UPMC Mercy Hospital FMRP

NATIONAL PROJECT ON THE COMMUNITY IMPACT

OF FAMILY MEDICINE RESIDENCY PROGRAMS

Mercy Hospital Family Medicine Residency Program:

A Report

(First draft)

One of the most important policy issues facing the country as a whole and, locally, Pittsburgh and the 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 Mercy 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 Mercy Hospital Family Medicine Residency Program

The Mercy Hospital family medicine program was established in 1995, and has graduated 34 family physicians, 15 of whom are practicing in the Mercy Hospital service area.  Four of these graduates utilize the Mercy Hospital when hospitalization of their patients is required, which contributes to the financial health of this important community institution. Each year the program graduates four 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, Mercy 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 Mercy 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.

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.

North Shore Family Health

A distinctive feature of the training provided to Mercy 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.

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 Mercy residency program’s family medicine center – North Shore Family Health at 1004 Arch Street in Pittsburgh – is staffed by residents, their supervising physicians, and other health professionals.

North Shore Family Health is specifically designed to be the medical home for its enrolled patients, utilizing a sophisticated medical record system to assure that their patients receive a full range of medical services.

Mercy 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, weight loss programs and mental health counseling within the family medicine center. Specialized services are available for adolescents.

The residency program also maintains in-house consultation in obstetrics and gynecology.

The Mercy Inpatient Family Medicine Service

Beyond the ambulatory care provided in the North Shore Family Health, the family medicine residency program maintains an inpatient service within the Mercy 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 Mercy emergency rooms.  Persons in this category will often be among the community’s most disadvantaged patients.

The hospital’s inpatient family medicine services provide pediatrics, gynecology, internal medicine, and post-surgical care. In the inpatient Labor and Delivery suites, they provide for obstetrical and post-partum care. The family medicine residency faculty supervise the intensive care unit for family medicine center patients.

Mercy’s School Health Initiatives

The Mercy family medicine program contracts to provide physicals for the Pittsburgh’s Allegheny Traditional Academy (elementary and middle schools) and Martin Luther King, Jr Accelerated Learning Academy. At the elementary and middle school levels, the residency program provides lectures to students to discourage smoking.

The Mercy family medicine residency also contracts with Duquesne Community College to provide discounted student health services at the Mercy family medicine center (North Shore Family Health).

Mercy Hospital Family Medicine Cares for a Community’s Most Vulnerable

The mission statement of Mercy Hospital states that it seeks “to understand and respond to the needs of our community through collaboration with others that share a common mission.  With attention to fiscal responsibility, quality services are made available and accessible to those who need them.” 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 – those on public assistance and the medically uninsured, the elderly and the disabled, with over 40% receiving public assistance, an additional 30% mostly elderly persons on Medicare, and another 6% who are medically uninsured or indigent.

The remaining 24% of Mercy Hospital family medicine center patients include working class families covered by the private sector health insurance plans. Yet, even these 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 Mercy Hospital family medicine program assists uninsured patients 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.  Because the residency program’s geographic service area has an infant mortality rate from two to five times greater than the remainder of Allegheny County, there is a special initiative to enroll young pregnant women.

Mercy Hospital Family Medicine’s Community-oriented Family Medicine

The residency program provides health services to many community-based agencies in Pittsburgh. The residency program participates in Operation Safety Net, a Healthcare for the Homeless Project that provides health services on the shores of homeless camps along the three rivers that surround Pittsburgh and on Pittsburgh’s streets. It also works with the Light of Life Mission, a shelter for the homeless on Pittsburgh’s North Side.

The Mercy family medicine residency also contracts with the March of Dimes to provide maternity services and infant care as part of the Pennsylvania Department of Public Welfare’s Healthy Beginnings program. It also participates in SBIRT (Screening, Brief Intervention, Referral and Treatment), an initiative of the federal Center for Substance Abuse and Treatment, administered by the Pennsylvania Department of Health.

Another initiative responding to an identified community need, was the establishment of a Hepatitis C Clinic at North Shore Family Health.

Mercy Hospital Family Medicine Residency 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.  The residency program provides home visits to the homebound elderly, and persons in assisted living arrangements.

For those patients requiring nursing home or end of life care, the residency program continues to serve its patients through skilled nursing facilities and hospice settings.

Chronic Disease Management 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 to be seen by sub-specialists.  The Mercy Hospital family medicine residency program has mechanisms in place to help most patients obtain the services they need.  In the case of public assistance or indigent 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.

Summary

The Mercy Hospital 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 Mercy Hospital, and contribute to the improvement of the community’s health.