The First Charles E. Odegaard Lecture was presented in March, 1994 at the Fifth National Conference on Primary Health Care Access at Ka’anapali, Maui, HI, by Emery A. Wilson, MD, then Dean of the University of Kentucky College of Medicine
Emery A. Wilson, MD
Dean and Executive Vice Chancellor
University of Kentucky College of Medicine
The First Charles E. Odegaard Lecture
Fifth National Conference on Primary Health Care Access
Hyatt Regency Maui
Ka’anapali Beach, Lahaina, Maui, Hawai’i
March 25, 1994
A PARADIGM SHIFT TOWARDS PRIMARY HEALTH CARE?
I was at a faculty meeting about two weeks ago and we were talking about space. Nothing animates faculty members more than space — particularly, taking away space. One faculty member became so exasperated he jumped up and called me a horse’s rear end — not exactly in those terms, you understand. At about the same time, four or five faculty members right around him got up and ushered him out of the room. I was impressed by that. I leaned over to Art Cleaver who is our chair of the faculty council and I said, “Gee, Art, I didn’t really realize that I was so well liked by the faculty.” He replied, “You aren’t. This is Kentucky. They like horses.” (laughter) You had to think about that, didn’t you.
When I think of significant developments in medical education, I first think of a young teacher from Louisville, Kentucky, who in 1905 left his private school for boys to enter graduate studies in psychology at Harvard and later continued his studies in Germany. In 1908, he wrote The American College: A Criticism, comparing colleges in the United States and Germany. He was subsequently asked by the Carnegie Foundation to study medical education in the United States and Canada. His name was Abraham Flexner. I then think of another person that I had the opportunity to work with. This person really developed and was the primary advocate for family practice in this country. He led that discipline for twenty years. He was a proponent not only for accreditation, but for re-accreditation and recertification. That person was Dr. Nicholas Pisacano.
The impact of Dr. Flexner’s study on medical education and his resolve to carry out his recommendations are strikingly similar to Dr. Charles Odegaard’s conceptual leadership and development of primary care. Dr. Odegaard’s persistent message to medical schools was presented to this group in 1992 when he said, “The present national concern with the status of health care delivery services may well lead to pressure from outside the medical profession for change. But, it surely is to be hoped that voices will be raised within medical school faculty on behalf of an improved balance between primary and specialty physicians.”
I am honored to be presenting the first in a series of lectures established in recognition of the contributions that Dr. Odegaard made to primary care. I appreciate the opportunity to be a voice from within the medical schools to try to address what I believe are some of the concerns that academic medicine has with primary care and with health care reform. I also want to address what I think are some of the opportunities for primary care.
I have to admit that I was pleasantly surprised when Bill Burnett and Sam Matheny asked me to make this presentation today. I assumed at first that it was because of some of the things we have done in the college of medicine. After thinking about it, I thought, “Well, I am a reproductive endocrinologist. I am a primary care physician (laughter) along with the primary care pathologist and the family radiologist.”
The present argument over the definition of primary care is really intriguing to me because I really don’t understand why we are having it. Let me take you briefly through it and then I also want to give you my perception of what should be done.
Dr. Odegaard and the Millis Commission were among the first to describe the terminology of primary care in the1960s. Dr. Odegaard defined a primary physician as one who is “educated to provide continuous and comprehensive care of patients with an emphasis on preventive actions as well as curative therapies.” The Millis Commission went on to say, “The good primary physicians, now in practice, have acquired much of their skill and wisdom from experience or intuition. What is needed – and what the medical school and teaching hospitals must try to develop – is a body of information and general principles concerning man as a whole and man as society that will provide an intellectual framework into which the lessons of practical experience can be fitted. This background will be partly biological but partly it will be social and humanistic for it will deal with man as a total, complex, integrated social being.”
