Annals of the 4th National Workshop: Background of National Project

The Annals of the National Workshops on the Community Benefits of Family Medicine Residency Programs present major discussions from the National Workshops.  The following presentation, from the Fourth National Workshop in Indianapolis, is entitled “The Taxonomy: What Services Do Family Medicine Residencies Provide to their Communities and Host Hospitals?”

From the Fourth National Workshop on the Community Benefit Of Family Medicine Residency Programs, Indianapolis, Indiana, September 13, 2004

Peter Nalin, MD, Indiana University School of Medicine; Indianapolis
Peter Nalin, MD, Indiana University School of Medicine; Indianapolis

Peter Nalin, MD, Department of Family Medicine, Indiana University, Indianapolis: Our first plenary panel of the morning will be presented by Doctor J. Jerry Rodos and Mr William Burnett.

They will provide the introduction to the National Project on the Community Benefits of Family Medicine Residency Programs.

William H. Burnett, MA [Mr Burnett is a Senior Fellow of the Coastal Research Group.]

Doctor Jerry Rodos is known to all of you who have attended the National Conferences on Primary Health Care Access and many other functions put on by the Coastal Research Group.

He is the former Dean of the Chicago College of Osteopathic Medicine, now part of Midwestern University.

He was the advisor for many years to the Director of the National Health Service Corps, and so, has had a major role over the years in Public Health Service policy.

Doctor Rodos will be giving the perspective of someone who has observed medicine from the last part of the twentieth century, and brings to us the analysis of a historian of primary health care access throughout the 20th century.

J. Jerry Rodos, DO, D. Sc., Midwestern University- Chicago College of Osteopathic Medicine [Dr Rodos is a Senior Fellow of the Coastal Research Group]: My task this morning is to paint a large picture in which this study, the National Project on the Community Benefits of Family Medicine Residency Programs, finds itself.

J. Jerry Rodos, DO, Midwestern University College of Osteopathic Medicine, Downers Grove, Illinois
J. Jerry Rodos, DO, Midwestern University College of Osteopathic Medicine, Downers Grove, Illinois

I am excited about doing that because it is very important to understand how we got to where we are, and why this study is so unique.

We are going to travel over six decades with remarkable speed – in fact, almost a decade every three minutes. However, we are not going to do it slice by slice.

You are going to make believe that you are back in the post-World War II era. It is going to be time without PowerPoint, because there is no television yet, and we are still in the sphere of radio. I am going to try to paint a picture for you.  Our picture is about the care of “the medically indigent”.

That was the expression then, not “the underinsured” or “the uninsured”, because many people had no insurance. Health insurance was not common in the Post World War II era. So this is the care of the medically indigent.

The biggest complaint at the time about care to the medically indigent was that it was not level.  It was uneven. It was sporadic. It was very good or very bad. It had great grace or it was absolutely miserable. In some small towns, like Avondale Pennsylvania, which had maybe three doctors and an eleven-bed hospital, the doctors actually rotated each month as to which physician would take care of those who were uninsured and unable to pay their bills.

You had non-teaching hospitals, that were a little larger and a little better organized, which had service arrangements you joined, not by choice. When you joined the hospital, you were required, as part of your membership, to provide service – inpatient, outpatient, if there was a such a service, and an emergency room if the hospital cordoned off a space for emergencies.

It was the era of the “endowed bed”. It is probable that hardly anyone in this room knows what an endowed bed is. That was when people actually gave money to hospitals, which were considered to be community charities. They were recognized as community resources. Communities supported them. People died and left money to endow hospital beds for those who were medically indigent – sometimes even an entire four-bed room, or a whole ward.

And then there were teaching hospitals. Pre-World War II, there was very little graduate medical education.  Post-World War II, was when residencies burgeoned. The teaching hospital used resident training on the medically indigent. The teaching hospitals would arrange services, and while you, the physician, still had to serve, you served by supervising the residents.

Medical schools in our country traditionally, most of them, have provided medically indigent clinics as a laboratory for their students – as an opportunity to provide community service. And you had other structures around the country varying from those with none to a highly sophisticated system like Philadelphia General, in which the five medical schools actually shared in the running of a city facility that is considered the first hospital created in the colonies.  It closed when Frank Rizzo was Philadelphia’s Mayor, for financial reasons.

