Since its foundation in 1973, the Wright State University Boonshoft School of Medicine has embraced a strong emphasis on primary care.
This priority has always been clearly reflected in the school’s mission, which includes “focusing on generalist training that is integrated, supported, and strengthened by specialists and researchers.”
“We put all the branches on the tree, but we start at its base, at the trunk,” said Gary LeRoy, M.D., associate dean for student affairs and admissions and associate professor of family medicine. “The foundation is primary care, so our students understand the value of that, no matter what specialty or subspecialty of medicine they go into.”
In the 1990s, the school was among the nation’s leaders in graduating physicians who pursued careers in primary care, including family medicine, general internal medicine, and pediatrics. Today, the school’s numbers reflect a widespread trend away from primary care.
In 2010, 43 percent of new Boonshoft graduates matched in primary care residency programs, compared to 37 percent of U.S. medical school seniors, according to the National Resident Match Program. While these percentages may seem healthy, the number of new physicians who actually plan to practice as generalists has plummeted. According to the AAMC’s annual Medical School Graduation Questionnaire for 2009, 73 percent of graduates entering primary care plan to pursue a subspecialty and practice in a narrower field, such as medical genetics or pediatric emergency medicine.
During the same time span, interest in family medicine residency programs has declined steeply, with the field attracting 17.3 percent of new U.S. medical school graduates in 1997, but just 7.8 percent in 2010. In terms of real numbers, 2,340 U.S. medical school seniors matched in family medicine in 1997 versus 1,169 in 2010, even as the total number matched to postgraduate year 1 positions grew from 13,554 to 14,992.
“In the last decade, in particular,” said Howard Part, M.D., medical school dean, “interest in the primary care specialties by U.S. medical school graduates has fallen off a cliff.”
A complex array of powerful disincentives
Individual medical schools, organizations such as the AAMC, and many state legislatures have long been fighting—and generally failing—to increase interest in primary care. According to the American Medical Association (AMA), only 32 percent of physicians in the United States were practicing in a primary care specialty in 2007. In most other developed nations, the ratio of primary care physicians to subspecialists is exactly the opposite, or closer to 70:30.
Part of the reason for the skewed U.S. specialty numbers may have an economic component. The AMA reports that the average educational debt of medical school graduates in 2008 was $154,607, an increase of 11 percent over the previous year.
“If you’re a 20-something thinking about choosing a career path, and wanting to have a family and put your kids through college,” Part said, “and you’ve really never taken on much debt, $155,000 is very scary. We think it is influencing student choice.”
Given this debt load, LeRoy believes, the allure of lucrative subspecialties can be all but irresistible for many students, though he strongly encourages them to keep an open mind.
“It’s not as though going into primary care gives you a vow of poverty,” he said. “It’s all relative. They’re going to be making more than 90, maybe 95 percent of the U.S. population.”
While concerns about the hardships of a primary care career may be overblown, they are not completely unfounded, according to Larry Lawhorne, M.D., professor and chair of geriatrics and professor of family medicine.
“The problem is that compensation has been driven by procedures and interventions that are highly technical and require very skilled practitioners,” Lawhorne said.
n essence, most insurance policies are designed to pay far more—and more readily—for an MRI or a CT scan, for example, or even for a consultation with a subspecialist, than for a visit with a primary care physician. This reimbursement structure is driven in part by the cost of researching, developing, and using advanced new technology, but it also reflects an underlying value system that prioritizes high-tech intervention over high-touch prevention.
“Generations of Americans have been taught to value subspecialist care,” LeRoy said, “and their insurance will pay for it, so they don’t see how much it’s really costing. You walk away oblivious to the actual cost, to you or to society, of your health care.
“It comes down to economics,” he added. “If this country is going to continue to reward students for going into proceduralist types of subspecialties, then they’re going to go there. They just are.”
To be fair, an individual’s career choice involves much more than a simple financial equation, no matter how stark a contrast one may perceive between educational debt and immediate earning potential.
“I’m absolutely convinced the students we accept here are all in it for the right reasons,” Part said.
While the income and prestige associated with many subspecialties often factor in to students’ decisions, he feels specialty choice also depends on what appeals to them intellectually, as well as the influence of mentors and role models.
Cynthia Olsen, M.D., professor and executive vice chair of family medicine, director of clinical operations for Wright State Physicians, and director of the Yellow Springs Family Health Center, strongly agrees.
“I believe in the abundance model,” Olsen said, “and I think there have been a lot more opportunities for students to look at career paths other than family medicine.”
At the same time, the pressures and challenges involved in primary care today—including the drive to see more patients in less time, constant struggles with insurance companies over authorization and payment, and even the pernicious influence of direct-toconsumer drug advertising—may be diminishing its appeal to many students.
