University of Pennsylvania FMRP

NATIONAL PROJECT ON THE COMMUNITY IMPACT

OF FAMILY MEDICINE RESIDENCY PROGRAMS

University of Pennsylvania Health System

Family Medicine Residency Program:

A Report

(First draft)

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 patients with medical insurance.  However, educational systems – including the University of Pennsylvania 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 nation, 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 University of Pennsylvania Health System [UPHS] Family Medicine Residency Program

The UPHS family medicine program was established in 1997, and has graduated 32 family physicians, 20 of whom are practicing in the Philadelphia area. Each year the program graduates six new family physicians.

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, UPHS 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 the UPHS 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 University of Pennsylvania Family Medicine Center

A distinctive feature of the training provided to UPHS family physician residents is that, in addition to the hospital inpatient rotations that constitute the site of learning for most physician specialties, each family physician resident 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 University of Pennsylvania 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 UPHS 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 UPHS Inpatient Family Medicine Service

Beyond the ambulatory care provided in the University of Pennsylvania family medicine center, Penn’s family medicine program maintains an inpatient service within University of Pennsylvania’s 1100-bed Penn Presbyterian Hospital.  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, 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 the family medicine residency women’s health program, a full range of obstetrical services is provided to all but the high risk obstetrical patients, from pre-natal care in the family medicine center through delivery in the program’s inpatient obstetrical services.

In its family medicine center the women’s health services include pelvic exams, pre-pregnancy wellness programs, osteoporosis screening, weight loss programs, and arranges for mammography and other diagnostic services for its patients. The program routinely provides such services as PAP smears, colposcopy, and endometrial biopsies within the family medicine center, and can arrange for mental health counseling or abortion services (up to 12 weeks).  It provides OB ultrasound in its Labor and Delivery Suite.

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 UPHS family medicine residency program has participated in asthma camps for the children enrolled in a community school. The program also provides diabetes screening at community health fairs and organizes group-based home visits to neighborhoods with high incidence of diabetes.

The UPHS family medicine program provides health care services to elementary and high schools in nearby low income Philadelphia neighborhoods, including the Drew Elementary School and University City and Sayre High Schools.  Additionally, the family medicine center is the clinical site for health services to University of Pennsylvania’s students.

The UPHS family medicine residency program is a center for sports medicine training, located within its family medicine center. 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).

UPHS Family Medicine Cares for a Community’s Vulnerable

The mission of the family medicine residency program’s University of Pennsylvania host department is “to be a top-rated Department of Family Practice and Community Medicine that is academically strong and attentive to community needs”.  One such need, and one of the most important contributions of the program to the Philadelphia area, is to provide access to comprehensive health services for many of the community’s most vulnerable populations.

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 UPHS 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, the disabled and those receiving public assistance through Pennsylvania’s Medicaid program.

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 UPHS family medicine residency program, working with the UPHS medical centers, has processes for assisting patients in obtaining health care financial assistance for which they may be eligible.

UPHS School Health Services

The UPHS family medicine residency program serves important community functions.  The program provides an advisory function on community health for local schools, working with school administrations, parent-teacher organizations, and students.  A major initiative is the newly established federally-qualified health center at Sayre High School.  The residency program participates on the health center’s community governing board.

All UPHS family medicine residents, as part of a community medicine rotation, are required to develop an initiative to help improve health in the local community.  Several of the family medicine resident-initiated activities have been associated with the residency programs ties with the school-based health center.  The residency program also advises domestic violence groups and law enforcement, and participates in community smoking cessation programs.

Additionally, the program provides 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.

Well over half of UPHS family medicine residency program have private sector health insurance, the majority of whom are from working families in the Downtown Philadelphia area, and another sixth are mostly elderly patients financed by Medicare.  A fourth 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 UPHS family medicine residency program has mechanisms in place to help most patients obtain the services they need.  In the case of public assistance 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.

Because of the rapidly growing numbers of ethnic and linguistic minorities in the Philadelphia area, the UPHS family medicine residency program has devoted resources to teach their residents competence in providing care to persons from diverse cultures.

The UPHS family medicine program is achieving its goal of promoting access to primary health care, and to comprehensive, continuous health care to the neighborhoods surrounding the University of Pennsylvania.  It community-based initiatives complement the goals of neighborhood organizations promoting health, are consonant with the service missions of the University of Pennsylvania and UPHS, and contribute to the improvement of the community’s health and well-being.