In preparation for the 25th National Conference on Primary Health Care Access, to be held April 14-16, 2014 at the Hyatt Regency San Francisco, we will be publishing a series of archival works of relating to educational linkages between community health centers and primary care physician residency programs, which will be one of the topics discussed at the 25th National Conference. The following presentation, introducing the National Conference’s joint session with the Western Regional Meeting of the Society of Teachers of Family Medicine, from October 17, 1993, is by Norman Kahn, MD, then of the American Academy of Family Physicians.
We gratefully acknowledge the sponsorship of the Wright State University Boonshoft School of Medicine Department of Family Medicine) for funding the transcription and editing of this section of the Proceedings of the First National Conference on Community Health Center-Primary Care Residency Linkages (Lake Tahoe, Nevada, September 16, 1993):
William H. Burnett, (Conference Planning Committee Coordinator): Before we begin the next plenary session as noted in the program, I did want to make again the acknowledgment that the National Conference on Community Health Center/Primary Care Linkages is co-sponsored by four very fine departments of family medicine at the Drew/King Medical Center, Charles Drew University in Los Angeles, The University of Kentucky in Lexington, the Medical College of Wisconsin in Milwaukee, and we will have two chairs here during some of our deliberations, only one is in the room right now.
I would like that chair, Dr. Mark Clasen of the Department of Family Medicine at Wright State University in Dayton, Ohio, stand and be properly appreciated by the group. Then I would like to introduce the Chair of the sponsoring academic department for the Western Regional Society of Family Medicine portion of the meeting, Dr. George Henry Hess of the Department of Family and Community Medicine at the University of Nevada School of Medicine.
Norman B. Kahn, MD, (American Academy of Family Physicians, Kansas City, Missouri): I want to welcome you all this afternoon to the afternoon joint plenary. Joint because it links together two conferences with a focus which is symbolic of a fusion of educational opportunities.
The first conference is focused on community health centers, on health professions education occurring in those centers, and, particularly, education in family medicine. The second conference, the Western Regional Meeting of the Teachers of Family Medicine, also focuses on education, again linking the centers with the education in that symbolic way.
These kinds of linkages are gaining increasing attention nationally. I think that is why we’ve seen these conferences on the subject of CHC – residency linkages over the past few years. It’s a natural fit. Family medicine, more than any other medical discipline, has had a mission focused on service.
If you look at the graduates of family medicine training programs, you see that, overwhelmingly, they go into the practice of primary care medicine. Furthermore, family medicine training program graduates are the only residency specialty whose graduates distribute themselves geographically in proportion to the population. No other specialty does that.
We always have had a unique focus on serving the under-served, again more than any other specialty, using a variety of criteria: percentage of Medicaid patients, percentage of various patients from various populations.
There are a number of studies which have shown, even before the concept of linkages, that programs which had a mission of service to the under-served had a unique success. A much-quoted article by Gessert, Blossom, Sommers, et. al., demonstrated that eight programs in California that had a focus on serving the under-served, achieved success in producing graduates who practiced in under-served communities.
CHCs obviously have a mission of service to those in need, and of delivering that service through primary health care. Thus, the linking of CHCs and family practice residency programs seemed a natural fit.
Now CHCs find themselves needing primary care physicians more than ever. Dr. Leong will comment on that in some of his remarks. There is a basic hypothesis, an intuitive one that is only partially tested – that if you link family practice training programs with these service-oriented, community-based delivery systems, that more of the graduates will practice in those sites.
Although it is not a hypothesis that has been proven, we believe in it. We have looked at other proxy samples in the literature which might lead us to that conclusion. We are planning a non-technical research project, to see if that hypothesis is indeed supported by data.
There are a number of problems that we have to overcome. You have heard both plenary speakers and discussants in the breakout groups that you have attended over the past couple of days, deal with the predominance of the service culture in the CHCs, the productivity requirements imposed by grant authorities, the need to supervise residents in every encounter and to assure appropriate faculty supervision of residents, the need to provide those faculty with teaching skills, the need to accommodate to the Residency Review Committee [RRC] requirements for the correct number of examination rooms per resident, for properly-equipped laboratories and libraries, and for a list of other necessities that cause CHC boards to tilt their heads and raise their eyebrows and ask what they are getting into.
The residency programs have found, of course, that they have to fit into the service delivery mode of the CHCs, as well as with the productivity requirements and adapt to the priorities of the community-based service delivery system.
Of course, the third problem is the financial support. WE have heard people comment on the fact, and I know we will hear more such discussion this afternoon, that one of the biggest financial supports for family practice training in the United States, are the Medicare “pass-throughs” from the Health Care Financing Administration, which are often not available to linked CHC-based family practice residency programs.
And, then the fourth is, of course, to comply with the rules for RRC. I want to make a comment or two about the RRC. I do not sit on it, although I am at each meeting as liaison. From my perspective, over the first two decades of our discipline the RRC generated a reputation, which I think was well deserved, of being rather rigid in their requirements.
I have come to a different perspective on that rigidity than I had when I was program director wishing that they were more flexible. I believe their inflexibility on certain points was intended to protect the quality of standards of the discipline and had the effect of doing so. However, within the last five years we have seen a significant movement on the part of the RRC towards greater flexibility.
We now have 12 family practice residency programs which, as demonstration projects, combine the first year of residency with the fourth year of medical school. We now have a half dozen or so rural training tracks. There are a number of rural training track leaders here. WE also have several non-rotationally based residencies. I think that the RRC has been willing to experiment.