“There are a lot of frustrations out there in practice,” Part admitted. As pressure on primary care physicians has mounted, he said, “The role models we’ve typically counted on to share the joy of a generalist profession have been harder to come by.”
That’s why physicians like Olsen play such an important role within the medical school.
She said, “When people ask me, ‘Do you still like going to work? Do you still like your job?’ I can honestly say, ‘Absolutely. I love what I do.’
“There’s a tradeoff between wealth and other things that satisfy you or don’t,” Olsen explained. While she makes an excellent living, she said, “There are things about being a family doctor that are much more important to me.”
For example, she enjoys the daily stimulation of a highly varied caseload, as well as the challenges of staying current on a broad spectrum of medical knowledge (rather than focusing in depth on a specific subfield). Most importantly, Olsen relishes the opportunity to develop close, enduring relationships with her patients, and to fulfill a vital need in her community.
“Not that specialists can’t also have that,” she conceded, “but I think you have to look at those parameters when you’re trying to decide, ‘Can I do this for the next 30 or 40 years?’”
An aging and expanding population
In terms of the nation’s health care needs, the decrease in primary care specialists couldn’t come at a worse time. The U.S. Department of Health and Human Services (HHS) estimates that 65 million Americans live in areas currently experiencing a shortage in primary care services, and the Institute of Medicine reports that more than 16,000 additional primary care physicians are required to close this gap. According to the HHS, the shortfall in the overall public health workforce (including physicians, nurses, physician assistants, and other allied health professionals) is projected to reach 250,000 by 2020.
In a December 2008 report, the HHS’ Health Resources and Services Administration projected that the ratio of physicians to population will continue to decline steadily, due in part to an aging physician workforce (with many reducing practice hours and approaching retirement), relatively slow growth in the number of new physicians entering the workforce each year (across all specialties), and ongoing growth and demographic changes in the U.S. population. The report predicts a 22 percent increase in demand for physician services between 2005 and 2020 due to an expanding and aging population.
“We’re going to basically double the number of people over the age of 65 in this country between now and 2030, from 36 million to 72 million,” Lawhorne said. The increase among those 85 or older will be even greater. “We’re going to go from about 4 million today to 20 million around 2050.”
Older patients tend to need more time at each office visit and require care that is often more costly than younger patients, especially as many develop multiple chronic conditions requiring ongoing treatment or careful management. In light of this reality, Lawhorne accepts that it will be impossible to prepare enough primary care physicians, let alone geriatricians, to care for so many older adults. Even so, he is hopeful that new initiatives at the medical school, including the recent establishment of a fellowship in geriatric medicine, will help address the coming need.
“Our goal at the medical school,” he said, “is to incorporate principles of geriatric medicine into the first two years, the basic science years, as well as the clinical years.”
In addition, geriatric medicine principles are already being integrated within the medical school’s Emergency Medicine, Family Medicine, and Internal Medicine Residency Programs. With time, he hopes to build connections with the rest of the residency programs as well.
“Physicians, almost no matter what their specialty, need to be prepared to take care of older adults,” he said. “Even those who are going into pediatrics are going to deal with grandparents raising grandchildren.”
Beyond the inevitable aging and continuing expansion of the U.S. population, demand for health care is likely to skyrocket with the passage of sweeping federal reform legislation expected to bring between 30 and 50 million new people into the health care system. In late 2008, the AAMC projected a shortfall of 124,000 to just under 160,000 physicians by 2025 based on population trends alone. Universal health care coverage, the same report concluded, would increase demand by 25 percent, creating the need for 31,000 additional physicians.
From national programs to local initiatives, a variety of efforts are underway to increase the number of medical school graduates, fund more and larger residency programs, create incentives and subsidies for new physicians who pursue primary care specialties, and revamp key insurance company practices. While few are optimistic that these efforts will completely address the looming crisis, they are resulting in some groundbreaking innovations that are generating excitement and creating a genuine sense of hope for the future.
Primary care: the best medicine
In any discussion of health care reform or public health improvement, primary care has to play a central part. Evidence illustrating the benefits of primary care for individuals, populations, and the health care system as a whole is both abundant and clear. A white paper published by the American College of Physicians (ACP) in 2008, for example, reviewed 20 years of research, including roughly 100 journal articles and other scientific publications.
Based on this review, the paper reported, “The availability of primary care is positively and consistently associated with improved outcomes, reduced mortality, lower utilization of health care resources, and lower overall costs of care.”
To cite one significant study in particular, in 2005 Barbara Starfield, M.D., M.P.H., of Johns Hopkins University published an analysis of four years of data from 3,075 U.S. counties, or 99.9 percent of all counties nationwide. She found that the number of primary care physicians in a given area strongly correlates with lower mortality rates from heart disease, cancer, and many other causes. Surprisingly, Starfield also found that higher numbers of specialists were often linked to an increase in mortality.
