Med School to implement new primary care program

Tuesday, November 13, 2012

Alpert Medical School faculty members are planning to pioneer a program in 2015 that will attempt to address a shortage of primary care physicians in the United States. The program will have a separate admission process from the rest of the Med School.

Approximately 70 percent of doctors in the country are specialists – and with the continuation of the Patient Protection and Affordable Care Act, President Obama’s signature health care legislation, the number of health-insured citizens in need of primary care doctors will likely increase, said Paul George, assistant professor of family medicine.

Jeffrey Borkan, professor of family medicine and a head developer of the program, said he hopes to enroll the first class of 24 students in the fall of 2015.

The program will emphasize skills involved in providing general care including primary care, general surgery and general psychology, Borkan said. He added that courses in the new program will emphasize health initiatives to benefit large populations, a change from the general Med School curriculum, which focuses on care for individuals.

The University will also examine the possibility of incorporating a masters program into the four-year curriculum, said Ira Wilson, professor of health services policy and practice, who will oversee that project. Such a program would allow students to graduate the program with dual degrees. The masters component is still in planning stages, Wilson said.

The curriculum will include small group work and case studies rather than lectures, Borkan said. For their residencies, students will devote half a day per week to each medical department for over a year, rather than spending the typical six weeks in a row in each, said George, who heads the group of faculty members developing the curriculum.

The curriculum will allow students to “develop relationships with patients and with mentors” over a longer period of time, Borkan added.
The Med School has provided the funding for this project so far, said Philip Gruppuso, associate dean for medical education and professor of pediatrics. He said there is enough space in the building to accommodate the extra students, but added that the Med School plans to hire additional faculty members for the program.

Before students can be enrolled in 2015, the faculty members involved will need to develop a more complete plan, Borkan said. The Liaison Committee on Medical Education, an outside body, must accredit the program before the University can officially institute it. The provost and the president must provide approval, he said.

“I think (this program) is a spectacular idea. It meets a need in society for not just primary care physicians, but ones who are trained in a scholarly way,” said Provost Mark Schlissel P’15.

“This is the perfect time to expand and transform how we teach in this area,” said President Christina Paxson.

elibruno

Apparently, Brown is in the minority in interpreting Obamacare correctly. Implementation of this new legislation mandates a primary care physician core that is tens of thousands short at this time. Way to go, Bruno!
Preston Calvert

Despite the glowing description of how this proposed program will work, there are many in the Medical School who have concerns about adding a second class of medical students to the school. There are many questions that have to be answered about this initiative:
1) Will the admission criteria for these students be the same as for the main medical student class, which are among the most selective in the country?
2) The choice of career path for medical students usually comes in their 3rd or 4th year, when they have been exposed to all the major fields of medicine in their clinical clerkships (not “residencies” as misstated in the above article). How will an individual student in the proposed program be handled if they decide that primary care or health policy are not really their forte, and that they would prefer to become a pathologist or a hand surgeon? To insist that prospective medical students choose their field of specialty before they are accepted to medical school is unfair to the students, and unrealistic.
3) What is the real focus of the proposed program? Is it to produce policy wonks to work in health care think tanks or government agencies? If so, is there a demand for freshly minted MD’s with that focus, without an MPH or further clinical and administrative experience? Or is it to produce additional happy and dedicated primary care clinicians, which could be accomplished with a more flexible primary care track, into which students could be attracted on the merits of the discipline, but also could leave if their interests become different.
4) What is the basis for teaching medical students to participate in the doctor-patient relationship, in which their personal interests and those of other outside entities must be secondary to the patient’s interest and needs, when the focus is on “health initiatives that benefit large populations”. The trust of patients in their physicians depends on their belief that the physician is making recommendations only in their behalf, unencumbered by organizational or societal conflicts of interest.
5) Practically where will these students do their clerkships? The current clerkships are quite crowded. There is a plan to use small, outlying hospitals in the RI area to train students, but are the practicing physicians in those hospitals, who would be their preceptors, of the quality to be Brown medical faculty?