The West and the Far West developed a different system in many areas. The development of County hospitals with outpatient services, was a totally different structure. Arizona is the best example of this. I use that as an example because it was the last state that held out against Medicaid. They had to be actually bribed – coerced – into joining Medicaid.

Now, that picture of time lasted for maybe twenty years. There were lots of things going on, not just worry about the uneven delivery of care to the indigent, but also concern about “socialized medicine”.  By 1965, Titles 17 and 18 of the US Public Health Service Act were passed, which did a number of things. It established a program called Medicare, for those over 65, and one called Medicaid operated through the states with a 50% federal share for those who met the federally defined requirements of  “medically indigent”.

It had other significant impacts. One of those impacts was that, by definition, there were no more “medically indigent”. By the presence of Medicaid, Washington said we eliminated the medically indigent. The result was that pretty much everywhere across the country, institutions and communities disassembled the infrastructure that was their service delivery system to the medically indigent.

Some retained them, and served Medicaid. Many of them, especially smaller institutions, simply closed their clinics – simply stopped doing service in the sense I described before.

And of course, we discovered we totally misjudged the numbers. We had a pretty good handle on who was over 65. We had absolutely no handle on who was going to be medically indigent. And the numbers were overpowering. Congress was in a dither, as it usually is when it misjudges the impact of legislation, about what this was going to do the budget, and how were we going to be able to afford this. And please remember, this was forty years ago.

There were other, I think, much more important and long-lasting effects of Titles 17 and 18.  Because of them, we dropped the ethical principal of the care of the indigent. Because there were no longer indigents, there was no longer the need to teach our medical students that we had, as a profession, an obligation to the less fortunate. Remember this was forty years ago.

The other impact was that we discovered we needed more physicians. We underestimated what the manpower needs were terribly. And we also looked at the dwindling number of family physicians, general practitioners and said “Holy cow, we need to change things”. The federal effort of carrot and stick to increase primary care, especially family medicine, was an important way of dealing with the needs created by Titles 17 and 18.

We formed a network of community mental health centers, community health centers, migrant health centers, and rural health centers. Now, out of all this flurry of activity, there were lists created of why people came to their doctors. Those were useful models in developing curriculum.

In the 1970s and 1980s, in order to help stimulate the output of primary care physicians, we had a number of community-based medical schools, whose charters and funding were really intended to emphasize primary care and the needs of the community.

Over a decade ago (at the Coastal Research Group’s Third National Conference on Primary Care Access), Dr G. Gayle Stephens did a wonderful review of what happened to those community-based medical schools. The results are very disappointing. Actually the one with the best record of all was Oral Roberts University, and it has closed.

But nobody really ever has looked at the service capacity. What does a residency do and what impact does that residency have? So, in that background, in that big picture I have painted with broad brushes, comes this study which says, “Let’s look at the impact that family medicine residencies have – not just on patients and why they come and complain, but on the community, not just on the services that people can access, but on the residencies as that point of access and how the residency serves the hospital?

Now those are all going to be different because the programs are all different, but the data is critically important and has never, ever been collected before. We have looked at what happened when Philadelphia General closed.  The Department of Family Medicine at Wright State University has been chronicling what happened when St. Elizabeth’s Hospital closed in Dayton and its impact of services in that community.

But we have an opportunity here to take information to our constituencies. Later this afternoon Bill Burnett is going to talk about who are those constituencies in greater detail, so I am not going to do that now. But, I would like to emphasize, at least from my perspective, that as more and more programs are surveyed, that this is a sentinel study.

With this study we can go to a constituency and say, this is what we are doing. This is the impact. Yes, we are training family medicine residents, but by doing it in this manner, by providing these programs, we have this impact on community primary care, on the needs of the community, on the access of the community to services that are critical.  Therefore, we need support. We deserve support. We need to have that support institutionalized so that we can continue to expand.

This is the first time I am ever aware of, after a very large literature search, that I can find anything that even comes close to this sentinel study.

