Primary Care in Medical Education: The Problems, The Solutions
—By Scott Harris
People often reference medical education's hidden curriculum — a set of unwritten lessons about practicing medicine that professors impart to their students. But despite its name, at times the hidden curriculum is anything but.
A large number of observers inside and outside academic medicine believe a big part of the hidden curriculum in undergraduate and graduate medical education (GME) discourages students — passively and not so passively — from pursuing a career in the primary care specialties.
But many medical schools and residency programs have made firm commitments — some new, some longstanding, and some largely under the national radar — to raising interest in primary care. Primary care is generally defined as family medicine, internal medicine, and pediatrics, although it is the adult-oriented specialties for which the problem exists most pointedly, physician workforce experts say. In the 2009 Main Residency Match, 3,703 U.S. allopathic senior students matched to an internal or family medicine residency program, compared with 4,617 in 2000 and 5,020 in 1996. According to AAMC data, all primary care practitioners entering general practice after residency are down from 8,162 in 2000 to an estimated low of 6,757 in 2007. The Council on Graduate Medical Education (COGME) claims that all primary care physicians currently comprise 35 percent of practicing physicians, but that number is rapidly declining because of increased retirements and fewer new doctors to replace them. Recent COGME studies show that fewer than 20 percent of all U.S. medical students are choosing primary care specialties.
Low interest in primary care is nothing new, however, and has root causes that extend far beyond the halls of medical school. Familiar systemic issues of lower compensation and high administrative burdens for primary care practitioners versus those in other specialties undoubtedly play a major role.
For Naseem Helo, now a third-year medical student at Loyola University Chicago Stritch School of Medicine, the hidden curriculum came into full view during a family medicine clerkship at an academic medical center he declined to identify.
"The program director discouraged me from entering primary care," said Helo, who plans to pursue radiology. "He stated that students have too much debt to enter a profession that does not realistically compensate physicians."
There are schools, however, that have established a commitment to eliminating this climate of negative reinforcement. Since 1970, the University of Massachusetts Medical School (UMMS) has made it a priority to increase the number of primary care practitioners in Massachusetts. According to school data, about half of all UMMS graduating classes enter general primary care practice after training.
"Culturally, we try to discourage this phenomenon of primary care bashing," said UMMS Dean Terry Flotte, M.D. "We have developed survey tools that ask how students get their attitude about primary care. But most of our efforts in this area are not structured. It starts with me and the chancellor embracing the primary care mission, and pointing out how central it is."
It is widely known that primary care practitioners are relatively poorly compensated in the current fee-for-service payment system, which tends to reward tests and procedures over so-called "cognitive services" such as patient consultations. This, in turn, hampers a doctor's ability to pay back student debt, which now averages about $156,000 for each medical school graduate, according to the AAMC. "Students realize that it is impractical to enter a profession where the compensation cannot cover student debt," Helo said.
"Students also feel a sense of entitlement, that being a physician defines them as a person that will have a good salary. Students want to see their hard work, sweat, and tears pay off financially, and that can often guide students away from primary care."
Some medical schools are offering help on this front as well. The Commonwealth Medical College (TCMC) in Scranton, Pa., which matriculated its first class in 2009, used philanthropic donations to provide scholarships totaling $80,000 — $20,000 per year — to its 65-member charter class. At UMMS, the Learning Contract serves as a major incentive for students. Created through an agreement with the state government, the contract defers two-thirds of a student's tuition payments and forgives it entirely for completing four years of primary care service in Massachusetts.
"It's removing one of those obstacles to primary care," Flotte said. "People don't choose their specialty based on debt alone, but having a lower debt burden can be enabling.
" For practicing primary care doctors, large administrative obligations and the short-duration, high-volume patient visits required to remain financially stable can mean an undesirable practice model. Many primary care practitioners who serve on medical school faculty observe that this clinical reality cannot help but seep in to the classroom environment.
