NATIONAL PROJECT ON THE COMMUNITY IMPACT
OF FAMILY MEDICINE RESIDENCY PROGRAMS
Lancaster General Hospital
Family Medicine Residency Program:
One of the most important policy issues facing the country as a whole and, locally, Lancaster County and the surrounding rural counties that comprise South Central 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 Lancaster General Hospital 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 have one from 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 are among 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 Lancaster General Hospital Family Medicine Residency Program
The Lancaster General Hospital family medicine program was established in 1970, and has graduated 413 family physicians, 130 of whom are practicing in Lancaster County and surrounding counties, and another 30 who practice in Central Pennsylvania beyond the Lancaster General Hospital’s service area.
Of these graduates, 114 utilize the Lancaster General Hospital when hospitalization of their patients is required, which contributes to the financial health of this important community institution. Each year the program graduates 13 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 care for children, men and women, including prenatal and maternity services.
For example, Lancaster General Hospital 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 Lancaster General Hospital 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.
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 and well-being.
The Lancaster General Hospital Family Medicine Centers
A distinctive feature of the training provided to Lancaster General Hospital 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 Lancaster General Hospital family medicine residency program operates two such family medicine centers, the Lancaster General Hospital Family Health Services at 555 N. Duke Street in Lancaster, and the Walter L. Aument Family Health Center in Quarryville.
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, both family medicine centers are staffed by residents, their supervising physicians, and other health professionals. The family medicine centers are 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.
Lancaster General Hospital Family Medicine Residency Women’s Health Services
The Lancaster 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 its patients. The program routinely provides such services as PAP smears, common gynecological procedures, birth control advice, programs for adolescents, exercise and aerobics, weight loss programs and mental health counseling within the family medicine center. Additionally, the residency program also maintains in-house consultation in obstetrics and gynecology.
The Lancaster General Hospital Inpatient Family Medicine Service
Beyond the ambulatory care provided in the Lancaster and Quarryville family medicine centers, the family medicine residency program maintains an inpatient service within the Lancaster General 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.
Lancaster General Hospital’s inpatient family medicine residency service encompasses labor and delivery and post-partum maternity care and gynecology. The residency program staffs intensive care units and provides the medical management for any family medicine patients admitted to the psychiatric services.
Training Physicians for Rural Areas
Although an important objective of the Lancaster General Hospital family medicine residency program is the training of physicians for communities the size of Lancaster, there are also many smaller rural communities that need physicians able to provide the comprehensive set of skills that family physicians learn in their residency.
Each of the family medicine residents spends a substantial portion of their three years of residency at the Quarryville family medicine center, the majority spending three or four days a week there. In both Lancaster and Quarryville settings, they provide health care services to an otherwise underserved rural population, thereby receiving direct experience in rural practice.
Long-term studies of the physician practice choice patterns have confirmed that the existence of a family medicine residency program in a region that it is oriented towards rural practice is a critical factor in recruiting family physicians to the small cities and rural towns in that region.
Because many small communities in South Central Pennsylvania presently need physicians or will soon anticipate the retirement of physicians currently in practice, the region benefits from having a residency program located in Lancaster that is producing new family physicians.
Lancaster Family Medicine Residency School Initiatives
The Lancaster family medicine residency program provides health lectures to discourage smoking to students of area public and private schools. Lectures are presented to 15 elementary schools in Lancaster, two in Manheim, and one each in Conestoga, Ephrata, Smoketown, Willow Street and Quarryville. More extensive health services are provided at the Carter and MacRae Elementary School in Lancaster and three other area schools.
Additionally, the Lancaster family medicine residency sports medicine program residency program works with the athletics teams at Solanco High School in Quarryville and the Thaddeus Stevens College of Technology in Lancaster.
Lancaster General Hospital Family Medicine Cares for a Community’s Most Vulnerable
The mission of Lancaster General states its commitment to “advance the health and well being of the communities of Lancaster.” This commitment is evidenced through the patient population served by the Lancaster General Hospital family medicine residency program.
The family medicine residency is a point of access to many of the community’s most vulnerable populations – those receiving public assistance, the indigent and the elderly, with over 72% (29,600) of the patients served by the residency programs principal family medicine center (Family Health Services) receiving public assistance through Pennsylvania’s Medicaid program. That Lancaster General Hospital family medicine center also had five percent uninsured or indigent patients, and an additional 10%, mostly elderly persons, enrolled in the Medicare program. Medicaid patients accounted for half or more of the family medicine residency patients at the Women’s and Babies Hospital (60%) and North Duke Family Medicine (50%).
Over 62% of the patients seen at the Walter L. Aument Health Center in Quarryville are also Medicaid, Medicare or indigent. The remaining 38 percent of the Lancaster family medicine residency’s Quarryville family medicine center patients include working class families covered by the private sector health insurance plans. Yet, even 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 Lancaster General family medicine residency works with the hospital billing office and social work staff to help the uninsured in obtaining health care financial assistance for which they may be eligible, and assists other patients gain access to needed pharmaceuticals and certain diagnostic tests which they could not otherwise afford.
Community Needs Assessment
The Lancaster family medicine residency has devoted considerable resources to community needs assessment. It has taken a leadership role within part Lancaster General Hospital’s strategic planning to improve primary care access for the underserved.
The Lancaster family medicine residency has helped set up asthma surveillance programs within the school systems, and has worked with the Latino community to identify and provide services to diabetic patients. As part of a HRSA-funded grant, the family medicine residency is implementing a program to send school children with Type I Diabetes to a summer camp developed for such children.
The Lancaster family medicine residency program has assumed national leadership in the development of programs to quantify the numbers of low birth-weight infants and better understand their health care needs. Concurrently, the residency program is developing and implementing strategies to discourage “rapid-repeat pregnancies”, known to contribute to the incidence of such births.
Lancaster Family Medicine Community-oriented Primary Care
Beyond the provision of care in the Lancaster family medicine residency family medicine centers, and the needs assessment initiatives described above, the Lancaster family medicine residency is involved in various community-based functions for groups and agencies that often have difficulty obtaining physician services.
The residency program assists at the Water Street Rescue Mission, a homeless shelter; at Vantage Gaudenzia House, a substance abuse and HIV+ treatment center; at a woman’s shelter and halfway house in South Lancaster; at a comprehensive health care center for HIV located at North Duke Family Medicine; and at the Planned Parenthood agency in Lancaster.
Lancaster General Hospital Family Medicine Residency’s Services for the Elderly
The Lancaster General Hospital family medicine residency provides an extensive range of services for its elderly population. Ongoing primary preventive, chronic and acute care is provided to maintain the health and well-being of the Lancaster General family medicine centers’ elderly patients.
In addition to the primary care and diagnostic services provided at the family medicine centers and the family medicine residency’s inpatient services at Lancaster General Hospital, the residency program continues to serve its patients requiring nursing home or end of life care.
This includes home visits of homebound elderly, and clinical services to area nursing homes, both for skilled-nursing patients and those patients needing long-term custodial care.
The Lancaster General Hospital family medicine residency’s hospice program is led by a distinguished medical ethicist and geriatrician, who is developing the residency program’s palliative care curriculum. Where appropriate, hospice care is provided through home visits.
Chronic Disease Management and Coordination of 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 to be seen by sub-specialists. The Lancaster General Hospital 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 Lancaster General Hospital family medicine program is achieving its goal of promoting access to primary health care, and to comprehensive, continuous health care to Lancaster County and the surrounding area. Helping fulfill the education and service missions of Lancaster General Hospital, the family physicians the family medicine residency program trains and the patient care services the residency program provides, contribute to the improvement of the community’s health.