William H. Burnett, MA; Coastal Research Group
William H. Burnett, MA; Coastal Research Group

Mr Burnett: Thank you, Jerry. Doctor Rodos and Doctor John Bradley (who will be joining us this afternoon), and I met and developed three Power Point presentations, that I will presenting. These will be used to develop some of the themes that we will be working on throughout the National Workshop.

Let me explain the study that Dr. Rodos is referring to and the taxonomy that the title is referring to. Over the last four years, we have had a series of workshops that have tried to analyze what family medicine residency programs do, and what happens in the family medicine center.

Many of you know about and some of you participated in the early history of the conceptualization of the family medicine residency program.  The idea of the “family medicine center” was conceived at the theoretical level in the 1960s, and at the practical level, from 1969 on, after the first family medicine residency programs were accredited.

Those family medicine centers were simply supposed to be “model family practice units”, places where residents could experience group practice. These model group practices likely would be near the hospital, and would contain a few physicians’ offices.

The early centers tried to come up with a representative group of patients that mirrored different parts of the community.  I was involved from 1974 on in surveying family medicine centers for the State of California, where from the very beginning, it was very clear that in some communities there would never be a family medicine center with a socio-economic mix that reflected the entire community.

So, we have something quite different from what was originally envisioned.  But nobody, as Dr. Rodos has said, really has looked at what we do have. So this is what the study is.

We have enlisted, voluntarily, any family practice residency program that wants to participate in this National Project.  Any is welcome to do so. We have scheduled time to visit each program. We have these National Workshops, where we developed a series of questions and modified them, and we have had smaller groups meetings between the National Workshops to modify questions as we get responses.

One of the concepts is that we are going to taxonomize what is happening. We have said at earlier workshops we are deliberately trying not to approach this with a research design. We want to be Aristotelian.  We want to be like Aristotle walking into his garden looking at this leaf and that leaf and trying to figure out what the patterns are instead of having a methodologist tell him what he should be looking for. We had said this prior to beginning the study, not facetiously, but without understanding just how powerful this would be.

Those of you in this audience could work together as we did two years ago in Louisville and come up with questions? “Let’s ask this question and then let’s ask this question” – and then send a surveyor out to any residency program that wants to participate to answer the questions. The questions, in some cases will prove awkward, and people will search for what they think the meaning is, and we will record those answers.

Then we will construct other questions that come out of those answers and ask those questions of everyone else. We have begun to get the taxonomy that we are looking for, the categorization of all those different kinds of services that family medicine residencies in the aggregate do in their communities.

We will look at what now (September, 2004) are fifteen taxonomy sections, each of which has their own list of questions. After we list these, we go into some initial working hypotheses for the first group of these taxonomy sections.

The first of taxonomy sections we call the Patient Care services group, and this includes a group of questions on ambulatory care services, inpatient services, and on community clinical services. It also includes chronic disease management, elder care (on which we will have a presentation later in this conference), and behavioral health services.

In the second taxonomy group, we are looking at qualitative benefits with taxonomy sections on access to patient care, quality improvement, and benefits to the host institution. We are looking at community needs assessment, at advancing institutional missions and advocacy. These are all questions that are derived from these National Workshops.

In the third taxonomy group we have questions that help define the amount of workforce training that is occurring, questions on physician graduates, on the activities that residency programs are involved in that teach health profession students, and on research and professional development.

As we said earlier, the National Workshops created and refined a site visit tool. We have conducted 29 site visits so far, in eight states, of what we called the Profiled Residency Programs.

We have additional survey site visits for 2004 and 2005 and over this next year, between the Fourth and Fifth National Workshops, we plan to begin some focused studies that will be looking at what specific residency programs are doing. Those studies will be culled out of the responses to the survey questions so far. We will select which ones have situations where we would like to get more information about what they are doing.

How do you become a Profiled Residency Program?  If anyone here is interested in getting into this study, any accredited family medicine residency program is eligible to be part of it. You will have at least one survey site visit, most will be part of focused studies, if you like.