"Rank-and-file family doctors are short-changed in terms of time," said David Deci, M.D., a family medicine practitioner and director of the office of medical student education at the University of Wisconsin School of Medicine and Public Health's family medicine department. "They shoulder the bureaucratic burden of the entire system. It's not the fun stuff. It's the referrals and pre-certifications and all the other things that come along with bringing people through the system."
From a literally more concrete perspective, clinical training facilities for primary care are often less well-appointed (and thus less impressive to some students) than others. This can be a function of the simple fact that primary care practice is a relatively low-tech operation, medical educators said.
"Modern medicine is enthralled with high-tech measures," Deci said. "We're all drawn to bells and whistles. The contribution that can be made through a long-term relationship with a patient needs to be shown as well. When you're working with an elderly patient with multiple conditions and diseases, and you manage to keep him out of the hospital for two years, you've made a great contribution. But it's harder to demonstrate that than it is to show the value of removing a tumor with gamma knife surgery."
UMMS makes a deliberate effort to ensure that primary care clinical sites include cutting-edge technologies such as teleconferencing and electronic health record systems. "We work hard to develop innovative primary care residency sites," Flotte said. "We try to make those teaching sites attractive. What we want is to have our faculty be happy in their work environment. We have built a new, state-of-the-art clinic with high-end IT infrastructure and teleconferencing capabilities. Students and residents who work there can still participate in grand rounds. It makes a really big difference in morale, and it makes the facilities in our own system that much more valuable."
Within academic medicine, students and faculty members have long observed that rivalries (friendly and otherwise) are common among specialties of all stripes, with each specialist believing his or her profession to be superior. And with most modern faculties consisting mainly of subspecialists, combined with the larger systemic factors of compensation and practice climate, primary care educators often find they are underrepresented in medical education, and the longstanding debates that take place there.
"Medical education is all about context," said Jeffrey Borkan, M.D., Ph.D., professor and chair of the department of family medicine at Brown University's Warren Alpert Medical School and the president of the Association of Departments of Family Medicine. "There can be an inherent bias because of who the trainers are and where the education happens. U.S. academic medical centers and medical schools tend to be in urban areas and have a predominance of specialist and subspecialist physicians, providing care in tertiary and quaternary hospital settings. Primary care and primary care physicians and educators can be underrepresented in these settings, even though present in the broader community and country."
Several schools are making concerted efforts to reverse this trend by exposing students to primary care doctors and more traditional primary care practice environments throughout the continuum of medical education.
During GME, most primary care residencies take place in hospitals or similar inpatient settings, where interaction with community practices is limited. This leads many resident internists to consider hospital medicine rather than general primary care. In 2007, 10 percent of internists entered hospital medicine compared with 4 percent in 2002, AAMC data show.
"Internal medicine residencies are based very intensely in the hospital," said Justin Weis, M.D., a third-year internal medicine resident at the University of Rochester Medical Center. "It gives you a narrow or absent view of primary medicine. The real work of practice happens in the clinic, but most residents just don't see this. Being a hospitalist is a natural progression from an internal medicine residency. To go into clinics, it's a much bigger wall to get over."
The expansion of regional branch campuses has provided fertile ground for training primary care doctors in a more representative setting. H. David Wilson, M.D., dean of the Kansas University (KU) - Wichita School of Medicine regional campus, said the comparatively rural location of most branch campuses allows exposure to a more conventional version of general practice.
"Our students get away from an environment where there is a super-specialist on every hallway," Wilson said. "It gets them into the real world where they have contact with practicing doctors and community physicians. Regional campuses can put students in a one-on-one situation. They see the local doctor as a very important person in a rural area, and a highly respected member of the community."
Wilson said that about a third of all KU medical students spend their final two years in Wichita, which has partnerships with three hospitals and many doctors' offices across the state. On average, 21 percent of KU medical graduates enter family medicine, Wilson said.
During TCMC's development, leaders recruited community physicians to not only serve as faculty members, but design the school's curriculum, sit on the admissions committee, and even interview applicants.