A similar type of functional definition was contained in the 1977 Interim Report of the Institute of Medicine . This report defined five attributes of primary care practice: accessibility, comprehensiveness, coordination, continuity of services, and accountability. Since then there have been many attempts to define primary care by task forces and specialists who are really trying to create a niche for themselves, I think, in the “post-health care reform” primary care world.
As a result of this, the AMA at an interim meeting developed the Board of Trustees Task Force to define primary care. Next month this task force will be proposing to the Board of Trustees the following to be adopted: “As a concept, primary care consists of a provision of a broad range of personal health services (preventive, diagnostic, curative, counseling and rehabilitative) in a manner that is accessible, comprehensive and coordinated over time. Care may be provided to an age specific or gender specific group of patients as long as the care meets the above criteria. There should be one physician responsible for coordinating a patient’s care at any one time, with shared care occurring only in the best interest of the patient.” You have to understand, this is a political definition. It includes everyone so that the AMA doesn’t have problems with the various specialists.
Why do we need a definition of primary care? Why is a definition so important? I’m not really sure that it is important. If it is important, it may be so that we — those of us in primary care –know what we are doing. With respect to health care reform, I’m not sure it is important because I think the marketplace will determine who are the primary care physicians and not some preset definition. I think in the marketplace that family physicians are the primary care physician. That is so for one reason that I can think of, it’s much easier to make up the call schedule with family physicians. If you have a pediatrician on the call schedule, then who is going to take care of the adults? If you have an internist on call, who is going to take care of the children? Therefore, it is much easier for family physicians to be the primary care physician. I’m sure that will raise some interest among you.
I also believe that it is important because specialties perceive it important with respect to reimbursement and control of patients. It seems to me that we should have a definition of primary care that is based on what we do. From a purely practical standpoint, I would propose that we define primary care based on something like CPT codes, or some other system of reimbursement for diagnostic and therapeutic procedures.
What you see here is a slide (slide 4) that has vertical columns that represent all of the clinical responsibility within each specialty. Every specialty should be able to identify within its discipline the content which is considered primary care versus specialty care. We could then visualize a threshold of care under which would be primary care and all procedures and technology above this threshold would be defined as specialty care. Third party payers might choose to reimburse those who provide primary care more, equal to or less than those who provide specialty care, presumably more if there is to be more emphasis on primary care.
Included in the primary care category and in the reimbursement of primary care would be the important components of preventive care, longitudinal care and continuity. For example, the first column represents all the responsibilities that a psychiatrist would have, the next represents the responsibilities of a family practice physician, the next of a neurosurgeon, OB/GYN, and so forth. Then, within each specialty, we could define what diagnostic and therapeutic procedures are primary care and which ones are specialty care. If we could do that, then we could say that a primary care physician is a medical school graduate who practices within the threshold that is defined by the solid bar on this chart, including the provision of preventive and longitudinal care for patients. What we are saying with that solid bar is — perhaps half of psychiatry, all of family practice, a small amount of neurosurgery, forty percent of OB/GYN — is primary care.
Presumably, reimbursements could be more, equal to, or less, than that paid for specialty care, but if we are going to put more emphasis on primary care, much of the reimbursement will come from the specialist, hypothetically, above this line into that below the line. What this also does then, is not only help us to define what primary care physicians would do, but within that concept or within that threshold would also be the important concepts of preventive care and continuity of care, for which they would be reimbursed. So that, we would then have a definition that would allow us to define what a primary care physician is.
We could go a little further and even define what physician assistants and similar practitioners would do within that primary care threshold. My bias is that many physicians really don’t want to have a lot of physician assistants doing health care because physicians really don’t understand what they do and because physicians think all of them want to be doctors. That may actually be true, but, I think if we had a better definition of what they do, then they would be better accepted.
