22nd National Conference Proceedings: How Will it Work?: The Physician Workforce and Medical Education (Q and A Session)

We gratefully acknowledge the sponsorship of the Penn State University Hershey Medical Center Department of Family Medicine (James Herman, Chair) for funding the transcription and editing of this section of the Proceedings of the Twenty-Second National Conference:

Robert Ross, MD, Klamath Falls, Oregon (Moderator): Thanks very much to our panel Doctors Norman Kahn (22nd National Conference Proceedings: How Will it Work? The Physician Workforce and Medical Education (Part 1, Kahn)) Gary LeRoy (22nd National Conference Proceedings: How Will it Work? The Physician Workforce and Medical Education (Part 2, LeRoy/Pugno)) and Thomas Hansen (22nd National Conference Proceedings: How Will it Work? The Physician Workforce and Medical Education (Part 3, Hansen)).  Dr. Boltri. you have the lead off question for our question and answer period.

John Boltri, MD; Mercer University, Macon, Georgia

John Boltri, MD, Mercer University, Macon, Georgia (Lead Question): Hello, I’m John Boltri from Mercer University. Thank you all three of you for a great presentation today.

We are in a period of rapid change. I believe that more change has occurred in healthcare and has occurred through healthcare legislation during the past three years than in the previous decade. There’s also a national interest in the results of health reform, as well as, a recognition of primary care as an important part of the solution.

Regarding medical education, there are many changes that have already occurred. These include things like academic health centers joining accountable care organizations, health information zones, increases in student enrollment in medical schools, renewed focus on quality and evidence based medicine, incorporation of the patient centered medical home concepts into training programs. There are many new medical schools popping up all over the country. The list goes on.

I’ve heard this week two very strong opinions. One is that the Supreme Court is going to shoot down PPACA and the other is that PPACA is here to stay –  that they couldn’t possibly make that go away.

Here is my three part question for each of you: (1) in your opinion what changes that have already occurred are enduring, (2) what is at risk, and, finally, (3) what can we, the participants of this conference, do to help move the process in the right direction?

They’re easy questions.

Norman B. Kahn, MD; Council of Medical Specialty Societies, Chicago

Norman B. Kahn, MD, Council of Medical Specialty Societies, Chicago: Actually, since Dr. Leroy said I gave his talk, I thought he would answer my questions. I’ll start for the sake of discussion and then you all can join in as well. I suspect that the 10% increase in reimbursement for primary care physician services is enduring. I don’t see any reason why that would be rescinded.

What’s at risk? Almost everything! Almost anything that isn’t already appropriated is at risk. Comparative effectiveness is at risk. There’s also another risk in here. You know that accountable care organizations (ACOs) look quite a bit like managed care. They look quite a bit like capitation. What happened to primary care in managed care and capitation in the past? You know that the backlash that occurred, can easily occur against the ACOs just like it did before. History might repeat itself. I’ll won’t try to answer what can we all do until after we all have a discussion of what’s enduring and what’s at risk.

Gary LeRoy, MD; Wright State University; Dayton, Ohio

Gary LeRoy, Wright State University, Dayton, Ohio: I’ll answer the first two questions as well. The changes that are enduring? I think that there has been more than ever a renewed emphasis on primary care and, I think, an appreciation for primary care.

When I was program director, I remember going to program director’s conferences. When I first started there was a sense that we were done as a specialty or that we were engaged in apologetics to defend our  being primary care physicians.

I don’t sense that anymore, I sense that there’s a renewed excitement within family medicine at least on we have a future, and it’s exciting. And I think that I’m hearing more and more from people outside of medicine an acknowledgement of the value that primary care brings to the table. And so I think that, that is something that’s going to be enduring regardless of what happens to the PPACA. I think that it has really helped people understand what we in primary care and family medicine do.

What is at risk? One of the differences I have found with the Residency Review Committee on Family Medicine (RRC) versus the Liaison Committee on Medical Education (LCME) is that the RRC is specific in so many areas – sometimes, I think, not in healthy ways. For instance, when I was a family medicine program director we had a requirement of 100 hours of health systems management, but exposure to endocrinology was only briefly mentioned.