There is a modest financial participation, which right now is simply being a institutional member of the Coastal Research Group, which is really only $325 a year at the present time. It will go up a little bit, but not very much, so this is an excellent time to sign on if you would like to have us come visit you and have you and your community become part of what we are studying.

What are the planned elements of the National Projects? It is our intention to develop analytical models to describe family medicine residency interactions with their institutions and their communities. We are planning to develop Policy Analysis Consensus Documents.

We expect to take subjects and bring together three, four, or five people to work on coming up with a policy document that is sufficient enough to explain what we are trying to do, but brief enough for policy makers to have time to read them and take them seriously.

Part of today’s National Workshop is the beginning of the idea of developing appropriate vocabularies to describe a family medicine residency’s impact. Now, let us come up with some working definitions that have been derived out of the first 29 site visits. We are beginning to use the term “system of medical care” and our working definition is “an organization of individuals who provide medical health maintenance and disease prevention services and who can coordinate and monitor referral services for a defined group of persons”.

We are defining a Family Medicine Center as “a medical home for persons within a system of care provided by comprehensively trained physicians and their associates.” We will expect possibly to be able to use the term “Teaching Family Medicine Center” as “a place where comprehensively trained physician residents master the provision of services within a system of care.” The Family Medicine Center “benefits to a community” – “various methods by which a family medicine center provides needed medical or social services to populations within a geographic area”.

The Family Medicine Center “Medicaid Population” is “a group of persons who participate in a system of care who qualify for specific financial benefits that accrue, in part, to the family medicine center.”  We should pause to think about Medicaid right now, because it is such a special case, because it is a group of patients that have appeared throughout almost all of the 29 at which we have looked.

Medicaid patients are part of almost everybody’s service program, either as capitated or fee-for-service Medicaid patients, or both.  (The one program that technically does not serve Medicaid is a free clinic for the homeless that does no billing, but it undoubtedly serves persons who would qualify.)

There are some potential advantages when you think of terms of Medicaid within a system of care.  Consider the Medicaid recipient – the person holding the card, or whatever you need to prove you are a Medicaid recipient.  You have instructions from somebody, “Here is your card, you figure out how you get your care.”

What the family medicine center care provides that Medicaid recipient, at least in the 29 places that we visited, is high quality basic medical and disease prevention services, improved access to needed specialty services, coordination of social services that complement care and multi-disciplinary team care.

We’re going to be breaking into five small groups later in the morning. The group leaders have these questions and you will be discussing them. The questions that we’re going to ask you to discuss:

1. Which of your patients regard your family medicine residency program as their medical home?

2. Who are your financial partners in care of these patients?

3. Do you deliver high quality, cost effective care to your patients?

4. Are your financial partners aware of that?

5. Does your family residency medicine program offer a range of services that cannot easily be found in one place?

6. Are your patients aware of the range of services?

One of the things that we would like to do throughout the meeting, and fortunately, we have built in time to do so, is to invite response from the group as a whole at various points in the process. What we are asking is, because this part of the meeting is being recorded, if you would like to comment one way or the other on Dr. Rodos’ history on health care access, or the presentation on taxonomy that I have just made, please come to the microphone at the beginning.

We ask that persons asking questions identify themselves, and their institutions, or their communities, or both, and that if you have questions, Doctor Nalin and I are here to respond to them. If you disagree with what has been posited so far, please let us know, if you agree, please let us know. Any questions? Any comments?

Terrell W. Zollinger, Ph.D., Indiana University School of Medicine
Terrell W. Zollinger, Ph.D., Indiana University School of Medicine

Terrell W. Zollinger, DrPH, Department of Family Medicine, Indiana University, Indianapolis, Indiana [Dr Zollinger is a Fellow of the Coastal Research Group]: I just have one question, Bill. I appreciated your slides and discussion about the Medicaid patients, but I wonder if you might also be interested in the Medicare patients, and the patients on other government programs.

Mr Burnett: Actually, our definition of “system of care” covers any group of patients where there is financial participation by some party, and that includes even patients that are in a free clinic setting, assuming that somebody, somewhere is financing the cost of that free clinic.

