This archiving and publishing of the proceedings of the introductory remarks and the first two plenary sessions of the First National Conference on Primary Health Care Access (April 20, 1990) is made possible, in part, through the generous support of the Michigan State University/Sparrow Hospital Family Medicine Residency Program, Lansing.
J. Jerry Rodos, D.O. Midwestern University, Western Springs, Illinois [Dr Rodos is a Senior Fellow of the Coastal Research Group]: Let me make some global comments. I think that we’re seeing a rash of meetings, of conferences about the issue of access to primary care and producing family physicians. I think that’s good! As many of you know, I am a family physician by roots and a psychiatrist by evolution. Clearly, we are all so frustrated by group meetings. We need to talk about the things we don’t control, that frustrate us, and we did a little of that this morning. I think we need to understand that we don’t have a problem that is isolated from the rest of the society in which we work.
The two speakers earlier this morning alluded to that and passed over it quickly and I want to emphasize it again. The status of our society, and its health is simply one issue in that society, is not going to be resolved, improved, changed, altered, without consideration of what is going on around us. What we have seen, which I think is very interesting, is a whole group of very local projects in which you and I and colleagues have control and can produce responses that serve the needs of our community.
But Sandral Hullett pointed out a very important issue and that is the issue of standards, controls, and bureaucracy. Those are projects, when they’re locally managed and that meet the standards and that meet the needs of that community. If we have a national set of standards, as many of us have experienced over and over again, because of our pluralistic society, we get into difficulties trying to mandate those in other parts of the country, no matter how good they are in basis.
For example, it is wise to deal with the issue of the use of psychotropics as restraining agents in nursing homes. But it is not reasonable to have a psychiatrist review records every six months when there are large parts of our country, as there are large parts of rural Illinois that do not have a psychiatrist available to perform that function.
And while we’re thinking of solutions and while we communicate with each other, we need, I think, to consistently keep in mind some basic principles. We need to look at errors we have made in the past because one of the things about our society and about our government is that it is not prone to admit its mistakes. It is not prone to say, “We developed Medicare and Medicaid to solve some very specific problems.
We believed that the disincentive for access at the tome was financial. If we could remove the financial disincentive, people would get the care.” Well, what have we discovered in the evolution of 25 years of this program – we’re going to focus a little more on that tonight – we have, in fact, taken what was tier care, said we’re going to eliminate it, and 25 years later have tier care that is more intense than we had when we set out to solve the problem. So there are some national issues. We’re going to have a chance to look at these issues. And then we have some local opportunities.
Here I think is where we can shine. Here I think is where you, all of us who have influence (and we in education do have influence) can weave into the fabric of our programs a reestablishment of what physicians’ roles are – what it is, in fact, to serve society. Because remember we didn’t have to do this. We stopped 25 years ago. There was no underserved. Remember, we eliminated it. There was no difficulty in access to care because we said we had taken care of it.
I’m old enough now and I have been involved in the issue of drug abuse, probably since 1957. I’m a veteran of more wars against drug abuse than I would like to count and I don’t think we’ve won a damned one. But we keep declaring war! We need to look at those issues and translate them from our ability to manage the national scene, which we can’t give up on, and continue to sharpen and focus our approaches to what we can do in the roles in which we play on a local level.
As part of that, I guess I want to share with you a fairy tale. I want you to have a fairy tale before lunch. But even before I start the fairy tale, let me point out that I think it is good that we have this meeting. And I want to compliment Dr. Midtling and Mr. Burnett for bringing us together, because I hope that there will be, in theses mall kinds of meetings, ongoing focus and sharpening of approaches that we can take both locally and nationally.
Once upon a time, because remember fairy tales have to start with “once upon a time,” in a section of this country which comprised six states, there was a group of physicians who came together because they were concerned about the fact that their average age was 66; that they were having difficulty getting students whom they had gotten interested in practicing in their region into medical schools; that for large parts of this region they were providing the only medical care in most of the rural areas and some of the urban areas; and that it seemed to them that no matter how hard they tried, the graduates of existing schools didn’t diffuse into their region. Those that did were ill-equipped to practice.
So they decided to develop a medical school in their region (remember this is a fairy tale!) with no public money and with only two of the 12 members of this board having any academic medical experience. They set about to meet monthly – I am, because this is a fairy tale, going to skip all the organizational issues that went along with it, to skip all the fund raising, all the efforts in site selection, all the activities that went about to gain professional support to prepare for accreditation, the necessary state charters, or public relations and legislative support, all of which are fascinating stories, each a fairy tale by itself. But I am standing between you and lunch.
And this inexperienced group of folks established some principles. Very easy to do when you have no biases based on knowledge and experience and that was the description of this group. So they wanted to produce family physicians and that was the description of this group. So they wanted to produce family physicians that would serve their area. That was their mission. They were going to do this by creating a curriculum that would focus on that goal.
The faculty would consist primarily of practicing family physicians in that region; the admissions committee would be composed of a majority of practicing family physicians; and applicants to the school would be encouraged from the region. Because their focus and mission was family practice, they wanted applicants focused on family medicine, even recognizing that applicants will tell you whatever it is you wish to hear. That much experience they all had! And early on, they indicated, as part of their principles, that the basic science faculty that they would hire would have to spend at least 50 hours with a family physician on the college opened and that that requirement would be continued for all new basic science faculty.
Now, because they had no experience and could meet monthly and you had to do something with this monthly meeting, they established a curriculum committee which consisted of four family physicians – one family physician would become a pathologist; one retired internist, who was an early gastoenterologist, practiced in the City of New York but had the experience of being an internal medicine department chairman at a college; and one family physician who was also part psychiatrist.
