Proceedings of the 22nd National Conference: The 21st G. Gayle Stephens Lecture: Dr Joshua Freeman

We gratefully acknowledge the sponsorship of the Kaiser Permanente Los Angeles Family Medicine Residency Program for the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:

 

Mark Clasen, MD, Ph.D., Wright State University (Moderator): This is the 21st G Gayle Stephens Lecture. Many of us who are family physicians have looked to Gayle as one of the founders of the specialty, certainly the countercultural nature of family medicine as was articulated by Gayle in his writings on the Intellectual Basis of Family Medicine. I am  very struck by the spiritual nature of his writing about family medicine; the “I thou” relationship which he borrowed from theology to talk about the doctor-patient relationship.

I do know that in trying to attract younger people into the specialty we can talk about population care and systems care and becoming mega managers of primary care issues, but the vulnerability of the one-on-one relationship with patients is still a major motivator of our students. That’s why they want to be family medicine people.

Gayle articulated all of this stuff along with a lot of humor. At the Second Nationl Conference at Beaver Creek, Colorado he talked about the “big red bull who eats and eats and never gets full”, and by that he meant the medical industrial complex, which has got the money and is part of the founders of resistance to medical care systems that we’re talking about that make sense and some of the change.

So, when I also saw who was doing this presentation this morning, Doctor Joshua Freeman, I was very pleased. Josh and I have known each other professionally a long time. The first time I came to know him, he was concerned about vulnerable patients and access to healthcare. So what a wonderful presenter we have. I think you all will be extremely pleased with Joshua Freeman is giving the Gayle Stephens lecture.

 

Joshua Freeman, MD; Kansas University Medical Center

Joshua Freeman, MD (Kansas University Medical Center, Kansas City): Thank you. I think I’ll follow up Rick Flinders’ tour guide role this morning and point out that at the edge of the Embarcadero on which this hotel is located is a memorial to the veterans of the Abraham Lincoln Brigade, which was a group of Americans who joined the international brigades that fought in Spain against Franco between 1936 and 1939.

It’s personally important to me, because my uncle was one of those who never came back from that battle, so I never got a chance to meet him. If you have a chance to drop by, it’s really worth seeing.

I thought I would talk about family medicine in the era of healthcare reform, or perhaps, family medicine in the era of healthcare change, since I’m not sure how much it’s going to be reformed yet.

It is a tremendous honor to present the G. Gayle Stephens lecture, to even be associated with his name. I’m not going to list Dr. Stephens’ accomplishments and contributions to the discipline of Family Medicine; but I would commend you to the remarkable festschrift that John Geyman, who is here in our midst, wrote in the January, 2011 issue of Family Medicine.

A festschrift (in case you didn’t know) is “A volume of learned articles or essays by colleagues and admirers, serving as a tribute or memorial especially to a scholar”. I had to look it up!

I will say that it was my pleasure to get to know Dr. Stephens only a few years ago in the context of his continuing active involvement in medicine and family medicine, and our own organizations. And I am very pleased to be able to say that Dr. Geyman’s festschrift is indeed a tribute, and not a memorial!

G. Gayle Stephens, MD; at the time he practiced in Wichita, Kansas

The context in which I got to know Dr. Stephens was the result of the 2009 murder of his friend, George Tiller, MD, in Wichita, KS, which was Dr. Tiller’s home town. Wichita was the long time residence of Dr Stephens, who was the first director of the Wesley family medicine residency. We were both outraged that neither the American nor the Kansas Academies of Family Physicians took any public position condemning the murderer.

I wrote an editorial on this topic, which was published in Family Medicine, and, of course the most articulate part of that editorial was the part that Gayle gave me permission to quote from a letter he had written to the Wichita Eagle.

 

As a physician, I feel profound disappointment that a family physician can be assassinated in Wichita and local physicians can be silent and largely absent from public discourse.

“If a firefighter or police officer were murdered in the line of duty, their colleagues would rise in anger and protest, call for justice and attend a public funeral in uniform. They would vow to seek justice and pledge support for the victim’s family.

“Tiller was a legitimate family physician who practiced medicine as well as performing abortions. He was not a butcher, profiteer, opportunist or fraud. His murder diminishes us all, and nobody is safer or better off because he is dead.”