These and many other questions need to be addressed before this initiative is realized. Most importantly to me, the need to avoid coercing young medical students to remain in a program that they come to find does not suit them must be avoided. Being a physician is hard enough when you love what you do. If you are coerced to follow a career path that you come to realize does not interest or suit you, the rigors of the medical lifestyle and the needs of the patients you encounter will come quickly to seem a burden, not a privilege.
Brown’s Medical School must think carefully before embarking on this initiative.

Preston C. Calvert ’76, M.D. ’79
President-elect, Brown Medical Alumni Association
Michelle Quiogue '96 MD'00

These have been interesting times to be a primary care physician. I am a family physician in rural CA and a former NHSC scholar. Locked into a primary care track by the NHSC, I found my choices for training and practice setting limited. But I am grateful to now find myself professionally and personally fulfilled in an place that my 20-year-old self could never have imagined I would end up.
When listening to policy wonks expound on the importance of primary care, I am too often left with that empty feeling similar to how it feels to eat cotton candy. How sweet but is that all? I am heartened to see Brown AMS put resources and set priorities to address the primary care shortage. Many make this shortage to be a zero sum game, but Brown will provide a creative alternative to that. Also, a primary care and social justice track speaks to the fact that those of us who thrive in primary care are motivated differently perhaps than other premeds.
I will always be grateful for the PLME for creating an environment that protected and encouraged my motivation to choose primary care: cultural differences, social justice, prevention, comprehensive care and the healing relationship between a patient and their doctor.
Anonymous

I am excited that my beloved alma mater is taking a much needed leap forward in reshaping medical school education to better match the needs of our society. If University of Washington to which I am now affiliated can consistently be a top-ranked medical school in both specialty care and primary care, so too can Brown.
Anonymous

There are models specific to primary care and to the needs of over half of Americans in need of care spread across 30,000 zip codes with lowest workforce. This model does not yet appear to be specific. Specific to primary care is over 90% primary care in result – a level that only family medicine can claim – mainly because FM grads remain over 90% family practice in their employment over a career.

There are numerous pathways to employed family practice result – 90% family practice for a career from FM programs, 7% for US MD schools, 17% for US DO, 25% from Caribbean, 25% of NP, and less than 23% from PA.

A primary care specific design that is specific to populations in need would begin with 100% family medicine over 6 years of accelerated and specific health access training. Even better would be 8 or 9 years of post high school education and training all ending with 3 years of FM GME for $800,000 cost instead of 1.2 million. Specific design also shapes those that pursue admissions and population based outcomes. The FM school is a 10% boost in workforce for 30% less cost of training (all post high school costs). This is a design that reaches $30,000 cost of training per Standard Primary Care Year ($840,000 / 28 yrs) compared to $50,000 (1.25 mill / 25) for current FM and over $90,000 for PD, PA, or NP and over $200,000 for IM. When the result is low percentage for primary care, the cost of training relative to primary care delivery over a career is too high. Without FM result, the cost of incentives to distribute is too high.

Training for a year or more in health access sites such as CHCs or rural sites can contribute to RN, MD, DO, NP, and PA training. But HRSA ignores decades of successes such as RPAP. This is also a model that contributes to health access delivery due to continuity of training design.

We train years 2, 3, and 4 at CHC sites at the School of Osteopathic Medicine in Arizona – and students have the option for an MPH track. 30% fluent in Spanish at our school is better than MPH focus, however.

Training must be located in 30,000 zip codes with lower to lowest workforce rather than in 1000 zip codes in 1% of the land area dominated by academic institutions with top concentrations of workforce – sites that attract those least likely for health access and situations that shape graduates away from health access.

Faculty who deliver health access every day of their careers are a good choice rather than faculty with multiple tasks other than health access (or specific medical education beginning with the learner’s needs).

Ultimately the health access school will have complete integration of training and practice – not separation. This school will be a legacy design where those preparing for school, those in school, those in residency, graduates, and faculty – all work together on health care teams.

Brown and others could team with ATSU and other health access schools for a real primary care recovery effort – but we would all have to be SMART – specific, measurable, achievable, realistic, and timely in focus upon primary care delivery for a career and primary care delivery where needed.

Robert C. Bowman, M.D. http://www.basichealthaccess.org