Vol. 33, No. 1 Winter 2010
Why We Care About Primary Care
The Doctor Shortage and UW Medicine
Helena is the perfect-sized town for a primary-care doctor, says Jennifer L. Brunsdon, M.D. ’96, Res. ’99. When you know your patients, says the Montana resident, there are decided benefits — like the day her cycling buddy came to her office complaining of pain. “When she says something hurts, I have a good idea of how seriously to take it, because I know her level of fitness,” says Brunsdon.
Still, all is not well in Helena. Brunsdon says that many local doctors have left their practices to work at the VA. “With all the changes that are going on in health care, and all the push to increase production, the VA has been pretty attractive to a lot of folks,” Brunsdon says. The city is “woefully short” on internal medicine doctors, she says, and they don’t have enough female ob-gyns.
What she and her colleagues do have, however, is the admiration of their patients. “I think family physicians here are respected,” Brunsdon says. “Patients feel that they’re not just the gatekeepers. They’re the people who truly will take care of you.”
The doctor shortage and the WWAMI region
Doctor shortages like those Brunsdon describes have been part of the national medical discourse for decades. In the 1950s, projected shortages prompted construction of new medical schools and expansion of class sizes in existing ones. Today, the American Medical Association and other organizations again predict shortages in primary-care fields (internal medicine, family medicine and pediatrics) and in other medical specialties in the coming years. In all, they expect a shortfall of 124,000–159,000 physicians by 2025.
“I think family physicians here are respected. Patients feel that they’re not just the gatekeepers. They’re the people who truly will take care of you.”
– Jennifer Brunsdon
The physician shortage, however, already exists in some areas. According to the American Association of Medical Colleges, the average doctor-patient ratio in the United States is 238 doctors per 100,000 residents. According to their 2007 State Physician Workforce Data Book, four of the five WWAMI states (Washington, Wyoming, Alaska, Montana and Idaho, the five-state region served by the UW School of Medicine) rank below the average.
Mark Doescher, associate professor of family medicine and director of the WWAMI Rural Health Research Center and the University of Washington’s Center for Health Studies, studies trends in the health-care workforce in WWAMI: dentistry, general surgery, nursing and primary care. “The region will be facing substantial shortages in the next 10 to 15 years,” says Doescher.
There are a number of reasons, he says. First, there’s a decline in people going into primary care. “At the same time, the regional population is expanding quite rapidly,” says Doescher. The baby boom generation offers a third challenge as it reaches its golden years; people who are 65 and older visit the doctor more frequently than other age groups.
A successful national health-care reform bill, which could provide access to tens of millions of Americans without current access to care, also might prove challenging. History shows that it’s likely to strain the limits of the health-care system, says Doescher. “There was a huge spike in demand back in the 1960s when both Medicare and Medicaid were enacted,” he says. Massachusetts provides a more recent example. In 2006, explains James E. Davis, chair of the UW’s Department of Family Medicine, the state extended universal health care coverage to state residents. “As it turned out, there weren’t enough [primary-care physicians] to meet the needs of the population,” he says.
The role of primary care
Why are primary-care doctors central to any discussion of the physician shortage? For many people, primary-care physicians are the first port of call. They treat sore throats, diagnose mysterious bumps, help manage chronic conditions like diabetes, and, when necessary, refer patients to other specialists, such as cardiologists, oncologists and psychiatrists. They know their patients, and they provide continuity of care. That makes them efficient, says Roger A. Rosenblatt, Res. ’72, ’74, professor and vice chair of the Department of Family Medicine.
“They know the patient in context and over time, and they can do a much more targeted intervention,” Rosenblatt says. Data shows that they also provide savings to the health-care system. “Ours is the only industrialized country that is not a primary-care-dominant system, and our health care is far more expensive,” he says.
Given the shortage of doctors (especially primary-care doctors) in the WWAMI region, and given their cost-effectiveness, it’s no wonder that producing them is a high priority for the UW School of Medicine. “One part of our mission of improving the health of the public is to train students to help meet the workforce needs of the region, with a special focus on primary care,” says Thomas E. Norris, Fel. ’89, vice dean for academic affairs. This process, however, is neither simple nor easy.
Primary care: problems and choices
In 2008, 8.2 percent of the nation’s medical-school graduates chose to specialize in family medicine, says Davis. UW Medicine’s percentage was nearly double that figure; 14.8 percent chose the profession.
“But if you look at attrition,” he says, “there are places around the country that have seen as much as a 20-percent decline in their primary-care physician population since 2000.” Some of this is simple math. Doctors who trained in the 1970s are beginning to retire. But some of the decline is caused by doctors who leave primary-care fields — doctors who are facing the same sorts of decisions as those faced by students choosing a specialty.