The TCMC curriculum heavily reflects that emphasis on primary care. First-year TCMC students spend their first three weeks shadowing a general internist, and are assigned to a patient with a chronic illness, who the students then track throughout their time in medical school. There are small-group research projects on primary care-related topics. In years three and four, students rotate through branch campuses in the smaller cities of Wilkes-Barre and Williamsport.
"It's about assisting with patients and learning from them," said Janet Townsend, M.D., the school's founding chair of family medicine and community health. "It's an immersion experience. They will be living the life of a community physician much more than in basic block rotations. It includes time in the office, and they get to round on patients who went to the hospital. From the beginning through the end, they are learning how physicians work in the community."
Although it is too early for data, Townsend said the school intends for 50-60 percent of all graduates to enter primary care.
Academic medicine is also working to address the disparities and shortcomings in the health care system that play their own role in discouraging interest in primary care. Duke University School of Medicine has created an intricate web of community partnerships that treat patients in their own neighborhoods and even provide in-home doctor visits and other primary care services. So far, Duke officials say the program has improved health outcomes in the greater Durham, N.C., area, while reducing costs by keeping patients out of emergency rooms. Many other academic health systems receive grants and form partnerships to test and study new models of care delivery that could one day bring more balance to the system.
For example, at the University of Cincinnati College of Medicine, Gregory W. Rouan, M.D., associate chair for education in the college's internal medicine department, is collaborating with a team of researchers from the AAMC, the Society of General Internal Medicine, and the American College of Physicians to study and disseminate information on different clinical innovations taking place in academic medicine, including the patient-centered medical home, a more coordinated model of care in which primary care providers are officially recognized as the central manager of a patient's health.
A recent survey of academic medical centers administered by this group found that faculty clinics are increasing their use of health IT, phone, and e-mail to coordinate and provide patient care, and 88 percent of survey respondents had fully or partially implemented evidence-based protocols in their practices. And of course, there is the ongoing health care reform debate.
Though the prospects of national reform legislation are currently uncertain, a series of federal regulations could result in up to a 6 percent payment increase for primary care services. Lawmakers are expected to increase the annual payment ceiling for participants in the National Health Service Corps, which provides debt relief to doctors who serve in rural areas, from $35,000 to $50,000, to keep up with debt levels.
According to AAMC Chief Advocacy Officer Atul Grover, M.D., Ph.D., changes in the larger health care system—such as a move toward managed care in the 1990s — can have a major influence on the medical education environment. Grover added that the current model is, on many levels, simply unappealing to students. "In 1995, interest in family medicine and other primary care professions jumped up. The changes were in the economics and the marketplace," Grover said.
"Everyone believed managed care would change things and primary care doctors would make more money because of their prominent role in that model. We were told if we wanted to be employed, we should not subspecialize. But of course, that didn't happen. "Today, there is some uncertainty over how primary care is evolving, and what the role of the physician will be," Grover continued.
"The current delivery system is often unappealing to people. Part of that goes back to reimbursement, because physicians see more patients in smaller blocks of time so they can keep practices afloat. With new models like the team-based medical home, as long as you are paying fairly, that might increase the attractiveness." Sometimes, however, simple explanations — and solutions — can also be effective.
In the 2009 AAMC Graduation Questionnaire, which is completed by all graduating medical students, role model influence was named as the top factor affecting specialty choice behind only the content of the specialty and its fit with personal interests. "I encourage my faculty to be the best physicians possible," said Wisconsin's Deci. "In that way, you'll be a role model. I share with learners the breadth of experience that I have, the kinds of care I have provided, and how all of that sustains me in a lifelong career in medicine.
But you have to know yourself. You have to know what you want. We certainly need surgeons and radiologists, too. So be true to yourself. What students have a hard time with is the outside negativity." Weis, the third-year Rochester resident, agreed. "Finding that somebody you want to emulate is crucial."