NATIONAL PROJECT ON THE COMMUNITY IMPACT
OF FAMILY MEDICINE RESIDENCY PROGRAMS
York Hospital Family Medicine Residency Program:
(First draft with residency program’s revisions)
One of the most important policy issues facing the country as a whole and, locally, York County and the surrounding counties of 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 York 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 are in one of these primary care specialties.
Barbara Starfield of Johns Hopkins University points out that adults with a primary care physician had 33% lower cost of healthcare and were 19 percent less likely to die than those without a medical home, even adjusting for underlying health and demographic characteristics. Each primary care physician added per 10,000 population is associated with a 3-10% decrease in mortality rate. Family physicians also have been shown to decrease economic disparities in healthcare, particularly for African Americans.
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 York Hospital Family Medicine Residency Program
The York Hospital family medicine program was established in 1969, and has graduated over 221 family physicians, of whom 60 percent are practicing in the service area of York Hospital. These family physician residency graduates use York Hospital when hospitalization of their patients is required, which contributes to the financial health of this important community institution. Each year the program graduates eight 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.
But, 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, York 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 York Hospital 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 Thomas M. Hart Family Practice Center
A distinctive feature of the training provided to York 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. For the York Hospital family medicine residency, this takes place in the Thomas M. Hart Family Practice Center, which is specifically designed to be the medical home for the Center’s enrolled patients.
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 Thomas M. Hart Family Practice Center is staffed by residents, their supervising physicians, and other health professionals.
In the Thomas M. Hart Family Practice Center, the women’s health services include pelvic exams, pre-pregnancy wellness programs and preconception counseling. The women’s health program arranges for mammography and other diagnostic services, such as osteoporosis screening, for its patients.
The York family medicine residency women’s program routinely provides such services as PAP smears, colposcopy, and cryotherapy; birth control advice and mental health counseling within the Thomas M. Hart Family Practice Center. Additionally, the residency program maintains in-house consultation in obstetrics and gynecology.
The York Hospital Inpatient Family Medicine Service
Beyond the ambulatory care provided in the Thomas M. Hart Family Practice Center, the family medicine residency program maintains inpatient services within the York Hospital. In these settings family medicine residents and faculty, in collaboration with colleagues in surgical and referral specialties, take care of Thomas M. Hart Family Practice Center patients who have to be hospitalized.
The family medicine residency program’s inpatient family medicine service at York Hospital provides internal medicine, pediatrics, gynecology, ICU and post-surgical care; and a Labor and Delivery suite for obstetrical deliveries. The program provides medical care to psychiatric patients, who are co-managed with the hospital’s psychiatric service.
Training Physicians for Rural Areas
Although an important objective of the York Hospital family medicine residency program is the training of physicians for communities the size of York, 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. All residents are required to spend a portion of their residency in the small rural town of Gettysburg, where they provide obstetrical services, and receive direct experience in rural practice.
The York Hospital Family Medicine Student Health Initiatives
The York Hospital family medicine residency program provides physicals to students at the York County School of Technology and provides medical services to the sports teams at both YCST and the William Penn High School in York. The family medicine residency program also presents lectures to discourage smoking to elementary and middle school children.
York Hospital Family Medicine Cares for a Community’s Most Vulnerable
The mission of York Hospital states its commitment to providing “quality, cost-effective health care services strongly supporting excellence in education, and offering essential services without regard for an individual’s ability to pay.” This commitment is evidenced through the comprehensive care provided by the Thomas M. Hart Family Practice Center to the patient population it serves, whose additional mission is to provide “high quality family-centered health care to our community and exceptional education to family physicians”.
The Thomas M. Hart Family Practice Center is a point of access to many of the community’s most vulnerable populations – the elderly and the disabled, with over 50% receiving public assistance through Pennsylvania’s Medicaid program. An additional 15% of its patients are mostly elderly persons enrolled in the Medicare program. A large percentage (10%) of those cared for are medically uninsured or indigent.
The remaining patients of the Thomas M. Hart Family Practice Center include working class families covered by 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 York Hospital family medicine program maintains both in-house social work staff and a close working relationship with York Hospital’s social services unit to help the uninsured in obtaining health care financial assistance for which they may be eligible, and works with the York Hospital to obtain discounted care for others in financial need.
The York Hospital family medicine residency also provides pediatric and obstetrical services to uninsured and indigent patients at the York Hospital Community Health Center.
York Hospital Family Medicine Services for the Elderly
The York Hospital family medicine residency provides an extensive range of services for elderly population, in addition to the primary care and diagnostic services provided at the Thomas M. Hart Family Practice Center. This includes periodic 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. Hospice care is provided both through home visits and within York Hospital inpatient hospice settings.
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 York Hospital 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 York Hospital 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. The range of services provided at the residency program’s Thomas M. Hart Family Practice Center are consonant with the service mission of the York Hospital, and contribute to the improvement of the community’s health and well-being.