Then we could also define specialists who do primary care, and those specialists could dip down below the threshold into primary care procedures and presumably be paid at the primary care rate. This could help decrease the need for primary care physicians. Specialists may not be providing longitudinal or preventive care, but then they would not be reimbursed for it either. Conversely, primary care physicians could specialize. (It actually is one of my concerns that we have generalists that are specializing rather than being generalists.) They could be reimbursed at the specialist rate for doing Caesarean sections or for other specialized procedures. This system would keep us from getting into the problem of defining primary care based on specialties or what specialists think they do. So I think there could be a lot of advantages to a system like this. In a very positive way, it delineates the responsibilities of generalists, specialists, and physician assistants.
I realize that this approach may violate the concept of primary and holistic medicine. I have no disillusions that this proposal would ever generate universal support. It’s far too simple and practical to be useful. It might be fun to discuss it.
In the past few years, medical schools have experienced intense public scrutiny to the point that we had to add an additional leg to the academic school. No longer are we providing education, research, and clinical service. We now have to respond to societal needs as well. Public opinion and political rhetoric reminds us every day that we have somehow failed to fulfill societal obligations.
Not long ago a bill was introduced into the Kentucky General Assembly that would mandate that 50% of all students entering medical school would have to do a family practice residency. These students would have to sign a contract that they would be family physicians. They would have to do their family practice residency in Kentucky. They would have to practice in the state for seven years. We have since been able to change the legislative language somewhat to include all of the primary care physicians and to make it an elective program. The existence of the legislation is clear indication that the academic medical centers are perceived as not meeting their societal responsibility. It is typical of many of the legislative proposals that are going on throughout the country.
At the University of Kentucky it is ironic because we think we are providing primary care practitioners. Last year, for example, we had if we count family practice, medicine, pediatrics and the combined medicine/pediatrics program, 55% of our graduates entered primary care, compared to the usual figure that you see from the AAMC Graduation Questionnaire of about fifteen percent. Actually, only about two-thirds of the students who receive the questionnaire, answer the questionnaire. The other third hasn’t made up its mind whether it is going to specialize or whether it is even going to seek certification. So this is a falsely low number. I like to use it because it makes my numbers look better. If we use the Kentucky definition of primary care, the statutory definition which also includes OB/GYN, preventive medicine and emergency medicine, then that number increases to 64% of our students who select primary care specialties.
I’d like to turn now to the impact of health care reform on our medical schools. Medical schools which gauge success by ever-expanding departments, ever-expanding faculties, and ever-expanding programs, have been shaken by the competition in the health care marketplace and by the anticipation of the health care reform. The question is – how will medical schools be able to do for society everything that we are asked to do – to teach, to do research, to provide clinical education, and to provide patient care – but with less money?
As a dean I have a number of concerns about the impact of health care reform on the medical school and its missions. I realize that these may not coincide with your concerns, but I am trying to give you the perspective of college administration and hopefully that will help you with dealing with deans and other college administrators. Let’s address some of the concerns, and also some of the actions that I feel might be appropriate.
My biggest concern about health care reform is the decline of clinical revenues. This may not be your concern, but clinical revenues have become a much larger component of medical college revenues and hence budgets. Any sudden or gradual decline in college revenues not only causes a decrease in clinical salaries, but it decreases our programs and it decreases our ability to subsidize education and research. As salaries decrease, physicians are going to be much less likely to subsidize education and research. That means that all of the income coming into the clinic will stay in the clinical realm and the income generated out of that used to cover clinical costs. It also means that the research enterprise will have to depend entirely on external funding. For education, we will have to depend on tuition, state funds, and endowments. It will likely unravel this complex, enhancing system of cross-subsidization on which academic medicine is now based. It will lead, I think, to separate cost and revenue centers for education, research and clinical care. I’m also concerned that a decrease in hospital revenues would prevent our development of tertiary care programs.
1. In order to prepare for this decline in clinical revenues and to position ourselves to be more competitive, we must be more cost-efficient. Teaching hospitals and academic practices are thought to be about 25 to 48% more expensive than private practice models. Significant costs can be reduced if we work together with a joint effort of hospital personnel and faculty to decrease our costs. We must become more responsive to changes in the health care marketplace and we must develop a primary care base.
