused on internal medicine, pediatrics and non-primary care specialties, but expanding family medicine training now is especially important, Dr. Phillips said.
“Harvard has a long tradition of seeking solutions to complex problems in medicine. The crisis in primary care has presented a terrific challenge, and the Center for Primary Care is evidence of a shift in focus,” Dr. Phillips said. “That said, we could and should do better.”
There are no immediate plans to develop a family medicine department at Harvard, but center officials are eager to expand student exposure to family medicine, he said.
“Ideally, we would like to see a family medicine residency program at one or more of our large academic medical centers that attracts the best and brightest to train and lead a transformation of health care based on a strong system of team-based primary care practices,” Dr. Phillips said.
Columbia University College of Physicians and Surgeons established its family medicine residency program in 1994, said Richard Younge, MD, MPH, assistant professor and director of the college's Center for Family and Community Medicine. He has seen an uptick in the number of students pursuing family medicine, as have other schools.
It's important that all medical students receive a foundation in primary care, Dr. Younge said.
“In family medicine, we deal a lot with diagnostic and treatment uncertainty,” he said. “All physicians can benefit from training in communication skills, clinical reasoning and application of clinical evidence that is a fundamental part of family medicine training.”
A major challenge for family medicine and other primary care disciplines is economic, Dr. Younge said. Primary care physicians historically earn less and get less respect than other physicians, he said.
“Not infrequently, our tertiary care subspecialty or research-oriented colleagues will suggest that students are too smart or talented to go into family medicine,” Dr. Younge said. “I've heard the comment more than once here and at other institutions that training primary care physicians is equivalent to turning medical education into a trade school.”
There is a common misconception in the medical profession that family physicians treat only colds and earaches, while specialists see the more interesting cases. That is simply not true, he said.
“In fact, family medicine is one of the most complex and challenging areas to be practicing,” said Stephen C. Shannon, DO, MPH, president of the American Assn. of Colleges of Osteopathic Medicine. “The family medicine physician has to be adept at a whole range of things that a highly specialized practitioner wouldn't have to do.”
As a family physician, Dr. Fogarty said he enjoys seeing a variety of patients of all ages with different complaints. He quoted Sir William Osler, whom many refer to as the “father of academic medicine,” in saying: “It cannot be too often or too forcibly brought home to us that the hope of the profession is with the men who do its daily work in general practice.”
But because most primary care occurs in outpatient settings, medical students trained in academic medical centers get little exposure to it and are more inclined to become specialists, Dr. Fogarty said.
Family medicine always has struggled to combat an image of being a “less prestigious” specialty, said Grant S. Hoekzema, MD, president of the Assn. of Family Medicine Residency Directors and program director of the Mercy Family Medicine Residency at St. John's Mercy Medical Center in St. Louis.
“That is in large part due to what the medical school establishment places value and notoriety on — subspecialization, technology, large research grants, etc.,” he said.
As a medical student, family physician Alma B. Littles, MD, said she felt that some colleagues didn't support her decision to go into family medicine.
“When you stated that you wanted to pursue family medicine as a specialty, you kind of got those looks that said, 'Why do you want to do that when you could do something else?' ” Dr. Littles said. She is senior associate dean for medical education and academic affairs and professor in the Dept. of Family Medicine and Rural Health at Florida State University College of Medicine.
Dr. Littles said she would advocate for every medical school to have a family medicine department.
“Without a department, anywhere else you are going to try to hide or place that training is just going to dilute it,” she said. “Trying to hide it under another department or another division is not a good way to expose students to a specialty.”