NATIONAL PROJECT ON THE COMMUNITY IMPACT
OF FAMILY MEDICINE RESIDENCY PROGRAMS
UPMC St Margaret Family Medicine Residency Program:
One of the most important policy issues facing the country and Southwestern Pennsylvania as a whole and, locally, Allegheny and Westmoreland Counties, 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 St Margaret 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 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 St Margaret Family Medicine Residency Program
The UPMC St Margaret family medicine program was established in 1970, and has graduated over 350 family physicians, 70 of whom are practicing in the UPMC St Margaret’s service area, and another 20 who practice in nearby communities. Many of these graduates utilize the UPMC St Margaret Hospital when hospitalization of their patients is required, which contributes to the financial health of this important community institution. Each year the program graduates 12 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 care for men, women and children, and to provide pediatric care and a full range of women’s health services, including prenatal and obstetrical care.
For example, UPMC St Margaret 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 St Margaret 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.
The UPMC St Margaret Family Medicine Centers
A distinctive feature of the training provided to UPMC St Margaret 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.
The UPMC St Margaret program operates three such family medicine centers in Lawrenceville, Bloomfield-Garfield and New Kensington. Each center serves distinctive communities – Lawrenceville, a predominantly working class neighborhood; Bloomfield-Garfield, an underserved inner city community, whose ethnic composition includes significant African-American and Southeast Asian populations; and New Kensington, a mixed community, with a large percentage of persons of Central and Eastern European descendancy.
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 UPMC St Margaret family medicine centers are staffed by residents, their supervising physicians, and other health professionals.
The UPMC St Margaret family medicine centers are specifically designed to be the medical home for their 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 centers, the women’s health services include pelvic exams, pre-pregnancy wellness programs and preconception counseling, and mental health services. The women’s health program arranges for mammography and other diagnostic services, such as osteoporosis screening, for its patients.
The St Margaret family medicine residency women’s program routinely provides such services as PAP smears and colposcopy, birth control advice, teen group sessions, and mental health counseling within the family medicine center. The centers are staffed to meet the special needs of adolescent females. Additionally, the residency program maintains in-house consultation in obstetrics and gynecology.
Services at the three health centers vary according to community needs. As an example, behavioral health services, which are particularly hard to obtain in the New Kensington area, are available in that health center through arrangements with mental health professionals, as are services, established in cooperation with the Westmoreland County Department of Public Health, to diagnose and treat sexually transmitted diseases. All three centers have the resources to coordinate social services to benefit their patients.
The UPMC St Margaret Inpatient Family Medicine Service
Beyond the ambulatory care provided in the UPMC St Margaret family medicine center, the family medicine residency program maintains inpatient services within the UPMC St Margaret Hospital and UPMC Magee-Women’s 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 St Margaret 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, pediatrics, gynecology, ICU and post-surgical care. If necessary, they provide stabilizing medical care to psychiatric patients before transfer to the UPMC psychiatric units. In their inpatient service at Magee-Women’s Hospital Hospital, they provide for obstetrical and post-partum care.
The UPMC St Margaret family medicine residency program is a center for sports medicine training, located within its family medicine centers. As evidence of the national recognition of the quality of UPMC St Margaret family medicine residency’s sports medicine activities, it is accredited to provide a sports medicine fellowship whose training leads to special skills and a certificate of a family physician’s added qualification in sports medicine.
The UPMC St Margaret Family Medicine School Health Initiatives
The St Margaret family medicine program maintains relationships with two Pittsburgh high schools designed to address the educational and social needs of inner city youth – the Neighborhood Academy and the Career Connections Charter High School, contracting to provide physicals and other clinical services to its students.
It also has long-established ties with the Fort Pitt, Friendship, McCleary, Woolslair and Urban League Charter elementary schools, where, it works with school nurses to provide parent-approved on-site screening physicals; follow-up, when requested, at the UPMC St Margaret family health centers; and health-related lecture series in the school classrooms and assemblies.