I often think that they keep psychiatrists in medical school administrations primarily to deal with the faculty. They made some decisions – again based on all of the inexperience that they could muster: that they would use a systems approach, that family physicians with a basic science faculty would be the coordinators of these systems, and that a majority of the clinical faculty teaching in these systems would be family physicians in the area. They did this, by the way in the selection of the systems approach as a mechanical issue of how to get people from their offices to be able to teach on the institution’s campus and get back to their offices in some reasonable plan because, (if some of you are beginning to smell a pre-Flexnerian model) they did not see whole-time physicians as an advantage. But the, again, this is a fairy tale!
They wanted early exposure of the student in their school to the health care delivery system. And so emergency rooms, rescue squads, public health clinics, visiting nurse programs, well-baby clinics, venereal disease clinics, other health agencies, practitioners’ offices (practitioners in the broad sense from podiatrists to dentists to a variety of physicians) attendants at the hospital, utilization review committees, quality assurance, time with the administrator, even participation in prison health care was part of the program in community medicine that began in the first quarter of the freshman year four hours of each week.
These programs all had learning objectives for each site and a small group debriefing which occurred monthly. The student was expected to conduct himself or herself in a professional manner in terms of dress, in attendance, and demeanor. The students were to study who was served, why they were served, and was to study carefully doctor-patient relationships in these environments.
An associate dean for basic science was brought on. He was asked to be innovative and develop no-traditional roles as he hired faculty, which he did extremely well. And so we really need to look at the end of this fairy tale and see what happened. The things I described to you occurred between 1972 and 1978. Making it that recent is hard to make it a “once upon a time” fairy tale.
And this institution, this make believe institution, that I have described opened in October, 1978. Because it’s a fairy tale, I can leave out all the problems that occurred between ’72 and ’78 or, in fact, between ’72 and ’90. But that’s the advantage of fairy tales. But this fairy tale did some interesting things. They did a survey to find out what happened to their graduates? I was hoping to update it beyond January, 1987, but, unfortunately, they do not have additional data.
They graduated 289 people. If you take out the 66 who are still in internships in our fairy tale school, there are 223 that are left. IF any of you are concerned, by the way, this is not Chicago. Now, of the people practicing in their region of those who graduated, 32% are practicing in their region; 13% in the state in which the medical school finally decided to live. Of those graduated, 66% are family physicians. And if one adds primary care to that as we traditionally define primary care, 87% of the graduates are in primary care.
Now, I have shared this fairy tale with you because it means that you can create institutions that do what it is you set out to do. Because one of our focuses is, in fact, the production of family physicians, and I am not going to be lulled into using that primary care piece, not as a slight to anyone else but because, in fact, what we need is family physicians.
Dr. Midtling’s studies, if nothing else, should alarm most of us that within the next five years, ten years at most, we are going to have a serious problem, a crisis problem – although I hate to use that term because we use it for everything – in family physician supply in this country. But you can, in an institution, create a program doing that which you know that will work.
And so, what’s the moral of our fairy tale? The moral of the fairy tale is that if you do what you say you are going to do and do what we know will work, it does. But then, again, this is a fairy tale!
Schmidt: Can we take some time to have some interaction between the panel and the audience? Questions.
David Kindig, MD: [The wording of Dr Kindig’s question is currently unavailable.]
Schmidt: My message, the bottom line, is that since we will not have a national health insurance program, whatever we do will have to be done on the local level and there are a half a dozen samples that we can choose from, a menu that we can choose from, that will fit into our local needs.
Rodos: Can I respond to both the issues that you raised? I think that the statement that needs to be made, without the chemical terms, is that there are parts of this country that will never have access to care because of the nature of that particular community – whether it is isolated, whether it is low population, whether it is inner city – and have special risks at issue. And that although you can reduce access problems, and I think Corps is probably going to go through several more changes if it becomes the focus of addressing that mission, that eventually we will decide how we’re going to care for and provide service to that group.
Now, by the way, without, I hope, some continued concern on all of our parts that health care is simply one issue. Prevention in inner city Chicago and in Eutaw, Alabama, and rural Illinois are very different issues. And prevention on the north side of Chicago is very different from all of those. Secondly, I think there is a message about local initiatives and local care. I happen to be becoming more and more convinced that we get into more and more difficulty by trying to find national solutions in a very pluralistic society. And we continue to ignore the principle of economics that I will mention again tonight.
The utilization of curative services rises to the level of the availability of those services. That’s not a new principle and it certainly isn’t Rodos’ principle. It has been around a long time.
If you visit Russia – and many of you have – where they don’t have access problems and manpower is not one of their problems, utilization is one of their problems. And how do they reduce utilization where it’s a problem? They post all the appointments on a blackboard outside in the waiting room. It has some impact. Some people shifted to use the emergency help service which, as you know, in the cities is excellent. And they finally had to redefine how the were going to give that service.
So unless we keep in mind some things as we design programs, we are constantly going to be in the position of having to make changes, which is what we’re doing now. We are ratcheting down physicians’ payments. We’ve already ratcheted down hospital payments. Without recognizing that the basic issues were created by the program to begin with, we’ve now maybe created problems that ten years from now we’ll be spending even more money to try to balance and correct them.
Dr Rodos’ presentation was preceded by: First National Conference on Primary Health Care Access (1st Plenary Panel, Part 3, Hullett)
Dr Rodos’presentation was followed by: First National Conference on Primary Health Care Access (2nd Plenary Panel, Part 1, Werdegar)