I’m going to talk about these as separate concerns. The AAMC is proposing two all-payer funds to be established to replace the academic medical center funding that is presently in the Health Security Act. The first fund is for teaching hospitals to help level the playing field by recognizing their higher patient care costs and more severely ill patients. The Medicare indirect medical education [IME] adjustment currently serves this purpose and the AAMC proposes to extend the payment adjustment to all payers to emphasize the important principle that all payers must support an environment in which education, clinical research and service can flourish.
The second fund proposed by the AAMC is an all payer fund to assist medical schools. It would provide a separate stream of revenue for medical schools to offset the projected loss of clinical revenues and to offset the educational costs as we shift teaching to ambulatory settings. As an alternative, I wonder if we should not just acknowledge that we now support educational and research activities with clinical income and request an all payer supplement to clinical income for academic and community-based faculty when clinical care is carried out in presence of students and residents. Politically, it is important to educate politicians and the public about what medical schools do and to make sure they understand that medical schools are important to the local economy.
2. My second concern is the organizational structure that we now have for clinical faculty. This differs with each medical school. At the University of Kentucky we have a centralized practice plan. In other academic settings, clinical faculty often are very loosely connected to the medical school. Health care reform may mean that physicians will have a very different relationship with academic medicine in the future than they do now. Community-based primary care physicians, for example, will be invited to develop closer relationships with academic medical centers while faculty positions for other specialties and subspecialties will be reduced. Because most schools are aligned with state institutions, university regulations and administrative bureaucracy preclude our ability to respond quickly to practice opportunities. Concepts and behaviors associated with traditional, department-oriented medical education programs are often not conducive to cost-efficient managed care. It will be interesting to see how primary care faculty adjust to a position at the top of the power structure, and to observe the attempts of those who are presently in that position to retain it. I hope it’s a gracious transition. Primary care is angry.
To address these concerns, we need first to develop a vision and culture for how health care is delivered. What is the role of the medical school in health care reform? Will we continue to be only a tertiary care center depending on patient referrals, or will we contract directly with companies? Will we develop clinical niches that others cannot provide, or will we develop a fully integrated health care system, including primary care. Personally, I believe we should do all of these. Every school is different and there are certainly a lot of models that can be selected, but I am convinced that each school must work out its own vision and culture and then establish an organizational structure to carry out the vision that is unique to that school.
Sooner or later we will have to address faculty size and determine the appropriate number of faculty members in each specialty. We can probably obtain information from more developed managed care systems about the appropriate mix of specialists. The organizational structure for clinical care may have to be outside the university in order to be more responsive. Departments may have to reorganize as well. Chairs can no longer provide all the needed leadership in education, research and clinical care. They should consider delegating these responsibilities to vice-chairs who can put more emphasis on each of the three missions.
3. In order to compete in the new marketplace, medical schools must build a primary care base. Over the past 30 years, medical schools have increased the size of their faculties with predominately non-primary care physicians. For example, at the University of Kentucky we have about 388 clinical faculty members, only about 15 to 20% of whom are in primary care. In order to have an appropriate mix of patients for education and to support the present number of faculty (if you accept one theory), we would need to have about another 300 primary care practitioners in order to reach that magical 50% specialty mix. Others have estimated the need for primary care physicians based on a ratio of 1 primary care physician for each hospital bed. So, if that were the case, we would need about 400 primary care physicians to maintain a 400 bed hospital.
These estimates may not be accurate because we may need to decrease the number of specialists or we may be able to use other types of primary care practitioners instead of physicians. As indicated previously, we will need to restructure our organization so that we can develop contractual relationships with community practitioners. Building a community base also requires sensitivity on the part of academic faculty to improve relationships with community physicians. We need to learn to be better consultants, to be more responsive and provide more follow-up information.
