Thursday, June 17, 2010

Why do some medical schools do primary care better?

A new study published in the Annals of Internal Medicine, ACP's flagship journal, finds that medical schools vary greatly in producing more primary care physicians and getting them into under-served communities.

- "Public schools graduate higher proportions of primary care physicians" than private schools.
- "The 3 historically black colleges and universities with medical schools (Morehouse College, Meharry Medical College, and Howard University) score at the top" in training primary care physicians who then go on to practice in under-served communities. (Click here for an interview with two recent graduates of historically black colleges and with Wayne Riley, MD, FACP, who is the president and CEO of Meharry Medical College in Nashville, Tennessee and a regent of the American College of Physicians.)
- "The level of NIH support that medical schools received was inversely associated with their output of primary care physicians and physicians practicing in underserved areas."
- Some institutions defy the trend: "Four large research institutions (University of Minnesota; University of Washington; University of California, San Diego; and University of Colorado) are in the top quartile of medical school recipients of NIH funding and of primary care output rankings. In addition, University of Washington and University of Minnesota are in the top quartile for overall social mission score."
- "Compared with other U.S. regions, the Northeast, with its preponderance of private, traditional, and research-intensive medical schools, had the lowest scores in ... [producing] primary care [physicians] and [serving] underserved areas..." Schools in urban areas, in general, scored lower on these dimensions than schools in less populated communities.

(Click here to see how your state's medical school rank on social mission.)

This study is likely to generate a highly controversial public policy debate.

If politicians want more primary care physicians, especially ones who are committed to practice in under-served communities, they could put more money into programs focused on the recruitment and training of underrepresented minority medical students.

They might increase support for public medical schools over private schools.

They might ask medical schools and grant making institutions, like NIH, to examine why research funding promotes technical medicine over primary care, and why some schools that receive substantial research funding buck the trend.

They might give preference to building or locating medical schools in less urban communities.

(Related, the Obama administration announced yesterday an investment of $250 million to support training of more primary clinicians, including $168 million for training more than 500 new primary care physicians by 2015, $32 million for supporting the development of more than 600 new physician assistants, $30 million for encouraging over 600 nursing students to attend school full-time, $15 million for the operation of 10 nurse-managed health clinics, and $5 million for states to expand their primary care workforce by 10 to 25 percent over ten years. ACP released a statement of general support for the administration's investment in primary care.)

The authors of the Annals study conclude with a challenge:

"Some schools may choose other priorities, but in this time of national reconsideration, it seems appropriate that all schools examine their educational commitment regarding the service needs of their states and the nation. A diverse, equitably distributed physician workforce with a strong primary care base is essential to achieve quality health care that is accessible and affordable, regardless of the nature of any future health care reform."

If medical schools won't re-examine their priorities on their own, aren't they inviting politicians to force change - by shifting funds to schools that have a better primary care track record?

Today's questions: Do you think medical schools should be accountable for training more primary care physicians? Should politicians shift money to medical schools (public, historically black, less research-oriented, and less urban) with a better primary care track record?


Steve Lucas said...

Doctors are making decisions when leaving medical school not on the publics need, but on their personal needs, and this is how things are suppose to be. The reality is that with a crushing debt load, and having spent years away, or delaying family, they look at the prospect of front line medicine and choose that field that will solve their personal financial and family problems. The problem is The Job, and The Job is a family and financial killer.

Those from historically black schools are choosing to return to their communities and should not only be applauded for that choice, but supported. They are choosing a difficult path.

This may be a good time for the medical community to look at its relationship with the academic world. We are not loosing our best and brightest in graduate school, we are loosing them at the undergraduate level. Today education has become a business. The results have mirrored that of medicine.

Along with a building boom, we see an increase in the number of highly paid administrators, while front line staff (doctors/instructors) and students (patients), see a declining income and increasing fees.

Statistics reflect the longer time it now takes to receive an undergraduate degree along with an all too common large debt load. We need to be concerned about not only the loss of potential doctors, but also lawyers, engineers, and all others that need a strong academic background to lead society and develop those lifesaving items we not take for granted.

This report should be a call to reevaluate the cost associated with out academic system at all levels.

Steve Lucas

Jay Larson MD said...

The whole system should be held accountable for training and maintaining primary care, unless there is a burning desire to continue the tread towards an even more expensive and dysfunctional system than we have now.

If medical schools are to be accountable for training more primary care physicians, they should reassess the tuition fees. Currently I have a college student following me around to observe a general internal medicine practice. He will be applying to medical schools this fall. When I asked him how much non-instate tuition was for medical school in Colorado, my jaw hit the floor. Something like $80,000 per year. With debt like that there is no way he would ever return to Montana as a primary care physician.

Politicians shifting money to medical schools (public, historically black, less research-oriented, and less urban) with a better primary care track record would unlikely to be successful politically and would not fix the problem of the current medical system primary care physicians have to endure.

Of interest, the Carnegie Foundation for the Advancement of Teaching recently released a book “EDUCATING PHYSICIANS. A Call for Reform of Medical School and Residency” by Molly Cooke, David M. Irby, and Bridget C. O’Brien. This book calls for a major overhaul of the present approach to preparing doctors for their careers. Our current educational system is based on recommendations put forth by Abraham Flexner 100 years ago after he studied medical education in the early 1900’s. He was sponsored at the time by The Carnegie Foundation. With all the changes that have occurred in the past century, it is time for a new look at how we educate physicians.

DrJHO7 said...

"Why do some medical schools do primary care better?"

They expose students to patient care in primary care settings starting in year 1 of med school.
They teach the importance and distinction of each of the primary care specialties (FM,Peds, IM)starting in year 1 of med school. They provide mandatory prolonged (1month or more) outpatient rotations in each of the various primary care specialties during year 3, and options for elective rotations in an ambulatory medicine setting in year 4.

They have academic departments of the above PC specialties that carry out research in the ambulatory setting and offer the opportunity for med students and residents to be involved in that research.

Osteopathic medical schools tend to have a greater focus on the above mentioned medical education programs than do "allopathic" med schools, and DO graduates were more likely (29% of DO seniors vs < 20% of MD seniors)in 2008 to choose a primary care medical specialty. Specialty choice is obviously a complex issue, and is affected by many factors. Interestingly, the interest in PC careers by DO medical grads nadired in 2006-07, and was on the rise in 2007-08, according to aacom data.