When I look at what my residents will need, I wanted to make sure that they knew how to treat diabetes. I felt that their knowing how to run a clinic isn’t something that they needed to spend that much time on, but the RRC is very specific.

I’m finding that the LCME is pretty general. There aren’t that many requirements compared to the RRC and those are vague, so it gives a lot more freedom.

What is at risk, is that there will be mandates that come out of government that will be so specific that we’re really locked into doing it a specific way. We will not be given the ability to say how we want to do it to fit the circumstances of our particular student population.

Regarding your question as to what is the right direction: I think that is what we’re all here trying to figure out.

Thomas Hansen, MD; Creighton University, Omaha

Thomas Hansen, MD, Creighton University, Omaha: I agree with the other panelists that what’s is likely to be enduring are those elements that are already in place. I draw the comparison to putting a patient on life support. Once you’ve done that, it’s very difficult to withdraw that support.

Once you’ve told an individual that they have now insurance, that they did not have could not afford before because at 22 they had “aged out” off their parents’ insurance, it’s difficult to withdraw that. It’s difficult to withdraw the benefits that people get because they’ve gone over their lifetime limits. I believe it would be very difficult to enact legislation that would change those elements of it.

What I feel is at the legislation’s enduring core is a social awareness of the workings of the house of medicine. For centuries, it’s been a mystery. Now it’s more transparent as to what we do, and how and why we do things in the house of medicine.

That awareness can be a strength that will endure, because people will have a lot better understanding of how medicine works after all this chaos about this reform bill of the past two years is over. Never waste a good crisis! Despite all the yelling and screaming, people understand medicine a lot more than they did before. and such.

The changes in medical education also will endure.  As an associate dean of a medical school, I’ve seen a seismic shift in medical education. That’s not going to go backwards. Primary care and prevention will be a “first thought” as opposed to an afterthought. That’s not going to change and go away any time soon.

What’s at risk? Well everything! Health care is is the 800 pound gorilla of our economy, 16% of our gross national product. If we don’t get this right, folks, we could go over the edge as a society and go back into a recession or a great depression. So that’s what at risk. For a long time, the United States has been seen as the leader in healthcare technology worldwide. All this could kind of go backwards if we don’t get this whole thing correct.

What can we do? I’ll poke at that skunk and say increase our own awareness. We should not be so pompous as to not put up a mirror and look at ourselves and see what we’re doing right or what we’re doing wrong, because we, as physicians, are part of the problem. We’ve been taught in a certain mind set. Sometimes we have to look at and say that maybe what we have been doing for years is not the right thing. I think we’re on the right road, but again we have to educate ourselves, our patients, our legislators, and the larger society of the need to take a closer look at this system.

Robert Ross, MD, Klamath Falls, Oregon (Moderator): Alright, we’ll take some additional questions.

Jay W. Lee, MD; UC Irvine/Long Beach Memorial Hospital, Long Beach, California

Jay Lee, MD, Long Beach Memorial Hospital, Long Beach, California: My name is Jay Lee and I’m from Long Beach Family Medicine. I have a comment and then have some thoughts that I’d love the panel to respond to.

It’s clear that we’re shifting away from the status quo of fragmented, volume-based care. What PPACA is allowing us to do is to  begin thinking about how that vector has been shifted towards integrated, value-based care.

You know theoretically these are the things that we are going to see out of the healthcare system. I really liked an expression used by Dr Weisbuch yesterday, that “we have a plethora of dirth”.  That was a very well-stated point.

What we do have a plethora of is medical students and residents and new physicians who are very social justice-minded who see that there’s been a divorce of public health from clinical medicine. They have the energy and the desire to bring those two together in this new model of care, whether it’s legislated or not.

I think there’s a lot of energy around the ideas that PPACA  is generating, allowing them to have a mental or spiritual revolution  around the ideas that family medicine can offer them.

Along those lines I think where there’s dirth in terms of our educating of students and residents. Dr. Hanson you eluded to some of the concerns I have, but there are two specific areas that I think would help tie medicine and public health together.