Other large-scale studies cited in the ACP paper found that adding just one primary care physician for every 10,000 people reduces overall mortality by anywhere from 14 to 49 deaths per year, as well as decreasing inpatient admissions (5.5 percent), outpatient visits (5.0 percent), emergency room visits (10.9 percent), and surgeries (7.2 percent).
While gratifying, these kinds of results are certainly not surprising to Mark Clasen, M.D., Ph.D., professor and chair of family medicine.
“Everyone who studies the impact of family medicine knows what a cost-saver and life-saver it is to have that kind of doctor,” Clasen said. “That does not hold up for any other type of physician.”
Clasen is quick to acknowledge how vital and effective his subspecialist colleagues are. Even so, he believes primary care physicians play a unique and indispensible role by forging long-term relationships with patients, emphasizing prevention and wellness, and helping to coordinate care from other providers. This coordination can actually make subspecialist care more effective, he said, which is why primary care physicians are capable of having such a broad, consistently positive impact. It also helps to explain why many countries with a larger percentage of primary care physicians tend to have significantly lower health care costs, higher care quality, and better patient outcomes than the United States.
“One of the worst things that can happen is to have a number of specialists treating a patient with nobody coordinating that care,” Clasen said. “Every time health care gets disintegrated, there are worse outcomes for patients.”
For example, a patient who sees a number of subspecialists, even for very valid reasons, may end up with unnecessary, minimally useful, or duplicate tests or procedures. In another familiar scenario, a patient might wind up with multiple prescriptions, each helpful in isolation, that could counteract one another or even interact to cause dangerous side effects. In these cases and others, a primary care physician can play an invaluable role by helping patients manage and make sound decisions about their overall care.
To illustrate this concept, Part likens health care to a wheel with primary care at its center, holding the wheel together and enabling it to keep turning.
“The primary care physician can serve as the hub,” he said, “and various spokes of the wheel are going out to different parts of the health care system patients need to access, whether it’s a surgeon, a cardiologist, a dietitian, or a physical therapist.
“There’s that central focus,” he added, “where one physician really understands the entire picture and is able to have some ongoing discussions with the patient in the context of that whole picture.”
Keeping the focus on patients
In an effort to build on the natural strengths of primary care and bring its benefits to more patients, a group of physicians and educators affiliated with the medical school is working to pioneer a new approach to health care: the Patient-Centered Medical Home (PCMH).
“We want to spend money differently and focus on what patients need, and not what insurance companies and hospitals need,” said Ted Wymyslo, M.D., associate clinical professor of family medicine and director of the Family Medicine Dayton Initiative, which seeks to apply the principles of PCMH to patient care and medical education.
“That’s why this Patient-Centered Medical Home is such an important concept, and one that probably everyone could embrace,” Wymyslo added. “It’s the best chance we’ve got for a model of health care for the country, because it keeps reflecting back on what’s good for the patient.”
The concept of a “medical home” offering pediatric primary care and coordination of other medical services for children originated in the late 1960s. The more detailed PCMH model was created 40 years later, when the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association outlined a set of joint principles to define the PCMH in early 2007. Today, the National Committee for Quality Assurance (NCQA) evaluates and recognizes primary care practices striving to implement these principles through its Physician Practice Connections–Patient- Centered Medical Home program.
The Wright State Physicians Family Medicine practice is working toward NCQA recognition and has implemented many of the core PCMH principles at its location in the new Ollie Davis Medical Arts and Education Center, which opened in 2009. The practice already has electronic health records (EHR) in place, for example, that are revolutionizing the way physicians care for individual patients and promote public health on a population level.
“Since I know what the complaints are for the people I’m going to see this afternoon,” Clasen said, looking over a detailed medical record on a laptop computer, “I’m actually going to have done most of the work for each of the visits before they get here.”
In addition to making patient visits more focused and effective, the EHR allows Clasen and his colleagues to look at their entire population of patients to analyze trends, identify issues, and evaluate results.
“It’s population medicine,” LeRoy said, “but it’s individualized, because you can use that technology to make it very specific for each individual. It’s really bringing health care into the 21st century.”
Another benefit of the EHR is the ability to provide patients with secure, remote access to their own health records, allowing them to be more informed and active in the management of their care.
“Anywhere in the world that patients can get on the Web,” Wymyslo said, “they can get into their personal record, with all their labs, all their X-rays, all their diagnoses.”
The combination of sophisticated data management and open patient access also makes it possible to shift the emphasis of primary care away from treatment and toward more effective prevention and management.