So yes, Medicare would be very much part of it. The reason why we highlighted Medicaid on our slides is because, very obviously, Medicaid might be one of the areas where, as our analysis is developed, we may want to share the information with the Medicaid authorities.

In certain states – the state of Oklahoma for example, where we have visited several programs, they have a Medicaid authority.  Doctor Charles Henley, who is here, could speak to that. Their Medicaid authority, which has turned over much of Medicaid (in Oklahoma mostly managed Medicaid), to Oklahoma University and Oklahoma State University, and some of the teaching programs there.

So one would imagine, that any analysis that we develop through the National Project, that can demonstrate that what OU and OSU are doing is the best that the Medicaid authority can get, would be of interest to the Medicaid authority.  We do expect to develop the vocabulary to talk to those policy-makers in Oklahoma and elsewhere.

But regardless of what the financing mechanism is, we argue you should think in terms of the range of services that is being financed as a “system of care”, be it Medicare, be it capitated Medicaid, or be it Medicaid fee-for-service. But it would also hold for the medically indigent that are not covered by any public or private third party payer mechanism, but where there is some kind of revenue stream in the institution, community or state that finances that care.

One of our profiled programs actually operates as a free clinic. Some of the programs that we visited have some kind of activity, usually not at their family medicine center, but something somewhere, that is actually “free care” from the patient’s perspective, provided without any type of money being exchanged. But that “free care” is still financed  – paid for by some mechanism.

If you have a provider of last resort, a hospital or other health facility, that is expected to provide these services, or even if it is pure charity care of the type that Dr. Rodos has described as existing in many communities before the mid-sixties, then our hypothesis is that the systematic care provided in family medicine centers is arguably, better care than the alternatives.

Warwick Troy, Ph.D.; Shueman-Troy Associates, Pasadena, California
Warwick Troy, Ph.D.; Shueman-Troy Associates, Pasadena, California

Warwick Troy, Ph.D., Pasadena, California [Dr Troy is a Senior Fellow of the Coastal Research Group]: I just want to bring up one issue that, of the many brought up by Jerry Rodos. He harkened back to the time when Medicaid was envisioned as the permanent solution to the medically underserved and unserved populations and he notes, in his dark way, a kind of implicit tragedy in this. The hope is long gone, sadly. Not that the services are not still critical, but the original hope has vanished.

What we have, and I think this is critical for this session, are non-profits, who once upon a time were institutional non-profits, such as hospitals, that are vanishing. We have other, ancillary non-profits, whose budgets and whose incomes are terribly constrained, and we have non-profit organizations and medical groups, and medical service entities, centers that are changing their non-profit status to “for profit” and in some cases spinning off conversion foundations, and funds and so on –  which variously serve the communities but not in ways that have been documented very well.

So what we have, and this is Jerry’s point, is a series of absolutely non-formal, ad hoc, marginalized, haphazard, unplanned set of services with no coordination and it is getting terribly, terribly worse than it was even five years ago. So, family medicine works in this chaotic setting, where the underserved and unserved will be increasingly less able to get the services they deserve. And  family medicine’s role in this, always precarious, is systematically threatened.

Mr Burnett: One of the things in the meetings with Dr. Rodos, one of the points that he emphasized, is that the decision to go into Medicaid, is based on absolutely no information. If you look into the Congressional Record, you get discussions of equity, and “this will be good for people”, but there never had been a study, community by community, to know who were the medically indigent, what the numbers were, how they were being served, whether the services worked well or not.

One of the things that is most interesting about the current debate, at least in Dr. Rodos’ way of looking at it, is that, in the discussions of the medically uninsured, you divide those numbers by taking the population, then taking a few estimates of the number on Medicare, Medicaid and private health insurance, numbers that you know and subtracting them from the population number, and arriving at the number of uninsured. But there have not been comprehensive studies, community by community, of what are the numbers of indigent, and how are the current services to those indigents being provided. We will be talking about this later in the day.

One of the points that Dr Rodos also had made, is that this process of going community by community to those teaching hospitals that are so much involved in the care of the indigent in those communities, has an analogy with the Flexner studies of 1910, looking at the state of each medical school that existed at that time, prior to the closure of many of them. The analogy doesn’t go too far, because the issues around the state of medical schools in the first decade of the 20th century are quite different from the problem of delivery of care to the indigent today.