“One part of our mission of improving the health of the public is to train students to help meet the workforce needs of the region, with a special focus on primary care.”
–Thomas E. Norris
“The big gorilla in the room is the relative pay differential between people who go into primary care and people who specialize,” says Doescher. “The average primary-care physician, over the course of a lifetime, earns $3.5 million less than the average specialist.”
In part, this situation is connected to the relative value scale, explains Norris, a scale — set by the government, the American Medical Association and other groups — that helps determine the fees doctors can charge for their services. Specialized procedures cost more money than routine care. And some care, such as the coordination of multiple medical problems, is simply overlooked by the billing system.
“Physicians in primary care do a lot of care management and care coordination, and those kinds of activities just aren’t reimbursed,” says Davis. “You’re essentially paid almost on a production basis. It’s much better if you see more patients than if you see fewer patients and take much better care of them.” It’s not a satisfying way to practice medicine.
Students at the School of Medicine are exposed to these issues through a variety of training programs, and what they learn influences their choice of career. Amanda Keerbs, acting assistant professor of family medicine and a clinical faculty member for the family medicine preceptorship (in which students shadow doctors), knows students are paying close attention. “It’s amazing to see how observant the students are and how in tune they are with these topics… like the use of medical resources, the time issues, the ‘can you really take care of a patient in 15 minutes’ issue, the lifestyle issues,” she says.
Of course, temperament also plays a role in choosing a specialty, says Sharon Dobie, Fel. ’89, professor of family medicine and a member of the Colleges faculty. “We admit students who are perfectionists and want mastery at a very deep level,” she says. Being a generalist, the role usually taken on by primary-care physicians, may be uncomfortable for some students. Alternately, there’s a persistent rumor that students who choose primary care aren’t reaching high enough. Dobie puts that rumor to rest.
“Obviously, I don’t have the depth of knowledge about kidney care that a subspecialist in renal transplant has,” says Dobie. “But I have a different set of skills, and they are equally meaningful. It’s not about being smarter or less smart. I think that’s hard to keep clear when you’re a trainee.”
With the TRUST program, begun in September 2008, the School hopes to make this complicated decision process a bit easier to manage — and to create more primary-care doctors for the WWAMI region.
Clearing the way with TRUST
The idea for the Targeted Rural-underserved Track (TRUST) came from the WWAMI states, and it builds on the successes of other programs that link students more strongly to the WWAMI region.
Brunsdon participated in several of those programs. For instance, she spent her first year of medical school at Montana State University, an educational program replicated at state universities in Washington, Wyoming, Alaska and Idaho. Brunsdon also participated in the Rural/Underserved Opportunities Program or R/UOP (directed by Rosenblatt and co-founded by Dobie, with multiple partners throughout the WWAMI region), in which students spend four weeks doing primary care in a rural or medically underserved area after their first year of medical school. And all students complete a family medicine clerkship.
“The big gorilla in the room is the relative pay differential between people who go into primary care and people who specialize. The average primary-care physician, over the course of a lifetime, earns $3.5 million less than the average specialist.”
TRUST is like those programs in that its goal is to train physicians for WWAMI, but the program is something more; it supports students on a primary-care track, from admission to graduation. TRUST “looks at admissions in a much more critical way,” says Davis, focusing the search for people who want to be primary-care doctors and who are more likely, statistically, to choose to practice in rural and underserved areas.
Montana was the first state to implement the program; Spokane, Wash., was added as a TRUST site in 2009. The cohort is small, says Davis, about five TRUST students per state each year, but they receive a lot of attention. They participate in a clinical experience before they go to medical school. They take specific TRUST courses. They’re required to do R/UOP, and they have two faculty mentors: one from their region and one from the School’s College system. They also participate in WRITE, the WWAMI Rural Integrated Training Experience, a 20-week-long clinical experience in their third year.
Research shows that this type of approach works, says Doescher. “If you set up an environment that really supports the types of decisions students want to make and shows them that [primary care] can be a viable career choice — that it’s very demanding, yet very rewarding — they’re more likely to do it.”
Looking toward the future
One rainy evening in November, the School’s Family Medicine Interest Group, an informal group for students considering a career in family medicine, holds a casting-splinting workshop with residents from Valley Medical Center. First, the students watch the demonstration. Then they take turns putting casts and splints on each other. Despite the obstacles they may face in their future profession, the room is full of smiling, talkative doctors-in-training.
“This is a tough time to be a primary-care doctor in some respects, in terms of the pressure to produce and the financial pressure,” says Keerbs. “And the fact that we are still able to find interested and excited and willing students, to me, it’s always a positive. Because the students are looking toward the future.”
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