One area relates to the social determinants of health. Those are the things that frustrate the heck out of us. When we tell a patient go and get some exercise and they say “Well, I’m more likely to get shot than I am to  derive any benefit from exercise”. We need to do something about that. We need to be vocal about that. We need to teach our students and residents how to deal with that. We need to teach ourselves how to deal with that.

Another concern is something that came out in a February 2011 article in the New England Journal of Medicine, entitled “Advancing Medical Education by Teaching Health Policy”. There are a lot of three letter acronyms [TLAs] in medicine. The RUC [Relative Value Scale Update Committe], for example. is one of them. Certainly advancing health policy curricula within medical schools and residencies would help with that plethora of dirth and allow for what I think is really, really important in family medicine and that’s leadership development.

We need to have leaders at the table. It is often said in organized medicine circles, if you’re not at the table, you’re on the menu. We need to be at the table. A family medicine revolution? Viva la revolution1

Dr Hansen: Was that a question?

Dr Lee: Those were comments.

Dr Hansen: I will borrow from a comment that Dr David Sundwall made this morning, this is not being a gnat on the butt of an elephant anymore. I think that prior to this healthcare reform or, to use Dr Lee’s term, this revolution, some of these issues that, from a societal standpoint, seemed like a gnat on the butt of an elephant that you don’t pay any attention to, are now more like a shotgun blast at the butt of an elephant. You can’t help but pay attention to it.  It’s that elephant that we heard screaming during the healthcare debate. They can no longer afford to ignore it.

When I gave a talk in Ohio a week ago, I asked the audience “How much education do you think we physicians get about nutrition in medical school?” By that I meant how many hours about nutrition were we as physicians taught in medical school? I remember the four hour lecture that I fell asleep about an hour into it. That was out of four years!

But our patients think we know a whole lot about nutrition. There’s a dirth of information related to  health education that’s really important. Your idea about leadership development is  something we provide very little attention to, nor do we devote any curricular time to policy development. We will have to shift some of the subjects that we have in our curriculum to accommodate these areas of study. But I agree with you. Thank you very much for your comments.

Dr Kahn: The difficulty is how to add it to a curriculum. We’re really limited by the number of hours, especially with requirements that there has to be time for self-study and reflection. That is the reality, especially in the first two years.  I’m finding this out and I’m fairly new to my job. Students are focused on the United States Medical Licensing Examination [USMLE] Step One. The information they want is what’s going to be applicable to USLME Step One.

I have difficulty getting students to come to class sometimes. They complain bitterly that we have some mandatory events. I was telling my colleagues that I now have both the first and second years wanting the notes from previous years, because they don’t even want to do any note service.  you know and so it’s really, they You ca say that you think that students really, really want the social justice orientation, but the reality is they just want to know what might be asked on USMLE Step One.

What I’m doing is hosting seminars in leadership, and seminars in teaching health policy, so that those who are interested –  whether they be first year or fourth year students – can attend. But it’s going to be a self-selected group who really has an interest in this.

My trigger finger is getting itchy. Next question please.

Warwick Troy, Ph.D.; Shueman-Troy Associates, Pasadena, California

Warwick Troy, Ph.D., Shueman-Troy Associates, Pasadena, California: I am curious about something appears to have vanished from my periphery that seems to have spoken once so fluently to the issues in graduate education and training in family medicine. Those documents were called the Future of Family Medicine. I’m wondering to what extent do those brave efforts still represent some kind of template for change, for reform of education and training at all levels in medicine?

Dr Ross: Easy question, who wants to start?

Dr Kahn: Well I’ll give that a try, because I’ve been out of family medicine now for three and a half years. In the spirit of full disclosure, I was the staff executive of the Future of Family Medicine project.

I think that the patient-centered medical home is a success of the future. You know if you look back on any particular medical lecture that you give, you would be gratified if the audience learned one thing and implemented that one thing in their practice. So the fact that pediatrics loaned family medicine the concept of the medical home, which now has taken off, should be considered a success.