That was just a couple of years ago. Gayle is still very active and very vocal and as John Geyman said, “he has been and remains by far the most original, thoughtful and eloquent voice in our field and among the few who best represents the moral conscience of the entire medical profession.” So, I’m honored to be here giving this talk in his name.

Where are we in 2011? Well, we’ve had a recession. This has been a very difficult couple of years for most of the America and most of the world.  Lots of people lost their jobs, lost their health insurance and lost their home. But apparently we’re told we’re in recovery, at least if we’re Wall Street. A lot of people who are not Wall Street are still having problems because they don’t have jobs, don’t have house, and don’t have health insurance.

The Economic Landscape

There is a lot of tension abroad in the land. We saw the frustration of people with this economy, manifested in the last election, where people basically voted for whomever wasn’t in power, because their lives were miserable. They haven’t, however, gotten any jobs. They’ve mostly gotten a lot of “social action” about abortion and gay marriage, but those were not the reasons, I believe, that people voted their frustration.

But none of those responsible for the meltdown is likely to be punished in a way that, way, someone who robbed $50 from a gas station would be. In fact, a lot of them are memorialized on our own institutions.

For example, Sanford Weill, the chairman of Citigroup, was responsible for the largest corporate meltdown in the financial sector before the one in 2008 was very proud of having a plaque on his wall that read “the shatterer of Glass-Steagel”, the law that prevented banks from getting involved in insurance companies and vice versa. Cornell Medical School has been renamed the Weill-Cornell School of Medicine, because of a big donation from Sanford Weill.

And in the middle of this brouhaha, this “let’s cut everything” campaign, is health care. The biggest single achievement of the Obama administration was the passage of the Affordable Care Act (ACA), is in jeopardy. It’s being challenged constiutionally. As we’ve heard this morning, it has its problems, but it has its good points as well. It certainly is the biggest change in health care since the passage of Medicare and Medicaid, but is the touchstone of opposition to all that the government is doing.

The law’s opponents apparently see in it everything that we don’t! The fact is that the law doesn’t bring us universal health care coverage, like Canada, or the UK, or Germany, or Switzerland, or Taiwan.

The health insurance “mandate”

In fact,  we have a system that is a big bailout of health insurance companies. And the price that the insurance companies demand for this – the requirement that everyone have to buy health insurance, the “mandate”, is what we hear being attacked, not the insurance companies . The question is: How can we talk about health reform, about the proper systems for delivering health care, about the proper mix of primary care and specialty physicians, about getting students into primary care fields and nurturing the doctors that those students become, in this context of “tear it all down”? I am sorry; I see no bold initiatives that will build anything.

The Legislation’s Good Parts

Some parts of ACA are rather non-controversial.  They may actually do some good and are good for family medicine (for most of us our specialty), in the sense that they are good for the health of the American people.

Those parts include the increased funding for Federally-Qualified Health Centers (FQHCs), although, with all respect to John Zweifler’s thought provocateur session, I believe that the FQHCs have some problems, which I will talk about in a bit.

The creation of a research panel to review the evidence of effectiveness of various health care interventions – if the idea works and the panel actually makes recommendations – could prove to be a tremendous asset to our healthcare system. The Primary Care/Health Extension services are also a very good idea, except it is unfunded in the current legislation and no money has been appropriated.

Then there are the Accountable Care Organizations, which are an effort to coordinate care, to keep people healthy by making a single group responsible financially. This works in Kaiser and other HMOs, but according to CMS administrator Dr. Donald Berwick’s guidelines just published in the New England Journal of Medicine, they will not restrict people from choosing where they go for health care – to doctors, hospital, Urgent Care centers, nursing homes, and EDs outside the ACO, so this will limit their effectiveness.

People are fearful that efforts to create ACOs will create the backlash associated with managed care in the 1990s, but that backlash is happening anyway – at least from politicians and pundits, if not from the population.

Health Insurance Companies and Managed Care

My personal belief is that the idea of the managed care plans in the early 1990s had two problems, neither of which should be blamed on the managed care itself.

First, the for-profit insurance companies were permitted to take part, whose profits could be increased by denying services. The efficiencies of consumer cooperative HMOs, such as Kaiser-Permanente, had benefited their members; these new entities denied care to benefit their stockholders.

The second problem is that, in an effort to control costs, everyone was made to jump through hoops, such as gatekeepers and prior authorization, which made people angry with managed care, but did not do much to reduce costs, since most people do not use much medical care.