Externally, what can we do? Well, at the University of Kentucky we are trying to build a primary care base. We go out and affiliate contractually with a large number of individual practitioners, clinics, physician hospital organizations and community health centers throughout our service area. What we are telling them is that we would like to sign a contractual agreement with them to identify those things that they can do for us and the things we can do for them. At present we are only asking our affiliates to participate in education and research activities and we are explicitly saying that they are not required to send us patients. We intend, however, for this to evolve into a fully integrated health care network.
What can we provide them? In return for their affiliation, we can offer them a number of support services, including locum tenans, physician recruitment services, telecommunications and continuing education. We have also established two primary care clinics. We are also looking to establish one at a community hospital. We are considering some practice acquisitions. We haven’t really started that yet, because we don’t have the organizational structure to allow us to do that. We are also doing some direct contracting.
Internally, primary care departments, I believe, can do a number of helpful things. With a vacuum in primary care services within the medical school, departments should look to increasing the number of primary care practitioners. In doing so, they should realize their power base is really not likely to be within the medical center but rather, outside in the community. They should develop linkages with community physicians. For example, since we are not likely to have additional college funding for faculty lines, departments should consider having a small core of teaching and research faculty complemented by a much larger core of clinical faculty that might be actually out in the community supporting the various programs of the department. They can see patients. They can teach students. Perhaps they even can contribute financially to the academic programs of the department. I think chairs should consider identifying a person within the department who is well known to community practitioners who would be effective in establishing and maintaining these communication linkages.
Many primary care departments — especially in family practice, because it is one of the youngest specialties — suffer from a lack of academic leadership. There is a lot of leadership in this room and I would encourage you to use that leadership to help to develop more within the academic departments. I think we can do that with academic fellowships and other academic programs for faculty development. Deans and chairs should begin to identify “champions”. We do that in other disciplines and we can identify champions in primary care as well and begin to build around them just as they do in other disciplines. Clinical tracks may be established in order to facilitate promotions since that seems to be a problem with clinical faculty. And if we have identified people with certain titles such as associate clinical professor or clinical professor, we should discard these titles in order to prevent those folks from being identified as “second class citizens”.
Chairs and faculty members in primary care departments should strive to develop better relations with the medical school administration. At a lot of primary care meetings that I attend, considerable time is spent talking about medical school administration, and how the environment within the medical school is not conducive to supporting the primary care function nor conducive to supporting primary care departments nor conducive to training primary care practitioners. That all may be true. Certainly, the deans don’t get any respect at those meetings. However, in future conversations, I would encourage everyone in this room to please discourage that sort of talk. We all have heard it before. These conversations waste a lot of time that can be used to develop action plans. Instead, I would encourage you to develop more active practices, action plans, and look at what the colleges of medicine need. What does the dean need? I can tell you right now that a lot of deans are looking at ways to develop primary care programs. What can you and your department do to help develop that base? I think you need to become a little bit more politically sensitive about medical school politics and that will get you to the table. I think that the primary care departments should make us deans offers we can’t refuse.
4. We need to respond to societal needs and political concerns by producing more primary care practitioners. We’ve talked a lot about that at this meeting. We do need to build a primary care base. We’ve talked about that. We’re going to see a shift towards ambulatory teaching and that may well be more expensive because it takes up time for those voluntary or clinical faculty members. We may no longer be able to have faculty members who will continue to do this at the same salary that we now provide them, which is practically none.
One important thing that we can do to increase the number of primary physicians, I think, is to make sure that all medical schools have family practice departments that are very well correlated with students’ interests and primary care. This has happened mostly in the private schools. I would just like to ask the question, do the 20 percent of medical schools without family practice departments really not need primary care or do they have deans who are internists or pediatricians? Medical schools should restructure their mission statements, admission policies, curriculum, and residency programs, all to interest students in primary care. They should provide support services to practicing physicians in order to prevent professional isolation.