“Our system right now depends more on patients calling us and scheduling an appointment,” Wymyslo said, “So we’re trusting them to know what they’re due for, or what they need, and we’re also largely depending on the patient to be symptomatic—something hurts, something is bothering me, so I’d better go see the doctor.
“What we want to do in the future,” he continued, “is have regular, scheduled interfaces with patients that are timed optimally to pick up things at an early stage. It’s a whole different way of managing people’s health, and it’s related to proactively determining what the patient needs instead of reactively helping them with problems or concerns or complaints.”
“It’s a big conceptual shift from a disease-oriented health care system to a preventive health care system,” LeRoy explained. “It’s more effective to prevent an accident than to say, ‘Okay, we’ve got lots of gear out here to mop up after the accident.’”
Another technology-driven component of the PCMH is enhanced communication with patients, who can now reach their physicians by e-mail or text message, and can even schedule appointments online. The theme of communication is also important as physicians in the practice work to connect and collaborate with other care providers serving their patients. In addition, the practice conducts educational outreach to share important health information with patients and community members. Throw in additional touches like electronic prescriptions (“escribing”) and few or no time limits on the length of patient visits, and the practice is very close to qualifying for NCQA recognition as a Level-3 PCMH.
Legislation and compensation
In addition to their efforts to implement PCMH principles locally, Wymyslo, LeRoy, Clasen, and Part have worked with state representatives to develop bipartisan legislation promoting PCMH in Ohio. House Bill 198, co-sponsored by Representatives Peggy Lehner of Dayton and Peter Ujvagi of Toledo, would establish a PCMH demonstration project by supporting, monitoring, and evaluating PCMH practices in Dayton, Toledo, Akron/Canton, and Athens. The project would help to determine the promise (as well as any potential limits) of PCMH as a model for more widespread adoption throughout the state.
In addition, the bill would create scholarships for medical students who commit to practice primary care in the state.
While the bill is still awaiting passage amid negotiations over the role and participation of advanced practice nurses and other allied health professionals, it illustrates the potential importance of the PCMH model. And Clasen and his colleagues are committed to staying the course, with or without legislative support.
“It is such a powerful model,” Clasen said, “that we’re even meeting with insurance companies now that are approaching us wanting to pay (a care coordination fee) each month for each of our insured people.”
This kind of shift in reimbursement is crucial, Wymyslo said. From implementing EHR to expanding hours and activities, switching from a traditional practice model to that of a PCMH takes a substantial amount of money, time, and effort, he explained. Without compensation commensurate with enhanced care quality and better patient outcomes, it can be difficult for physicians to justify such costly and far-reaching changes. Fortunately, paying more for coordinated primary care also makes sense for both insurance company profits and national health care expenditures, which by some estimates include as much as 30 percent needless spending.
The transition to a PCMH model, Wymsylo said, “is affordable if we can go ahead and stop the waste—expenditures that are not translating into better health for anybody. Let’s get the cost to where it’s going to get the most bang for your dollar, which will be the primary care physician’s office.”
A bright future for primary care?
While the future of primary care, like the prospects for meaningful health care and insurance reform, remains uncertain, physicians affiliated with the medical school remain both committed and hopeful.
“We’re moving in the right direction,” LeRoy said.
“Something has to happen,” he added. “Whether or not it comes out of Washington, we as health care educators and medical professionals have to say something in concert. To do nothing is not an option.”
Part agrees with his colleague and shares his optimism.
“I still think now is a great time to go into medicine, unequivocally,” he said.
In particular, Part added, “I think we have a new hope for family medicine now, where students are going to have an opportunity to spend time with our doctors in a setting that is fairly close to a PCMH, and I think that will be a very good experience for them.”
As someone closely involved in both caring for patients and training the next generation of primary care physicians, Clasen may be in the best position to make predictions. He also may be the most optimistic.
“I think the student incentives are going to start changing,” he said, “and a lot more people are going to go into family medicine for all of the positive things that are exciting us here—especially if they like the relationship side of medicine, knowing the whole person.
“With the concept of the medical home,” he added, “the technology, getting away from a ‘room-to-room-to-room’ approach to patient care, and comprehensively looking at disease management and high-level prevention, this is a wonderful workshop for the future.” VS
Phil Neal is senior writer in the medical school’s Office of Marketing and Communications. He can be reached at firstname.lastname@example.org
Photo 1: Photo of Larry Lawhorne, M.D., and Jess Levy, a third-year medical student, looking over an electronic health record (EHR) in the Wright State Physicians Family Medicine practice office.
Photo 2: Gary LeRoy, M.D., who remains active in family medicine practice in addition to serving as an associate dean with the medical school.
Photo 3: Mark Clasen, M.D., Ph.D., who, despite the challenges and uncertainty that lie ahead, is optimistic and excited about the future of primary care.