Ultimately, no money was saved, because healthy people don’t use the healthcare system, resulting in all of the dollars being spent on the non-healthy.

Who Uses Health Care the most?

Here are graphs that demonstrates this. About half the people use a moderate amount of dollars (the chronically ill, older folks, who see the doctor a few times a year, may have a hospitalization or surgery every couple of years), and a very small percent use about half the health care dollars. This includes those with unexpected crises – patients with cancer, multiple trauma from car accidents, infants in NICUs – and people whose chronic diseases have gotten so bad that they are frequently admitted, often to Intensive Care Units.

Almost all of us, however, could get into a major car accident and need multiple surgeries, or suffer burns in a fire, or be diagnosed with cancer, or have an infant born prematurely.That’s the basis for the social contract that covers our costs if we suddenly go from the 50% group that uses very little in the way of healthcare services to the 5% who use a lot.

Dr Atul Gawande in February 2011 had a New Yorker piece called “The Hot Spotters”. He looked at two New Jersey communities, Camden and Atlantic City. In Camden, Dr Gawande used geographic mapping to discover that 1% of the population used one-third of Camden’s healthcare dollars – 1,000 people out of 100,000. There were two addresses – a nursing home and a low income housing project – whose health care costs were $200 million over a six year period. That’s phenomenol!

So they developed programs to work with those who were at greater risk to address, not just the medical issues, but, in particular, the social determinants that caused them to use a significant portion of healthcare dollars. They used nonmedical personnel whom they called health coaches and that we might call permitidos.

These are the people who should be targeted for intensive intervention, not only medical but in terms of the social determinants, such as in the programs highlighted by Needless to say, such interventions are being funded on a shoestring, while the high-tech interventions get all the money.

Student Interest in Family Medicine

So, what about our field, Family Medicine? We have seen some uptick in the residency match. We are told, that there is an interest in family medicine among medical students, but we are not sure of the reason for this yet. We won’t know for a couple of years whether this is real or episodic.

We hope that it is a real increase in interest, rather than a result of increases in medical class size and number of medical schools without a concomitant increase in residency positions. Failure to expand residency slots across the specialties mean there will be more students who cannot match into the specialties they really would prefer, like orthopedics and radiology, and instead “settle” for family medicine.

Common sense, and some recent data (especially regarding loan burdens), suggests that money and reimbursement plays a big role, although the Arizona study from several years ago did not show that it did.

We also have reports of increased negativity among medical students toward the real or perceived lifestyle of primary care, as well as persistence of the idea that primary care – family medicine – is not as interesting or challenging or, maybe just not as exciting, as practice in other specialties.

A recent article that appeared in the New York Times on Saturday, April 2, was entitled “More Physicians Say No to Endless Workdays”. The article illustrates many of these issues as it describes the decision of a young female student, Kate Dewar, who is about to enter Emergency Medicine rather than the primary care practice of her father and grandfather before her.

She is the mother of twins and although she says Look, I’m as committed to being a doctor as anyone. I went back to work six weeks after my boys were born. I love my job,” she adds; “But I was in tears walking out of the house that first day. I’m the mother of twins, and I want to be there to feed them, play games with them or open presents with them on Christmas morning. Or at least I want the option to do those things without fearing I’ll be called back to the hospital.”

So what should we make of the fact that emergency medicine is regarded as an easier lifestyle that a primary care practice? Is her commitment really not there? Was it just a throwaway sentence that she is committed to the practice of her father and grandfather? Maybe, she’s more committed to her family, and maybe that’s not a bad thing.

Her grandfather, Dr. William Dewar II, is quoted as saying, “My son and I had deeper feelings for our patients than I think Kate will ever have”.  Her father, Dr. William Dewar III, to whom the waitress, whose family he had taken care for three generations, brought his usual Diet Coke without she being asked, said, “Kate will never have that.’”

 

But she will have fewer hours. The article notes that “emergency room and critical-care doctors work fewer hours than any other specialty, according to a 2008 report from the federal Department of Health and Human Services, “and, she will not get paid less for working those fewer hours”. A couple of years ago, the website www.studentdoctor.net interviewed Dr Gary LeRoy. Gary said “If medical students know that a specialty gets higher remuneration for not that much work, everyone else knows it too”. Well, apparently Medicare and the other insurers haven’t figured it out yet, because Kate Dewar is going to get paid a lot more money for her shift work.

