NATIONAL PROJECT ON THE COMMUNITY IMPACT
OF FAMILY MEDICINE RESIDENCY PROGRAMS
Family Medicine Residency Program:
One of the most important policy issues facing the country as a whole and, locally, the urban and rural counties that comprise Southwestern Pennsylvania, 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 UPMC McKeesport 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 created three-year accredited residency programs accredited 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.
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.
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 UPMC McKeesport Family Medicine Residency Program
The UPMC McKeesport family medicine program was established in 1978, and has graduated 154 family physicians, 16 of whom are practicing near McKeesport, and another fifty who practice in Southwestern Pennsylvania. Sixteen of these graduates utilize the UPMC McKeesport Hospital when hospitalization of their patients is required, which contributes to the financial health of this important community institution. 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, UPMC McKeesport 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 UPMC McKeesport family medicine residency program are trained to diagnose and treat congestive heart failure and coronary artery disease, hypertension and high cholesterol, working with referral cardiologists and surgeons when appropriate and necessary.
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 UPMC McKeesport Family Medicine Center
A distinctive feature of the training provided to UPMC McKeesport family medicine residents is that, in addition to the hospital inpatient rotations that constitute the site of learning for most physician specialties, each family medicine 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 medicine resident a three-year experience in providing a full range of medical and health maintenance services to the same group of patients, the McKeesport family medicine center is staffed by residents, their supervising physicians, and other health professionals.
The UPMC McKeesport family medicine center is specifically designed to be the medical home for its enrolled patients, utilizing a sophisticated electronic medical record system to assure that their patients receive a full range of medical services.
In its family medicine center, the women’s health services include pelvic exams, pre-pregnancy wellness programs and preconception counseling. Group services are available for adolescents, as is mental health counseling.
The women’s health program arranges for mammography and other diagnostic services, such as osteoporosis screening, for its patients. The program routinely provides such services as PAP smears, colposcopy, cryotherapy and endometrial biopsies, birth control advice, teen group sessions, and mental health counseling within the family medicine center. It can arrange for weight loss programs in the UPMC McKeesport system. The residency program also maintains in-house consultation in obstetrics and gynecology.
The UPMC McKeesport Inpatient Family Medicine Service
Beyond the ambulatory care provided in the UPMC McKeesport family medicine center, the family medicine residency program maintains an inpatient service within the UPMC McKeesport Hospital. In these settings 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.
Additionally, the program, through its participation in “unassigned call”, assumes responsibility for caring for many patients without a physician who are admitted to the hospital through the UPMC McKeesport emergency rooms. Persons in this category will often be among the community’s most disadvantaged patients.
The hospital’s inpatient family medicine services provide internal medicine, gynecology, and post-surgical care. In a separate section of the hospital they provide psychiatric care services. In their inpatient service at UPMC Magee-Women’s Hospital, they provide for obstetrical and post-partum care. (The center’s pediatric patients are admitted at Children’s Hospital.)
School Health Initiatives
The McKeesport family medicine program provides over 200 school physicals for the community’s elementary, middle and high schools, in both the public and Catholic school systems. It conducts lectures to elementary and middle schools students to discourage smoking, and provides sports physicals for high schools.
Care for chronic diabetes, not only takes place in the family medicine center (or, in extreme situations, in the hospital), but in the community as well. The residency program works with Lions Clubs to promote diabetic education; and is engaged in lifestyle counseling of patients to ameliorate the impact diabetes on health.
UPMC McKeesport Family Medicine Cares for a Community’s Most Vulnerable
The mission of UPMC McKeesport states its commitment its charitable responsibilities and to its role as a major resource to the communities it serves. This commitment is evidenced through the patient population served by its family medicine residency program.
The program is also a point of access to many of the community’s most vulnerable populations – the elderly and the disabled, with over 70% receiving public assistance through Pennsylvania’s Medicaid program and an additional 20%, mostly elderly persons enrolled in the Medicare program.
The remaining patients of the UPMC McKeesport family medicine center include working class families covered by the private sector health insurance plans. Yet, even the small number of privately 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.
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 program has devoted considerable resources to community needs assessment, and has an advisory board that meets regularly on the health care needs of the McKeesport area. This has resulted in such initiatives as a medication voucher program to help persons in need of affordable pharmaceuticals, working with Womanplace, assisting with the health impact of domestic violence; and provision of physical exams for school-age children. The most critical finding was determined to be the need for increased a community free clinic for the medically uninsured. The UPMC McKeesport program has taken a key role in planning for such a facility.
The UPMC McKeesport family medicine program employs medical assistants who help uninsured in obtaining health care financial assistance for which they may be eligible. The program works with a family planning agency to enroll target populations of medically uninsured to assure access to health care services for the medically indigent .
The program works with UPMC McKeesport Hospital to enroll Medicaid patients, and also work with the UPMC charity care program and with a community federally qualified health center to assure access to care from those who otherwise do not qualify for free or discounted care. Additionally, the program has a special initiative to enroll elderly Medicare patients, involving the hospital’s discharge department.
UPMC McKeesport Family Medicine’s Community-oriented Family Medicine
The residency program provides health services to many community-based agencies in the McKeesport and Pittsburgh. These include First Steps, a Head Start program in McKeesport; Career Link, a Jobs Corps program; the Auberle Home for adolescents under the supervision of the police or judicial systems, WOMENSplace of Western Pennsylvania, a domestic violence shelter located in McKeesport; services to developmentally disabled patients at the Center for Independent Living in Avenue in Pittsburgh; and community-based HIV testing, behavioral counseling and psychiatric services at MonYough Communty Health Services. For the McKeesport Housing Authority, the residency program provides health services to Crawford Village.
The residency program has an extensive range of services for the community’s elderly. The residency program faculty and residents provide health-related lectures in various community settings, including nursing homes and senior centers. In addition, the residency provides extensive clinical services to area nursing homes, both for skilled-nursing patients and those patients needing long-term custodial care.
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.
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 UPMC McKeesport 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.
The UPMC McKeesport family medicine program is achieving its goal of promoting access to primary health care, and to comprehensive, continuous health care to the McKeesport area. It community-based initiatives complement the goals of neighborhood organizations promoting health, are consonant with the service missions of the UPMC, and contribute to the improvement of the community’s health and well-being.