NATIONAL PROJECT ON THE COMMUNITY IMPACT
OF FAMILY MEDICINE RESIDENCY PROGRAMS
Thomas Jefferson University’s
Family Medicine Residency Program:
One of the most important policy issues facing the country as a whole and, locally, the counties that comprise the Metropolitan Philadelphia area is the need to find better ways to assure that the area’s population has access to health care that is of high quality and is affordable.
A common complaint is that the health care system is fragmented, with many health care facilities and personnel offering very specialized services, often at high cost even to medically insured patients. However, educational systems – including Thomas Jefferson University’s family medicine residency program –
exist for training physicians that can provide health care comprehensively and that can assure continuity in the care provided.
Forty years ago the United States, through a partnership of the medical professions and the federal and state governments, established the family physician medical specialty and accredited three-year family medicine residency programs to train them. Family physicians, with general internists and general pediatricians, are the physicians who provide primary health care in the United States. Most persons who have a personal physician are in one of these primary care specialties.
Of the various physician specialties, family physicians are the most proportionately distributed to where the country’s population lives. Family physicians, unlike referral specialists, practice in most neighborhoods and communities. Often the practices of one or more family physicians will be one of the major employers in a neighborhood.
The accredited entities that train family physicians are called family medicine residency programs. A physician who is training to become a board-certified family physician is called a family medicine resident.
The Jefferson Family Medicine Residency Program
The Jefferson family medicine program is one of the oldest family medicine residency programs in the nation. Each year it graduates nine new family physicians. Even though the Jefferson medical school provides physicians throughout the State of Pennsylvania (and, indeed, the world), at least 60 of the residency program’s graduates currently are practicing physicians in the Metropolitan Philadelphia area.
Although helping a patient maintain good health is a principal goal of all family physicians (and primary care physicians generally), possibly the majority of patients that seek care are concerned with acute or chronic illness. Family physicians are trained to diagnose and actively manage the range of medical problems that a person or family may encounter in their lifetime.
Unlike other primary care physician specialties, family physicians are trained to provide both pediatric care and women’s health, including prenatal and obstetrical services.
For example, Jefferson family medicine residents provide obstetrical, gynecological and pediatric care, as well as adult and geriatric care. Additionally, all residents and faculty and all graduates of Jefferson’s family medicine residency program are trained to diagnose and treat congestive heart failure and coronary artery disease, hypertension and high cholesterol – when appropriate and necessary, working with referral cardiologists and surgeons.
Similarly, such chronic diseases as arthritis, diabetes, asthma, chronic obstructive pulmonary disease (COPD) and chronic renal failure are best treated when detected early, and family physicians are extensively trained in determining which of their patients either show signs of these problems or are at risk for them. A family medicine resident or board-certified family physician will be able to obtain the diagnostic tests and, whenever medically appropriate, specialty procedures that a patient needs.
With proper care, most persons whose medical problems have advanced to a stage needing surgery or a highly specialized medical intervention, can still achieve a satisfactory lifestyle after their surgery or specialized treatment. A family physician, working in collaboration with the surgeons or specialists to whom the patient has been referred, will provide ongoing care afterwards to maximize a person’s health and well-being.
The Jefferson Family Medicine Center
A distinctive feature of the training provided to Jefferson University family physicians is that, in addition to the hospital inpatient rotations that constitute the site of learning for most physician specialties, each family physician trains in a family medicine center, which provides care in an outpatient setting like a family doctor’s office.
Designed to give the family physician resident a three year experience in providing a full range of medical and health maintenance services to the same group of patients, the Jefferson family medicine center is staffed by residents, their supervising physicians, and other health professionals.
An important public policy objective is to encourage everyone to establish a “medical home”, in which all of a person’s medical information can be cared for by a single medical entity, including direct patient care, providing or obtaining diagnostic testing, referral to sub-specialists when needed, coordination of pharmaceutical prescriptions, and management of chronic conditions. The Jefferson family medicine center is specifically designed to be such a medical home, and utilizes a sophisticated electronic medical record system to provide a full range of medical services to each of its patients.
The Jefferson Inpatient Family Medicine Service
Beyond the ambulatory care provided it the Jefferson family medicine center, the Jefferson family medicine program maintains an inpatient service within Jefferson Medical Center. In this setting family medicine residents and faculty, in collaboration with colleagues in surgical and referral specialties, take care of family medicine center patients who have to be hospitalized. The hospital’s inpatient family medicine service provides internal medicine, pediatrics, gynecology and post-surgical care on its primary service, and obstetrical and post-partum care in the family medicine residency program’s Labor and Delivery suites.