What about the other part? The lack of intellectual, or at least, adrenaline-infused, challenge? – the “Marcus Welby” vs “ER” dynamic. Kate Dewar, the medical school graduate profiled by the Times, says “…that treating chronic conditions like diabetes and high cholesterol — a huge part of her father’s daily life — was not that interesting. She likened primary care to the movie “Groundhog Day,” in which the same boring problems recur endlessly. Needing constant stimulus — she e-mails while watching TV — she realized she could not practice the medicine of her forebears.

But what about intellectual stimulation? Is she correct that primary care does not have enough? If we look at only medical and surgical subspecialties, it is hard to make that argument. They all see a much narrower range of diagnoses than we do. I would suggest that for most of them, five diagnoses account for 80% or more of their business; whereas, for family medicine our top 20 diagnoses account for perhaps 30%. In fact, it’s probable that most of us went into family medicine to get that variety.

Maybe the Emergency Room is indeed different. There are certainly the big, exciting cases. But, as we know, a lot of it is routine too. ER docs complain that they have to do so much primary care – without the satisfaction that doctors like the older Dewars from doing it. In addition to the primary care, there are the overdoses, and accidents, and the “frequent flyers” that characterize much of emergency department work.

ER doctors can resuscitate people from the overdose, but they don’t treat the depression or the domestic violence that might have led to the overdose. Yes, they can stabilize the fractures and abdominal trauma so that they can be admitted to the surgeon’s wards. It’s not like the television show where they seem to do major surgery in the ER, not to mention pushing babies back into the uterus of eclamptic women for whom there is “no room” on the OB ward! But they do nothing to prevent the next one from coming in.

Yes, they can admit the person from the nursing home who has decompensated congestive heart failure, and get them back into the ICU. But we know that, if these live until they get discharged, they will be back again soon.

ER docs can complain complain about the lack of primary care services available that make people come in with relatively minor illnesses, or more important, come in with advanced stage illnesses that could have been prevented by better primary care – but they don’t want to be the ones to do it.

Kate Dewar says “I like it when people get better, but I’d rather it happen right in front of my eyes and not years later. I like to fix stuff and then move on.” At its face value her statement can be seen as immature. While such attitudes can and do persist for many doctors for their entire careers, they become less pervasive as they learn both the satisfaction that her father and grandfather exemplify by following patients over years, as well as the frustration that comes from “fixing” the same stuff over and over again. Maybe Kate Dewar is an adrenalin junkie, and the ER will be a good place for her.

But the adrenalin rush can wear off and erode over time. I worked for many years at Cook County Hospital, where there is a Department of Trauma. It recruits many skilled young surgeons, many who want to be like Hawkeye Pierce on “M*A*S*H”, seeing people get better right in front of their eyes.

Except they don’t always get better; they die, and you have to tell their family. Another auto accident, another gang shooting, another alcohol-enhanced beating and, after a while, you get tired of it. That is why so many trauma surgeons spend so much of their time out in the community, talking to people, trying to prevent themselves from coming in and giving them more business. Bringing people in again and again is not the business model that most hospitals like.

Maybe Kate Dewar doesn’t have the commitment that her father and grandfather did. Maybe those memories of deep relationships with patients left her with memories of her dad getting up and leaving the dinner table as soon as he sat down. We have to be able to do something about lifestyle issues for family medicine docs.

There are changes to primary care practices. I’d say not all of them are good, although I won’t go into this in great length. Kate’s father, William Dewar III, said that in 2006, after Wayne Memorial Hospital hired hospitalists — doctors who specialize in taking care of hospitalized patients — Dr. Dewar finally gave up hospital rounds. For his hospitalized patients, the change meant putting their trust in a doctor who knew them less intimately but was more available and more adept at hospital care.

“My patients are getting better care now in the hospital,’ Dr. Dewar said. And the change saved him hours of work each week. ‘It meant getting off the hamster wheel,’ he said.” He says that patients are getting better care now. I don’t know that that’s really true; maybe Dr Dewar just hopes that they are.

I’m cynical about hospitalists, whom I call the “4-day Emergency Room docs”, because instead of knowing you for four hours, they know you for four days if you’re lucky enough to get admitted on Monday and not on Thursday.

I think that it may be good to have a surgeon operate on your cancer and to have a radiation oncologist and a medical oncologist prescribe your therapy and probably good sometimes to have the nephrologists come in and take care of the renal failure that you got from the therapy, but it’s also important to have a doctor who knows you. That’s not an issue of “social rounds”, that’s a matter of managing in the context of all these doctors.

