Research-Intensive Medical Schools Expand Focus to Build Primary Care Workforce
AAMC Reporter: November 2012
—By Kim Krisberg, special to the Reporter
During his emergency medicine clerkship, Michael Learned, M.D., kept trying to find out what happened to patients he treated the night before. It was not typical protocol for an emergency doctor—in fact, Learned said his colleagues gave him a bit of flak for it. But it was a telltale sign of his future in primary care.
“I don’t like drawing boxes around people’s problems,” said Learned, who recently completed the Primary Care Internal Medicine Residency Program at the University of Colorado School of Medicine and is now chief medical resident at a Denver hospital. “I like being able to help people with whatever they need.”
Learned said he was drawn to Colorado by the “commitment from subspecialists to teach us.” But the school’s commitment to research, he said, enhanced his education more than he expected.
“A lot of the faculty members who were teaching me how to be a primary care doctor also were doing research,” he said. “I’d say the [school] is definitely well-positioned to help transform primary care because it’s so research-driven.”
Learned is finishing his training at a time when physicians in many specialties will be in short supply. According to the AAMC, the nation will experience a primary care shortage of about 45,000 primary care physicians by 2020. The primary care shortage will come as up to 32 million newly insured Americans enter the health care system under the Affordable Care Act (ACA). Across the country, work is well under way to address physician shortages. Research-intensive medical schools are playing a big role, teaching students how to combine research and primary care principles to improve care for underserved communities and increase community engagement.
“Research is often the foundation driving this work [to improve care] for the underserved,” said Elisabeth Wilson, M.D., M.P.H., an associate clinical professor of family and community medicine at the University of California, San Francisco, (UCSF) School of Medicine. “It is a foundational skill for those going into primary care. If we can graduate more students who understand how to partner with community leaders and engage communities to achieve better health, they will be much more successful. That’s one of our biggest goals.”
Expanding the primary care pipeline
Earlier this year, the University of Maryland School of Medicine received a five-year, $877,000 grant from the U.S. Health Resources and Services Administration (HRSA) to expand primary care. In receiving the grant, E. Albert Reece, M.D., Ph.D., M.B.A., the university’s vice president for medical affairs, noted that “while we remain a toptier research-intensive institution, we must recognize our responsibility to primary care to ensure access to health care, especially in underserved communities where health disparities may exist.
The new primary care track will build on the school’s family medicine program, integrating internal medicine and pediatrics, said Richard Colgan, M.D., lead investigator on the HRSA grant and associate professor of family and community medicine at Maryland. Specialized tracks already have been successful there. In 2007, the school began offering a family care track. In the program’s first group of graduates, nearly three out of four pursued primary care. About one-third of the 2011 entering class applied for the family care track. The primary care track, which will eventually absorb family care students, accepted its first class in October.
Mentorship will be central to the new primary care track, Colgan said. Through a partnership with the state’s Area Health Education Centers, students will observe primary care physicians working in underserved areas.
“We’re looking to build a pipeline and expose students early on. They’ll have a greater understanding of primary care and service to the underserved and will be more inclined toward it,” Colgan said. “With our primary care track, we’re looking to make the community our classroom.”
Colgan noted that “we are really fortunate because we have faculty who come here for purposes of being aligned with a powerhouse research institution, and we have some truly amazing faculty members who are doing incredible research.”
Rebecca Switzer, 26, who will graduate from Maryland’s family care track next year, said the continuity of the primary care disciplines attracted her to the field. “Some of my mentors had treated families for years, sometimes for generations. That was really cool,” she said. “And the excitement from [the school’s] researchers just adds to your education. They’re always working on something new.”
In the South, at Duke University School of Medicine, the Primary Care Leadership Track officially launched in 2011 after a two-year pilot phase. The program combines community service, experience, and community-engaged research, with a pointed goal of preparing physicians to work with and learn from communities to improve care delivery and produce better outcomes.
Barbara Sheline, M.D., M.P.H., director of the Primary Care Leadership Track and assistant dean for primary care at Duke, said that in 2011, there were 200 applicants for the track’s six slots. The program is attracting students interested in both primary care and research, Sheline said, adding, “I think that with ACA, more students are looking for opportunities [in primary care]. They’re out in the community, meeting agencies and organizations that work with underserved communities.”
Sheline noted that medical schools and teaching hospitals have an obligation to partner with communities and reexamine the types of doctors they are producing. “We want students who are interested in figuring out a primary care solution. They have the potential to be change agents, and that’s what we were looking for.”
Being at a research-intensive institution will be a “huge benefit” to primary care students, who are required to spend a year conducting community-engaged research, Sheline said. In doing such research, these students learn that to address community health problems, they need to understand where their community is coming from, learn about the community’s interests and barriers to better health, and know how to use such data to shape interventions and services. Fortunately, Duke is home to faculty who can help students understand the significance of community-engaged research in improving patient outcomes.
Engaging communities in primary care
Across the country at UCSF, interest is high for the Program in Medical Education for the Urban Underserved (PRIME-US), an effort aimed at producing leaders to care for urban underserved communities. In most years, up to one-third of the matriculating class has applied for a spot, according to Wilson, who also serves as the PRIME-US program director. While PRIME-US is not a dedicated primary care track, Wilson said a majority of participants enter primary care disciplines. And community-based participatory research is a big part of the experience for PRIME-US students.
For Monica Hahn, M.D., M.P.H., M.S., a PRIME-US alumna now in UCSF’s Family and Community Medicine Residency Program, primary care is “all about the prevention of medical problems before they become severe; it’s about promoting health instead of treating disease. To me, that was really pivotal.” She said primary care aligned perfectly with her passion for social justice and closing health inequity gaps.
“I feel very fortunate to have trained at [UCSF], where primary care is valued. Although it is a research-heavy institution, there is community-based research and research on primary care, health disparities, and policy,” Hahn said.
Karen Chacko, M.D., program director of the University of Colorado’s Primary Care Internal Medicine Residency Program, one of the very first federally funded primary care training programs, said part of the program’s mission is finding students who want to care for underserved and rural populations after graduation. She noted that being home to “such high-powered researchers” gives the program an advantage when attracting students. Many come with the impression that primary care means spending all of their time in the clinic, but career opportunities, including those in research, exist across the board. And while primary care residents are not required to conduct research, it is definitely an option.
“We’re looking to build a pipeline and expose students early on… so they’ll have a greater understanding of primary care and service to the underserved and will be more inclined toward it.”
Richard Colgan, M.D.