I was on two task forces. One for the AAMC and one for the AMA, to try to provide guidelines for medical schools as to what they can do to increase the number of primary care practitioners. These are the things that they came up with:
- We need to provide a mission statement. Within that mission statement, we need to be responding to societal needs by emphasizing primary care.
- Our admissions committee should adhere to the mission statement.
- The curriculum should be changed to provide more emphasis in primary care.
AMA was reluctant to take the position of controlling residency positions, but they did say that they would support a change in national policy to control the number of physicians and the specialty mix. The reason they were not totally supportive was because of concern of some actions being construed as violations of antitrust laws.
It was recognized that medical schools really could be supportive of physicians in practice, particularly those in underserved areas. That we could provide such things as telecommunication, continuing education, and other services which would prevent service isolation. There could be such financial incentives as scholarships and loan forgiveness. Tennessee, for example, has a very good program. They provide about 50 to 75 thousand dollars at the beginning of the last year of residency for those residents, whether in a training program within the state or outside, who sign a contract saying they will come to practice in Tennessee. Since the implementation of Tencare, I’m not sure that they will be able to continue to be as successful. But, so far, I can tell you that Tennessee has eaten our lunch in Kentucky in attracting physicians with that type of incentive program.
If we really cannot provide all of the primary care physicians and if we are going to depend on physician assistants and nurse practitioners, then I think we need to teach medical students, nurse practitioners and physician assistants together so that they are educated together, to provide models for team care. We need to identify funds to compensate the community-based faculty. This is an example of an academic unit that could be formed that might be very helpful to them.
It’s a primary care Center of Excellence that some of you from New York will probably recognize. A folder was sent to me from the Buffalo program that was also sent out to all students interested in primary care. The first of a number of pamphlets in the folder is about family practice. There are pamphlets for pediatrics, internal medicine, and there are other recruiting tools that focus on primary care. I think it would be extremely important to have something like this. It increases the visibility within the school and outside the school of primary care.
I’ll show you quickly some slides of our own new curriculum at University of Kentucky as a result of a Robert Wood Johnson Foundation grant. We have, I think you will see, restructured our medical education to provide more basic science and clinical interaction, included more primary care, and more active learning on the part of the student. We have implemented most, if not all, of the suggestions outlined by the AMA and AAMC Task Forces.
This is briefly what our curriculum looks like. (slide 12) It is a curriculum that is trying to be more rational. When I think of the traditional first medical school year, I think of biochemistry, when I should be thinking of the intercellular environment, its anatomy and pathways. What we have done in the second block, for example, is to combine microbiology, cell biology, biochemistry and genetics all into one course of cellular structure and function. The first block includes anatomy, gross anatomy, histology, embryology. We have a block of neuroscience, a block of human function.
You notice that “introduction to the medical profession” is where we would teach communications, interviewing and physical diagnosis. That starts early in the first year and actually continues throughout the first two years. At the end of the first block, after human structure, we send students out to primary care physicians for one week. It’s not so that they can be a doctor — maybe do a little brain surgery. It’s not so much that they learn a lot of medicine, but that they do learn an appreciation of primary care. They also learn how the basic sciences can be important for anatomical medicine. At the end of that first year there is also an optional block for primary care.
The introduction to the medical profession is continued throughout the second year. This year is focusing mostly on immunology and infectious diseases as well as pathophysiology and pharmacology. All of this is much more integrated than it was before. In the third year we have tried to consolidate some of the courses in order to be more rational. For example, in the last block you’ll see that medicine, internal medicine and surgery is adult medicine so we have those two services working together to try to provide more of a consolidated curriculum.