 

Frankly, I think the move to hospitalism is a negative direction, because while people are happy to see your partner if they have a cold, or just need their blood pressure checked. But when they are sick, when they are really sick and in the hospital is when they want to see their doctor, the doctor who knows them.

One of my sisters was admitted to a hospitalist service in California some years ago (she is OK now) and after a few days the second (or maybe third) hospitalist told her that she looked a lot better. He’d known her for two days. My other sister, visiting from out of town, said “She may look better to you but she didn’t look like this last week! She is in no way back to normal!” The hospitalist didn’t know that. Good for sisters who come in from out of town, but some people don’t have that happen!

We need more primary care doctors, more family physicians, more doctors who can provide continuity for the health-related portions of our journeys through life. But when we get these doctors, what is their life like? I recently met a very smart, committed young family doctor who works at a Federally Qualified Health Center in one of our more “desirable” cities. Even though she doesn’t do OB, and doesn’t take care of inpatients, she still feels she’s on a hamster wheel.

She gives less than the best care she knows she can do, because the patients are being hustled through so that the FQHC could “make its numbers”. She wanted to know what we can do to support the family doctors who are out there. Will this new funding for FQHCs just mean we can twice as many patients at the same rate and give inadequate care to them?

There has to be a solution that provides the benefits of a primary-care based healthcare system to our people without building it on the backs of overworked primary care doctors. That solution should provide the primary care physicians with enough time for their families, and enough time to care for their patients. Nor should family physicians have to give up the good parts of family medicine like delivering babies, which is wonderful and exciting; nor give up the part where you help somebody whom you’ve known for many years transition through death; because you no longer take care of people in the hospital.

That’s what they’re doing now. They’re doing all the things. They’re seeing people really in a hurry and maybe inadequately. They’re doing it for a fraction of the salaries that their medical school classmates will make.

even the satisfactions that come from the happy moments of primary care, like delivering babies, or the times when your patients are admitted to the hospital and then really need you. And doing it for a salary that, even if it far exceeds that of the average American, is a fraction of what your medical school classmates are getting for working less hard, and makes it difficult to pay off your loans.

We’re going to have to figure out a way to help students to choose specialties that we need, by choosing the right students, by putting them through a medical education system that supports them, and by having a system when they finish that continues to support them throughout their careers.

I’m going to go very briefly through some issues. Dr Prislin will talk more about medical students tomorrow. But we know the characteristics of medical school applicants who are more likely to enter family medicine in underserved and rural practices. They’ve come from rural areas. They come from under-represented minority groups. They are older at the time of matriculation. They come from less affluent families. They probably have lower MCAT scores.

But we also know that for the students who don’t fit that profile, that come from higher-income, white, suburban families (who have always been and continue to be the vast majority of those admitted to medical school), they have other characteristics. They have done proactive volunteer work, whether it’s for the Peace Corps, VISTA, Teach for America, or they volunteered in a free clinic or they just carried the rape crisis pager in college – something that showed proactive commitment to volunteer work.

Meanwhile, we have lots of demonstration projects for special student admissions that shows what works, but are never implemented in large enough numbers. I’m tired of the demonstration projects. I’m tired of the programs for five students in a class. I want to see the whole medical school who only accepts students who meet those criteria. Can I say this more clearly?

Below is the list of the top 25 medical schools that the U. S. News and World Report ranked for family medicine. It surveyed the deans and other chairs as to what they regarded as the top 25 family medicine schools. A lot of it is based on reputation and not all of it is based on the school’s success in putting their graduates into family medicine.

I’m not arguing that success in producing family physicians should be the only criterion. The quality of the faculty and their publications might be important as well, but putting people into family medicine should be considered important.

Here is the first of two graphs. The first is organized to rank the “top 25 family medicine schools” as rated by U. S. Newsin order of the number students entering family medicine:

The squiggly line represents the percentage of each medical school class, that varies depending on the total class size, and the blue line between the University of Kentucky and the University of Michigan is the national mean for the number of students.

Here are the same data presented the other way, ranked on the basis of percentages, with the up and down line being the absolute number.

What you can see is that you could be a top 25 school according to US News and World Report and produce significantly less than either the average number or average percentage of students entering family medicine.