It does suggest that going to places and getting information about the places, brings you a much better foundation for making a decision, and discussing policy than just trying to do it in the abstract, without information of how it impacts community by community. There are many communities that are doing things surprisingly well, and we certainly have found systems that are working really quite well for which they are not getting credit. But, that we will be discussing in another one of the sections. Any other comments?

Randall Longenecker, MD; Ohio State University Rural Traning Track, West Liberty, Ohio,
Randall Longenecker, MD; Ohio State University Rural Traning Track, West Liberty, Ohio,

Randall Longenecker, MD, Ohio State University Rural Training Track, West Liberty, Ohio:  I am Randy Longenecker, from the Ohio State University Rural program. I may have missed it in your taxonomy, but I was wondering if you are also looking at less easy to measure and more indirect kinds of benefits.

Two in particular, one is the simple presence of an educational program in a hospital and the importance of that to the vitality of the institution, a learning institution if you will. And the second is, provision of leadership, to medical staff, to hospital, to community health, that many residency programs provide through their leaders.

Mr Burnett: Yes, actually, there is quite a list of questions that relate to the impact on the hospital. The whole taxonomy section on benefits to host hospitals includes questions of that type, and we do include quite a few questions on which committees you are on, whether you are part of the leadership. However, there is always an opportunity to find even more places where residency programs impact the communities.

One of the largest impacts we observe is that of the physician graduates.  One of the subjects that we will be doing a lot of studies on, is the impact of the physician graduates of your programs that have distributed themselves in, and have become, your medical community and how they impact those communities.

I think one of those hypotheses we’ve developed over time, is that any residency training occurring in the community over some number of years, say, ten or more, is going to impact that community in very positive ways.  How that impact occurs, we believe, is affected by the way that that residency program is organized.

Dr Nalin: Also, further responding to Dr. Longenecker’s comments, his implication is that, somehow, these programs are influencing either the working, or the learning, or the professional development environment of the institutions they are in.

And, if there are ways that we can capture either of those, or other features, so as to describe what that impact is, it will be helpful to have that kind of scrutiny to the questions, so that we do not miss the richness that kind of program brings to an institution.

My second response is about the provision of leadership. Leadership may also be indirect in that the family medicine residency?s influence on that environment, may in turn lead other people to take on leadership roles in the other activities that they do. So the family medicine presence in the hospital may cause other people to take perhaps an underserved perspective, or a community-oriented primary care perspective to the other organizations that they influence. So then you have a kind of web, or a multiplier effect that is occurring because of the existence of the residency.

There is a growing recognition that the culture in some health care institutions is toxic to the people who work in it. And nursing is looking in this a lot, that somehow, the nature of modern care is somehow not only a dehumanizing experience for some patients as they experience it, but is a kind of occupational dehumanizing experience for some of the people who are asked to practice in it.

So, to the extent that we can somehow see whether family medicine residencies influence this in a positive way, and if they are not, figure out how to get the data where that remedy needs to be ? sort of a best practices versus a worst outcomes comparison.

Jamie Osborn, MD, Loma Linda University, Loma Linda, Callifornia
Jamie Osborn, MD, Loma Linda University, Loma Linda, Callifornia

Jamie Osborne, MD, Loma Linda University, Loma Linda, California: I would like to piggyback about what you were saying, Peter, about family medicine as an anti-venom in the toxic environment. Somewhere in that community, there are qualitative benefits that are derived from just the faculty and the residents that are attracted to a training program.

These are phenomenal people, and even beyond the very precise measurements that we can do about how many patients they are seeing that are medically indigent, we need to find some qualitative ways to describe the impact that they are having in their community – not in an organized COPC way, but as soccer moms, and as kindergarten helpers, and particularly with this new generation of part-time physicians influxing into family medicine.

Those very difficult qualities to measure, but the contributions that our faculty and graduates are making are significant.  This may be a very important next step to looking at some of the qualitative community participation.

Mr Burnett: Are there any other questions at this time, or comments?