In Jefferson’s women’s health program, the family medicine residency program provides a full range of obstetrical services to all but the highest risk obstetrical patients, from pre-natal care in the family medicine center through delivery in the residency program’s Labor and Delivery Suite at Jefferson Hospital. The residency program provides pelvic exams, arranges for mammography and other diagnostic services for its patients. It has the capacity to provide such services as colposcopy, cryotherapy, and endometrial biopsies within the family medicine center, OB ultrasound in its Labor and Delivery Suite, and LEEPs at the Jefferson Surgi-Center.
Jefferson’s Community-oriented Family Medicine
Care for chronic diseases, such as asthma and diabetes, not only takes place in a physician’s offices (or, in extreme situations, in the hospital), but in the community as well. The Jefferson family medicine residency program collaborates with the Philadelphia Department of Health and Environmental Protection Agency in “STEPS, a city-wide asthma initiative. Jefferson family medicine residents participate in, a student-created effort called “Move for Health” which promotes health education for Philadelphia-area diabetic patients.
The Jefferson family medicine residency program is a center for training in sports medicine, located at the Rothman Institute (925 Chestnut in Philadelphia) and for providing sports medicine services to such area colleges as the Newman College and St Joseph’s University in Philadelphia, and Rutgers’ Camden (NJ) campus. It is closely associated with the Jefferson University Department of Family Medicine’s sports medicine fellowship program.
The residency program provides a full line of sports medicine services from nutrition counseling and physical therapy to care for sports injuries (muscle or soft tissue injuries, casting, splinting, taping, fracture management, evaluation of surgical needs). As evidence of the high regard for its sports medicine services, the program contracts with the Philadelphia Phillies to provide medical coverage at the team’s baseball games.
Jefferson Family Medicine Cares for a Community’s Vulnerable
Even insured patients may find it difficult to negotiate the health care system without such advocates for their health care as they might obtain in their medical home. Although the Jefferson family medicine center provides a substantial percentage of care to populations covered by the private sector health insurance plans of working class families, it is also a point of access to the community’s most vulnerable populations – the elderly, those on public assistance, the indigent and disabled.
Because the costs of health care have become increasingly difficult for many individuals and families to manage, persons in these vulnerable categories of patients often defer necessary health services until they become acutely ill. The community at large benefits if such persons are encouraged to establish a medical home to assure quality health care on an ongoing basis. The Jefferson family medicine residency program, working with the Jefferson University medical center, has processes for assisting patients in obtaining health care financial assistance for which they may be eligible.
The Jefferson family medicine center serves important community functions. They provide ongoing care to persons with such chronic conditions as diabetes, cardiovascular and neurological diseases, severe asthma and behavioral disorders. With ongoing, continuous care, most of these patients can be kept out of hospital emergency rooms, one of the most costly ways of providing health services. In the case of public assistance or uninsured patients, the financial impact of the community of avoidable emergency room use can be very high.
Although half of Jefferson’s patients are from private sector health insurance, the majority of whom are from working families in the Downtown Philadelphia area, and another tenth are mostly elderly patients financed by Medicare, a third of its patients are Medicaid-financed, who are among Philadelphia’s lowest income citizens.
One of the functions of family medicine residency programs is to help patients determine when they need diagnostic tests or to be seen by sub-specialists. The family medicine residency programs also have mechanisms in place to help most patients obtain the services they need. In the case of public assistance or uninsured patients, these mechanisms prove invaluable, since many sub-specialists often do not offer their services to persons who do not have private sector health insurance.
Jefferson’s program works with community organizations to enroll low income Medicaid and indigent persons in the Downtown Philadelphia area, and has outreach programs to add elderly patients, with specialized activities at its Senior Center site for clinical services.
Among Philadelphia’s most vulnerable populations are its adolescents. The Jefferson family medicine residency provides both clinical and psychiatric services to Philadelphia’s Adolescent Shelter, and also sees patients ats the Youth Emergency Services Inc., Project Home, and the Hahneman Learning Center.
It is importantly involved with the Northeast Addiction Rehabilitation Program, and provides community-based HIV and AIDS-care services at the Mazzone Center in Downtown Philadelphia.
The Jefferson family medicine residency program’s community outreach activities provide ongoing clinical support to Philadelphia’s Department of Public Health. Additionally, the Jefferson family medicine residency program has a long-tradition of volunteer community service.
Because of the rapidly growing numbers of ethnic and linguistic minorities in our community, the Jefferson family medicine residency program has devoted considerable resources to teach their residents competence in providing care to persons from diverse cultures, and in addressing care of non-English speaking patients. Not only does the residency program have specialized training in achieving cultural competence, but it gives special attention to selecting and training residents who themselves reflect ethnic and racial minorities underrepresented in the health care system.