More important is that even the acutal top schools have pretty low percentages. Below is the list of the actual top schools averaged over a five year period from 2004 through 2008, put together by the American Academy of Famly Physicians and annually published in Family Medicine each September.

The reason the 25 schools are allopathic is that the osteopathic schools were not ranked before last year, so I don’t have the five year history for them. But those on the list that are the “best FM schools” are between 13% and 20%, which is where schools like Harvard and John Hopkins should be, while schools like University of Minnesota and Kansas University Medical Center should be doing 70% or better.

This is a real problem. We’re never going to get to a 50% primary care workforce by training 20% or less of our students in family medicine. The math doesn’t work out.

Family medicine education needs the following process variables. We need to be sure that students in medical school have exposure to family medicine role models. They need to meet family doctors and mentors who are happy. They need to have exposure to longitudinal continuity, interdisiciplinary and inter-professional health care settings, so that they realize it is all on the doctor to do everything – that there are other professionals who can contribute.

These experiences should be positive. There should be no bashing allowed; people should be disciplined for saying something negative about surgeons or psychiatrists or family doctors. There should be some emphasis on non-hospital settings. It is not remarkable that most internists who do not subspecialize become hospitalists, because they think that the hospital is where all healthcare takes place.

There need to be changes in our reimbursement system. I think the American Academy of Famly Physicians has demonstrated that family physicians should get 70% of what a specialists gets. That would be the magic number that would make people make decisions on other than reimbursement. We need to have loan forgiveness programs that are 100% for those who work in primary care, with faster loan repayment schedules for those who work in underserved or rural areas.

There have to be opportunities for those people who want to provide the full scope of practice. I hate to say this, but a lot of this is about money. That’s what I told that young doctor from the federally qualified health center. If you got more money for each patient, you wouldn’t have to see so many patients, assuming that there’s somebody else around that could see them.

We don’t want people to feel like they’re on a treadmill. They have to have opportunities to experience life, to be with and grow up with their families. They need at the same time to have the opportunity to have relationships with their patients and be able to provide their care.

We need to change our system so that other people participate in the care of patients. We need to have alternatives to face-to-face visits. Everybody doesn’t need to come in to see the doctor. Some people don’t need to take a half day off of work and drive in and look for a parking space and wait in your waiting room.

I have two stringent criteria for whom should actually see the doctor face to face. One, do you the physician think you need to see that patient face to face? Two, does the patient want to see you face to face. If not, we shouldn’t have to do it. We can take care of it by telephone or e-mail or any number of other mthods, but we will have to be reimbursed for doing it that way.

We do need specialists. So, it is good that Kate Dewar wants to do emergency medicine, or that others like to put people to sleep, read slides or x-rays, perform surgery, or see the same diagnoses over and over again in subspecialty practices.

But we need a lot more primary care doctors – and nurse practitioners – more family doctors. We need them creating policies at every one the accredited medical school, hospitals, and residency programs, and the state and federal governments, that will encourage people to pursue primary care. We need to encourage eople to pursue family medicine and to be able to feel that they can do this, that they can enter a primary care practice and provide excellent patient-centered care, population-conscious, care without giving up all of up their personal lives and sacrificing their families.

Where will this money come from? Well, there isn’t going to be more money. We, as a country, already spend twice as much money per capita as most other industrialized countries, for worse healthcare outcomes. It is going to have to come from other parts of the health sector; the money the specialists make, plus the hospitals, plus the nursing homes, and especially the profits taken out of the system by health insurance companies and drug companies.

There can be no place for people making profit in the healthcare system. It’s not a place where the market works. This, of course is the big failing of PPACA.

The Patient-Centered Medical Home

The recent article the Annals of Family Medicine by Rosser et al. describes their experience from 2004 with the family healthcare team program. They base it on the principals of primary care, a patient-centered medical home, which has been put together by AOA, AAFP, American College of Physicians and the American Academy of Pediatrics.

The idea of a physician-directed medical practice irritates some nurse practitioners, but it’s one of the principles of the concept that includes whole person orientation, coordinated or integrated care based on quality and safety, with enhanced access to care and, of course, payments that recognize the additional value of the primary care medical home.

So what did they discover in Canada? 170 family health teams across the province cared for two million people. What was the response to these teams? Patient satisfaction went up. Well, what about the quality measures? All went up.