I suspect that there are some others as well, for example, if you look at the 11 attributes, the 11 things that were in the original definition, some of them are now finding their way into meaningful use of health information technology (HIT). There are some other successes of the Future of Family Medicine project, but we don’t have time to go into any more detail.

David Sundwall, MD, University of Utah

David N. Sundwall, MD, University of Utah: I’m David Sundwall. I’m a family doctor from Utah, and I love to come to these meetings! I get refreshed, I get uplifted.

Where’s Dr. Lee? I just love to hear young people like him say the things he did because those of us who felt that way 50 years ago wondered if it all frittered away, but it didn’t.  So, thank you!

I’ve had the privilege of being a state health officer for six years;.There are a number of state health officials who are family doctors. You’ may be surprised that Paul Jarris, the executive director  of the Association of State and Territorial Health Officers practiced family medicine in Vermont.

My successor as President of ASTO was also a family physician – Judith Monroe, MD – and she is now deputy to Dr Tom Frieden of the Centers for Disease Control (CDC), so there is a lot of cross-fertilization between family medicine and public health.

I’m, this is just an information item for you, I’m on a new Institute of Medicine (IOM) Activity called Integrating Public Health and Primary Care. It’s just a terrific committee. Doctors Larry Green, Kevin Grumbach and Winston Wong are just three of the family doctors that are part of the activity. We have a report scheduled for completion by June 2012 that will address and “solve” all of these problems of integrating primary care and public health, and how to integrate it into curriculum.

Thank you.
Donald Frey, MD; Creighton University, Omaha, Nebraska

Donald Frey, MD, Creighton University, Omaha: The subject of leadership came up in Dr. Hanson’s presentation. As we look at what’s at risk and what we can do about those things that are at risk, it occurs to me that medical schools have really not stepped up in terms of providing leadership. As the issues of what’s going to happen to PPACA confront us, the reality is in many enormous amounts of misinformation out there. Quite frankly, I’ve heard misinformation spread as much by faculty members, including tenured professors – people who should be objective, and who should understand what’s at risk.

When I talk to medical students about the Clinton health plan, I said what the Clinton health plan fiasco taught us was that fear of the unknown and the ability to spread fear of the unknown will always trump real information. The reason that the Clinton plan failed was articulated yesterday – the “Harry and Louise” television ads. The fear of the unknown trumped what was, in fact, a pretty well articulated plan.

The reality is this could very well come about with the PPACA as well. Fear of the unknown could have enough political influence to overturn it. We see that it is happening right now that when people are confronted with fear misinformation, they tend to go with be affected by the worst possible fears that are out there.

The question I would have for each of you is how can we as leaders within our institutions and within our educational programs  provide the kind of leadership that will allow our medical schools to examples and to speak out to help to dispel some of this misinformation?

Quite frankly, I think we’ve done a very poor job in our medical schools in providing that leadership that the public desperately needs. People listed to professors and think that they know what they’re talking about. In fact, I’ve heard medical educators spread as much misinformation as comes from some of the political groups hostile to this initiative. What do we do about it?

Dr LeRoy: Whoa, that’s interesting! If you’re not aware of something, you can’t understand it, bottom line! But I think people do now understand if you mention healthcare reform in the United States. I don’t have to ramp people up to that point of understanding. Obviously, just because these professors have a PhD, or MD behind your name doesn’t mean that they have a wealth of awareness about everything. Sometimes it gives them some degree of authority to profiticate about things they know nothing about. (I do it myself often. As a matter of fact, I’m going to do it right now. Be good at faking it!)

But just sharing your thoughts about the healthcare reform issues with folks around the break room at the office, discussing them with patients, and with legislators, can be important.  Get to know the elements of the legislation –  the good, the bad, and the ugly and the elements of healthcare reform – and talk about those things to people. Be that constant chatter box about those issues, and you’ll be amazed at how many times people will say “oh I didn’t realize that”.  Then those people will talk to someone else. That’s all I can say we need to do. We need to clarify some of those misconceptions that are out there, but we have to understand them ourselves, very clearly. (We need an elevator speech for that.)

Dr Ross (Moderator): Thank you panelists very much, and also to everyone who asked the questions.