We have drawn the ambulatory experiences in family practice, pediatrics and internal medicine together to create a course entitled “The Principles of Primary Care”. This is a twelve week course, four weeks of which is spent in an off-site location. You’ll see that there is an elective in a specialty or primary care in a rural site. This is an AHEC rotation. The fourth year also has more clinical management skills because the third year has become more a teaching year. Because the fourth year emphasizes clinical management, we give them surgical and medical internships, and experiences in emergency medicine and gerontology. The student spends time in an intensive care area of the hospital in the morning, such as an intensive care unit in cardiology, CCU, operating room, labor and delivery. Then in the afternoon, they study the drugs that were being used that morning. The final blue column is called the dean’s colloquium. That is an opportunity for the departments to bring the students up to date right before they graduate. It also provides information on managed care licensing and a number of other issues.
Since the average medical student debt is now over $59,000, financial incentives such as scholarships and loan forgiveness may prevent student debt from being a factor in specialty selection. However, adjusting the financing for the seven years of training in medical school and residency will not necessarily compensate for 40 years of subsequent practice that is poorly reimbursed and unappreciated. There must be a shift of reimbursement from higher paid specialties to primary care. I believe this would influence specialty selection more than anything. Although factors such as income potential and lifestyle do have influence on career choice, we need to demonstrate that being a physician to the whole patient over extended periods of time provides intellectual excitement and respect. Medical education programs that do not relate to other health professions may develop primary care models that are too expensive to compete with those that rely on health care teams. Therefore, we should be developing ways to provide team education for medical students, physician assistants and nurse practitioners, as well as providing settings for team care. We will need to identify funds to accommodate the increased cost of ambulatory education, possibly the AAMC fund for medical schools or a supplement to clinical reimbursement.
5. Increasing the number of physicians in underserved areas not only would respond to societal needs, but would relieve some of the political pressure on medical schools. Placing physicians in underserved areas could help us to build an integrated care health network and provide a stream of patients for other subspecialties. We have a placement service which has been very helpful in placing physicians in underserved areas. We place about 30 physicians a year, not all in underserved areas, but some. The placement service has recently been expanded to include other health professionals as well.
Recruitment in underserved areas might be easier if the practitioner could be aligned with the university through a faculty appointment and if the university provided support services to prevent professional isolation. Academic medical centers should support legislation which would provide direct financial incentives such as bonuses or a significant increase in patient care reimbursement to individuals interested in location in an underserved area. The federal government should also expand the National Health Service Corps to include all the health professions, which should be integrated with local academic medical centers which may be more likely to be familiar with the primary care needs of the region and which will support the practitioners in practice.
6. The Bureau of Health Professions and the Council on Graduate Medical Education (COGME) have projected an oversupply of physicians with the total number of physicians in 2020 being about 810,000 or a physician to population ratio of 276 per 100,000 people. These projections have been used to develop specific workforce policy proposals that have become the basis for legislation and for federal planning activities. COGME has proposed to limit the number of first year residency positions to 110% of the number of 1993 US graduates. Since international medical graduates (IMGs) account for about 25% of first year residents, the limitation in physicians would have its greatest effect on IMGs.
In addition to the aggregate physician supply, policy makers have been concerned about the specialty mix of the physician work force. COGME has also proposed that 50% of all residency positions be allocated to generalists. COGME advocates a two-fold increase in minority students in medical school in order to meet the needs of increasing minority populations. To manage this system, COGME advocates a National Physician Work Force Commission, which would allocate the number of funded positions to consortia consisting of at least one medical school in addition to teaching hospitals and other organizations that would provide graduate medical education. The consortia would determine where those physicians actually would be. By shifting the GME funding from the teaching hospitals to the consortia, COGME is attempting to encourage training in sites outside of the hospital.
By limiting the number of first year residency positions and by reducing the number of IMGs, I am concerned that the number of underserved areas is going to increase because these positions are the ones that are often filled by IMGs. This is true not only for underserved areas in Chicago and New York, but in Appalachia and other areas as well. It may be that the impact will not be felt in these areas for some time. I think that this potential situation is another reason why we should consider a mandatory National Health Service Corps. It would get people into the underserved areas for a two year period of time after the first year of postgraduate training. Again, coordination and integration of the National Health Service Corps and the academic health centers would be helpful.