Family physician income went up significantly, from 180,000 to 250,000 Canadian dollars a year. Student interest, which had been dropping in Canada, as well as, in the United States, went up. (It had been down to 24% of medical school graduates entering family medicine, which in Canada, as in most places in the world, is the only primary care specialty. it   There’s no such thing as general internists) increasing from 24% to 2005 up to 35% in 2010. This was in no small part because the changes created by the medical home, and also the fact that panel size went down because there are interprofessional teams working together to provide population-based healthcare.

It was made a little bit easier in Canada because they already had a single pair system, so everybody had the same insurance company, but I think that, while that made it easier, it isn’t necessary. We could do it here if we had the intention of doing it, and I think that we will. So, thank you all.

Dr Clasen: We have a question from Dr Frey.

Donald Frey, MD; Creighton University, Omaha, Nebraska

Donald Frey, MD, Creighton University, Omaha, Nebraska: Josh, you and I have been provoking each other for years, so it’s a real pleasure to continue to provoke you, in what is a fairly formal setting. Josh, you had so many wonderful things in your talk. that it’s hard to pick one particular area.

I know you’ve always been very passionate and outspoken about is the process of medical school admissions; that the first step of admissions is probably one of the most important interventions we can make to increasethe  primary care workforce.

I would like you to comment on this provocative scenario. What if we had a system in which all medical school applications were screened at the very outset for a minimum GPA and a minimum MCAT score from the standpoint of once one achieves that score there’s a relatively good assurance that that person could academically handle the rigors of medical school.

Once that initial screening occurred, those applications would be blinded with respect to the actual number values. All that the admissions committee and all that the individuals interviewing those students or anyone having anything to do with the admissions decision, would be the information that these people achieved a certain minimal MCAT score and GPA. Beyond that that committee would be charged with looking for those qualities in those individuals that would insure the kinds of educational outcomes that would allow them to be successful – in fact make them more likely to go into family medicine.

At this point, I’ve never seen a study that has shown me that edge that healthcare outcomes are better when that healthcare is delivered by a physician who had a 34 MCAT and a 4.0 GPA compared to someone who had a  26 MCAT and a 3.4 GPA. First, how do you think that such a system might work and second, given the fact that you are from one of the medical schools high on the list of primary care and family medicine oriented medical schools, how likely is it that would accept an admissions process such as I’ve described?

Dr Freeman:  I think it would be a good thing. Actually, KU is doing something very close to what you describe, We have identified an MCAT score below which nobody ever fails out of medical school for academic reasons (although obviously people might have personal issues not related to their academic performance). Excepting the small number of students who applying to the MD-Ph.D. program that has a higher level required,  we choose the basic class from applicants who are at that level or above. We are essentially blind. I think the number is around 24. It’s not even like 29. If you’re above that level, we say “enough with the MCAT and the grades. Let’s start looking at whether you’re somebody who is smart enough to learn this stuff, and can actually use it to enhance people’s health”.

I’m reminded of another medical school where I was on the family medicine faculty.  There, when somebody finally failed the clerkship the second time, we had to let them go from the medical school. We went back and looked at their admissions interview. An interview, which was done by a cardiac surgeon, said in big letters “great scores, no interpersonal skills, admit!”

That’s wrong. Not every school is going to be as bold as KU. A lot of people – even in family medicine – are still stuck in the incorrect belief that high scores make better people or something like that. They have kids who want to get into medical school. Unfortunately for them, my system says that we should take a lot fewer doctors’ kids and doctors neighbors’ kids into medical school.

We need to get a workforce among physicians that looks like America. That’s going to require more than just blinded admissions. It’s going to require programs to get people who fit that profile who think that they can become doctors some day. We need to encourage the kid who grows up in Garden City, Kansas, whose father works in the meat packing plant and whose mom makes beds in the Motel 6, to think that they can become a doctor or a nurse or a respiratory therapist. Then we need to support them through their growth long before they ever get to college. This is what I was hoping might come from the health extension services.

Yes, I think your plan is good, but I also think we need to work further back and we need to resist people who associate smartness and competence with good scores on standardized tests.

Dr Clasen: Thank you, Joshua.  I just may proffer my opinion, that if you want more primary care and more family medicine graduates, and more underrepresented minorities, and if the medical school’s Dean and the President want it done, it will happen. Whenever the Dean and the President want it done; it happens.

 Thanks again, Joshua, for a splendid presentation.