NATIONAL PROJECT ON THE COMMUNITY IMPACT
OF FAMILY MEDICINE RESIDENCY PROGRAMS
Family Medicine Residency Program:
(First draft with training program revisions)
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 Shadyside 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 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 Shadyside Family Medicine Residency Program
The UPMC Shadyside family medicine program was established in 1970, and has graduated 209 family physicians, 40 of whom are practicing in the UPMC Shadyside service area, and another 50 who practice in Southwestern Pennsylvania. Forty of these graduates utilize the UPMC Shadyside Hospital when hospitalization of their patients is required, which contributes to the financial health of this important community institution. Each year the program graduates nine 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 for children, men and women, including prenatal and maternity services.
For example, UPMC Shadyside 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 Shadyside family medicine residency program are trained to diagnose and treat all of the common chronic conditions, including diabetes, congestive heart failure and coronary artery disease, asthma and COPD, hypertension, arthritis and high cholesterol, among others. They do so as the first contact physician, primary managing physician, and perhaps most important of all coordinator of care, working with referral cardiologists and surgical specialists.
Similarly, such chronic diseases 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.
The UPMC Shadyside Family Medicine Center
A distinctive feature of the training provided to UPMC Shadyside 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 Shadyside family medicine center is staffed by residents, their supervising physicians, and other health professionals.
The UPMC Shadyside 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.
Family Medicine Residency Women’s Health Services
The family medicine residency women’s health services include pelvic exams, pre-pregnancy wellness programs, preconception counseling and comprehensive, family-centered maternity care.
The family medicine residency women’s health program arranges for mammography and other diagnostic services, such as osteoporosis screening for those with risk factors, for its patients. The family medicine residency program routinely provides such services as PAP smears, common gynecological procedures, birth control advice and mental health counseling within the family medicine center. Specialized services are available for adolescents.
It can arrange for weight loss programs in the UPMC Shadyside system. The residency program also maintains in-house consultation in obstetrics and gynecology.
The UPMC Shadyside Inpatient Family Medicine Service
Beyond the ambulatory care provided in the UPMC Shadyside family medicine center, the family medicine residency program maintains an inpatient service within the UPMC Shadyside 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 Shadyside 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 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.)
UPMC Shadyside’s School Health Initiatives
The Shadyside family medicine program contracts to provide sports physicals for the Pittsburgh’s schools, in both the public and Catholic school systems. Additionally, it has developed special contractual relationships with two high schools that are in neighborhoods with a high percentage of low income families.
At Schenley High School, the Shadyside family medicine residency program provides physicals without charge to students, for many of whom this is their point of access to quality health care. Additionally, at these schools, the residency collaborates with the school in training students to be mentors for middle school students to help postpone sexual activity. At the elementary and middle school levels, the residency program provides lectures to students to discourage smoking.
Community-based Chronic Disease Care
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. This is one of several significant initiatives that are part of the Center for Healthy Hearts and Souls, a community-based non-profit corporation which was originally sponsored and continues to be supported by the UPMC Shadyside family medicine residency program and its faculty.
UPMC Shadyside Family Medicine Cares for a Community’s Most Vulnerable
The mission of UPMC Shadyside states its commitment to 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 30% receiving public assistance, an additional 25% mostly elderly persons on Medicare, and another 10% who are medically indigent or enrolled in UPMC’s charity care program.
The remaining patients of the Shadyside Hospital 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, which has led to such initiatives as the establishment of the Center for Healthy Hearts and Souls. Through that Center, focus groups provide a mechanism for community concerns to be identified and addressed. In response, the residency program established its school health program to encourage postponing of sexual activity, and has added a component for sensitizing residents to the effects of gender-based discrimination. The residency program is one of the community’s few access points for health care to the developmentally disabled.
The UPMC Shadyside family medicine program employs a social worker who helps uninsured patients to obtain health care financial assistance for which they may be eligible. The program is engaged in outreach programs to add Medicaid, Medicare and uninsured and underinsured patients, working with local churches and community centers, as well as the Center for Healthy Hearts and Souls.
UPMC Shadyside Family Medicine’s Community-oriented Family Medicine
The residency program provides health services to many community-based agencies in Pittsburgh. These include the homeless shelters maintained by the Salvation Army; the Bethlehem Haven’s Fifth Avenue Commons, whose primary focus is homeless women and those seeking emergency shelter; and the Wood Street Commons, an initiative supported by the Allegheny County Department of Public Services.
The residency program is the principal primary care provider for the Alpha House of Pittsburgh for treatment of alcohol and substance-abuse; and for community agencies that assist cerebral palsy patients and other developmentally disabled.
UPMC Shadyside Family Medicine Services for the Elderly
The residency program has an extensive range of services for the community’s elderly. Ongoing primary preventive, chronic and acute care is provided to maintain the health and well-being of the family medicine center’s elderly patients. For those patients requiring nursing home or end of life care, the residency program continues to serve its patients through UPMC’s skilled nursing facilities and hospice settings. In collaboration with the UPMC Shadyside Department of Internal Medicine, a nationally-accredited geriatrics fellowship program is offered, whose activities enhance the UPMC Shadyside family medicine residency program’s geriatric 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 Shadyside 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 Shadyside family medicine program is achieving its goal of promoting access to primary health care, and to comprehensive, continuous health care to Pittsburgh. It community-based initiatives complement the goals of neighborhood organizations promoting health, are consonant with the service missions of UPMC, and contribute to the improvement of the community’s health and well-being.