Jan Realini, MD, the RRC Chair, has spoken specifically to the issue of linking residencies with CHCs. Her comment has been “that either the [CHC-linked] program needs to comply with the requirement of the Residency Review Committee or it needs to demonstrate how it compensates for” and those are her words, “compensates for the requirements.”
There are now a number of examples of programs that compensate for requirements. So I think that the movement of linking residents to programs with community health centers is finding a new receptive venue in the Residency Review Committee. They are not willing to sacrifice any quality standards, but they are willing to look at how creatively people can provide training at such sites and still provide quality.
There are a number of solutions to the dilemmas, some of which I have pointed out earlier. Rather than being self-serving, Paul Gordon could not go into too much detail about the AAFP-NACHC Family Practice Residency Community Health Center Linkage Manual, so I will.
I want to acknowledge Paul Gordon, Frank Hale, Denise Denton, and Louise Warwick for the work that they did in creating the Linkage Manual. I know many of you have read it cover to cover and word for word and you know what I am talking about. If any of you have not, you can obtain it from our office. Just call the Academy’s 800 number and ask for Jerry Hejduk.
I mention his name because in his usual humble way working behind the scenes, Jerry does not need to take credit for anything, but the facilitation of this project is in a large part due to Jerry Hejduk, who is the manager of graduate education at the Academy.
I also want again to call your attention to the May 1993 issue of “Family Medicine” in which there are a series of articles that were devoted to the issue of service education linkages. John Zweifler has an interesting article there, a particularly important resource for discussing the cost-analysis of these programs.
Other authors include Mary Verdon, Paul Gordon, Frank Hale, Nick Zervanos and Don Weaver, all important references. Jan Realini has her article about the RRC’s position. And those of you who have not yet received a copy of Terry Pitts dissertation book,
I would highly recommend it as an in-depth study of a particular linkage. I hope that Terry will be able to get enough of those printed for people who want to learn more about the ins and outs and the details of a particular example.
To summarize, there are some methods emerging that can assist a person, even at this early state, in the analysis of prospective service-education linkages.
While one of the goals of a proposed linkage may be to produce people to serve in sites with a desperate need for health care providers, such sites may not be the best sites to create a linkage program.
For sites to be successful as linkage programs, they first need to be successful as CHCs, which means that the CHC’s provider staff and delivery system is already in place and functioning well.
The most successful linkages are those in which there is a mutual understanding. Believe me, when you start out there exists no common framework for mutual understanding. That understanding needs to be developed through open communication and respect for each others’ position – the needs and demands on both sides.
There needs to be an involvement of a variety of folks. Not only in the CHC administration and its governing board, but, in many cases, the federal project also. On the residency side, the RRC needs to be included to make sure that all of the requirements are set before stumbling into something where the pieces are difficult to pick up afterward.
There is the need for faculty development (you have heard this from others and have heard it from me already in my few remarks, and you will hear it again, but the redundancy underscores the importance). Good clinicians are good clinicians, but good clinicians are not always good teachers.
If we are going to promote a training milieu in which we expect our graduates to have an experience that will benefit the larger society, then we have to be sure that the good clinicians in that milieu have become good teachers.
We should look back at those programs which were succeeding in service-education linkages, before there was a national focus on such linkages. The programs which were studied in Gessert’s article and others that you know of, many of whom are represented here today, had at least four characteristics, which are probably absolutely essential for success.
What are those characteristics? One, you need to take residents into these settings who want to be there, residents who want to serve in this kind of environment, residents who have an interest. That is not so dissimilar from asking the question “How do you get medical school graduates to want to be family physicians?”
Perhaps one of the most important and successful ways is to take applicants to medical school and ask them if they want to be family physicians and if they say they do, then you take them into medical school. The same is true for these CHC-linked residencies.
Second is the modeling of faculty. Modeling is a strong motivator. If residents see their faculty who are “walking the walk as well as talking the talk,” they are more likely to emulate them. They will be reinforced through that critical development process that occurs in residency training.
That becomes important in having that graduate succeed and then go into practice in a CHC delivery system. As an outstanding example, 75 percent of the graduates of the Montefiore system have their first job in a CHC. T hose faculty then, who are graduates of the program, become models for the next group and from there it becomes an upward spiral.
Third, in addition to selecting the right residents and having appropriate faculty role models, you need the reality of an effective delivery system. People talked in a couple of the workshops that I attended this morning about the importance of everyone working as a team, in mutual commitment to making the CHC an attractive site.
Such a team includes not just the physicians, but the receptionists, the nurses, the nurse’s aids and the billing clerks. Team commitment is not only for the residency training to be successful, but ultimately the practice.
And, finally, there must be an environment that supports a career. 75 percent of Doctor Bob Massad’s graduates at Montefiore take their first job in a CHC, but if you measure them then years later there are not 75 percent left in CHC practice.
Perhaps ten years from now it will be different, but the environment needs to be supportive of career longevity, include a level of income support which many of the CHCs are currently unable to accommodate. It also means an environment which is supportive of everyone working as a health care team.
Our speakers this afternoon are going to address some of these arenas. We are very fortunate to have two leaders of the service-education linkage movement with us this afternoon. They are Doctor Darryl Leong and A.J. Henley. Both have been described as being on the cutting edge.
I am reminded that one of the difficulties with the metaphor of having a wedge that moves into the future, is that if you are on the cutting edge and don’t have the right characteristics, you can get cut off. However, if you wanted to have a wedge that cuts into the future, you would probably want to put diamonds on the front edge.
To continue the same analogy, many of the characteristics that these two gentlemen share are cutting edge diamonds – the hardness, the clarity, and the value to be able to survive the process of moving us into the future.