To address the impact of asthma on child health, the residency program works with the community’s schools and parent organizations. The residency program is active in both in-school and after-school programs to discourage teen pregnancies, and also conducts lectures to elementary and middle schools students to discourage smoking.
UPMC St Margaret Family Medicine Cares for a Community’s Most Vulnerable
The mission of UPMC St Margaret states its commitment its meeting the health care and health education needs of the communities it serves. This commitment is evidenced through the patient population served by its family medicine residency.
The program is also a point of access to many of the community’s most vulnerable populations – the elderly and the disabled, with over a third receiving public assistance through Pennsylvania’s Medicaid program, or through Adagio Health, which administers gynecologic services funded by the Pennsylvania Department of Public Health. An additional 15% of its patients are mostly elderly persons enrolled in the Medicare program. A large percentage (34%) of those cared for are medically uninsured or indigent.
The remaining patients of the UPMC St Margaret 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 UPMC St Margaret family medicine program maintains an in-house social worker referral system to help uninsured in obtaining health care financial assistance for which they may be eligible. The program provides one on one review of the application questions, to be sure that its patients are aware of all funding sources for which they may qualify, including UPMC’s charity care program.
UPMC St Margaret Family Medicine’s Community-oriented Family Medicine
The UPMC St Margaret family medicine residency has devoted considerable attention to assessing and addressing community needs. In addition to the asthma awareness programs at community schools,
a community-oriented diabetes initiative has been established in two of UPMC St Margaret’s family medicine centers, which has created a registry of diabetes patients.
The residency program contracts to provide health services to many community-based agencies and Catholic charities. These include the Salvation Army’s homeless shelter in Downtown Pittsburgh; Women’s Center and Shelter of Greater Pittsburgh, a domestic violence shelter serving the East Liberty Neighborhood; and the Pittsburgh Action Against Rape, a rape crisis center.
One of its most important ongoing contractual relationships is with the Lincoln-Lemington Office of the East Liberty Family Health Care Center, a federally-qualified health center that serves the community’s indigent populations.
The residency program has established relationships with local community dentists, to better coordinate the medical and dental needs of patients under the residency program’s care. It also has established outreach to the increasing Somali populations of the area, and provides special Somali interpretative services within the residency.
UPMC St Margaret Family Medicine Services for the Elderly
Of the nation’s large urban counties, Allegheny County is second in the percentage of persons over 65. Therefore, the residency program has an extensive range of services for the community’s elderly.
This includes over 40 home visits annually of homebound elderly, and extensive clinical services to area nursing homes, both for skilled-nursing patients and those patients needing long-term custodial care. Nursing homes served by UPMC St Margaret family medicine residents and faculty include the Seneca Manor in Verona and the Willows of Presbyterian Senior in Oakmont.
In recognition of the excellence of the teaching resources available to the UPMC St Margaret family medicine residency program, it is accredited to offer two formal geriatric fellowships each year, for advanced training in the field. The geriatric fellows and their supervising faculty enrich the family medicine residents’ experiences in caring for this rapidly increasing population.
The residency program provides clinical services at such assisted living communities as UPMC’s Canterbury Place, and health-related lectures in various community settings, including adult day health centers and senior centers. Hospice care is provided through home visits, freestanding inpatient hospice, and in dedicated beds within St Margaret Hospital’s inpatient settings. It also participates in clinical and diagnostic services within the UPMC St Margaret Classic Care Gerontology Center, one of a small number of Western Pennsylvania’s approved geriatric assessment units.
Chronic Disease Care and Specialty Referrals
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 need to be seen by sub-specialists. The UPMC St Margaret family medicine residency program has mechanisms in place to help most patients obtain the services they need. In the case of public assistance and 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.
The UPMC St Margaret family medicine program is achieving its goal of promoting access to primary health care, and to comprehensive, continuous health care to the community it serves. 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.