In addition, the shift to graduate medical education ambulatory sites will cause a major loss of service for the teaching hospitals that is now provided by the residents. That is what the teaching hospital directors are most concerned about. It’s not only that they are going to lose the funding, but that they are also going to lose the service that is being provided by the residents. It has been suggested that perhaps these residents could be replaced by physician assistants or by nurse practitioners. But this would require funding that is no longer available to the teaching hospital. It would reduce the pool of practitioners that would otherwise be available for primary care.
Since medical schools are now attempting to introduce more clinical contact for students earlier in the curriculum, I would speculate that this gap in the care that is being provided, is going to be taken over by fourth year or senior medical students. It would seem to fit a medical paradigm shift that is developing in medical education that medical students receive more clinical experience, earlier in the curriculum. That allows them to develop a lot more clinical skills by the time they reach the fourth year. Some fourth year students could even enter into accelerated residency programs, then enter one or two-year generalist training as well as participate in the National Health Service Corps.
Some physicians might remain in the underserved areas and others would return to sub-specialize. The disparity in training between generalists and specialists, similar to that we see in Canada, might encourage more physicians to remain generalists and keep a number of these people in the underserved areas. We should support financial incentives for minority students through legislation. In Kentucky, our health care reform bill includes specific language for providing stipends and tuition waivers for minority students. We should initiate GME consortia centered around one or more medical schools in an effort to establish a good working relationship before funding becomes an issue. The proposed AAMC fund for teaching hospitals would help to offset the IME adjustment for patient severity.
Before concluding, there are a few other concerns that I have that I would like to share briefly with you.
- It is important that we build integrated health care networks for the medical schools and it is also important that we help to maintain community health systems. Some small community hospitals will close. Some probably need to close. Others will become community health centers. Academic medical centers should make every effort to maintain community health systems intact if possible. I’m telling local physicians, for example, and their local hospital directors that they need to go to all of the small companies in their community and sensitize those executives to the need for selecting health care plans that will keep patients in the community. Company executives need to understand that when outside health care providers come into their community and pull 100, 200, 300 of these company employees out of the local health care system, then eventually that is going to hurt not only their local health care system but their communities overall. I think that employers need to know that and need to help maintain the local community health care system.
- We need to support medical liability tort reform, not because it helps reduce our malpractice premiums (these malpractice premiums only account for about 1% of the cost of health care), but to give us the confidence to practice clinical judgment. There are lots of examples. We can’t do a pelvic exam without an ultrasound. If a child comes in that has bumped his head, we use to tell the mother to do a neurological check every two hours and by morning the child would be fine. Now we can’t let the child leave without a CAT scan or an MRI. We need tort reform to give us the clinical confidence to practice clinical judgment.
- We’ve talked about the loss of cross-subsidization of research and education for clinical revenues. Health care reform is also asking academic medical centers to conduct more clinical research in medical decision making, more clinical epidemiology, more patient outcomes research, more cost-effectiveness, medical information systems for tracking patients and what happens to them. Many schools do not have the infrastructure — statisticians, epidemiologists, etc. — dedicated to this shift in research emphasis. We need to encourage the federal government and its agencies to provide us with at least temporary funding for a clinical research infrastructure and for the development of medical information systems.
- Finally, I’m concerned about the time and energy that is expended in trying to stay just one step ahead of health care reform. I feel like I spent about 75 percent of my time in this. I don’t remember what I did before health care reform. I feel that health care reform is stealing our valuable academic time and energy from teaching and research. — not only from me, but from every clinical faculty member.
In summary, medical education is changing as it has never changed before. The most potent medical requisite that will occur as a part of this change is the re-evaluation of primary care. There are significant concerns, but there are also significant opportunities. If we can build a better health care system with all of the requisites of primary care — accessibility, comprehensiveness, coordination, continuity and accountability — we will all be the better for it. Again, I thank you all very much for honoring me with this invitation and I appreciate your attention. (Applause)