Primary Care

The typical medical student begins residency $139,000 in debt. On Scrubs, J.D. and Turk stole fruit cups and toilet paper from Sacred Heart Hospital to help cover their expenses, but the Michigan State Medical Society has a few other ideas to help medical students cope with the rising costs of education and enable them to go into fields like primary care, instead of more lucrative specialties like dermatology.

Their ideas—presented as a resolution at the American Medical Association's annual meeting—were reported in a well-researched piece in the Detroit Free Press this week. The resolution noted the average doctor in his or her first year of residency could expect to pay nearly half of his or her after-tax income repaying school loans. This burden was especially difficult for primary care doctors who earn about 30 percent less than the average base-year salary for all physicians in 2006 according to the Association of American Medical Colleges.

USA Today ran two pieces the other day about the crisis in ERs. An editorial told an alarming story about a toddler having a seizure. The ambulance was diverted from a nearby but too-crowded ER where the family's doctor was waiting. The piece called for changes in how ERs are run. The other was an opinion piece written by the head of a leading hospital organization saying the way to solve the ER crisis is to cover the 47 million uninsured.

Both are right. But even if we followed all their recommendations, we'd still have a missing piece—adequate primary care in the United States.

The story of 23-month old Bella Nannini and her seizures, (she has insurance, by the way) is not a rare occurrence. Thankfully she was not harmed. Not everyone is so lucky. In Houston and Los Angeles, for example, the average hospital waves away or "diverts" ambulances away about one-quarter of the time. Nationally one ambulance is diverted from an emergency room a minute. Diversion is not always benign.

We've been hearing for years now about racial and ethnic disparities in health care; both The New York Times and the AP reported this week that black diabetics, for instance, are far more likely to have a leg amputated than a white with the same disease, or that a black woman is less likely to get a mammogram than her white counterpart.

But evidence has mounted that disparities are not just racial, cultural, or even socioeconomic. They are also regional, or geographic. Some parts of the country practice a far more intensive form of medicine than others—sometimes doing too much more, running up procedures and costs and inpatient bills and specialty consults without any true health benefits. And sometimes they do too little; millions of people do not get the proven benefits of primary and preventive care and screening.

Benjamin Brewer, M.D., is a small town doctor who moonlights as a Wall Street Journal columnist. He writes often about the crisis of primary care in our country. In today's column, he laments the trend of too many medical students looking for a "fast track to minimal call, high pay and the lifestyle perks," in more lucrative specialties like Radiology, Ophthalmology, Anesthesia and Dermatology (ROAD). Compare that, Brewer writes, with a career in primary care that offers "long hours, unpredictable schedules, big med school loans, paperwork hassles, and declining income compared with other medical specialties and the legal risks. "

But the end result is also increasing clear: a crisis of primary care in our nation that has been linked to higher costs and lower quality across the nation. We've talked before about potential ways to create more incentives for primary care (such as medical homes, and loan reimbursement). But Brewer presents another powerful reason for choosing primary care: the patients.

Since 2006 more than 340,00 previously uninsured residents of Massachusetts have gained health insurance. As The New York Times recently noted, the expansion in coverage stretched the state's health care resources, especially in primary care. That's why we were particularly encouraged to read Elizabeth Cooney's Boston Globe piece on how community health clinics in Massachusetts have successfully recruited much-needed primary care physicians through a loan repayment program.

Funded by a $5 million grant from the Bank of America and administered by the Massachusetts League of Community Health Centers, the program provides up $25,000 a year for three years to repay loans. In its first year the program recruited 47 clinicians—more than double what they expected. Before the incentives, these centers last year had been unable to fill about 10 percent of their primary care positions.

I mentioned that I attended a conference a few weeks ago of the Institute for Healthcare Improvement, where doctors thought about how to reinvent their own clinical practices. The conference was not classic CME (continuing medical education) in the sense that they were not, for instance, learning that this drug was better than that drug for diabetes, or that this device was better than that one for a failing heart. They were addressing how they organize their practices and deliver the care to make it both more efficient and higher quality. And they were encouraged to think about being a doctor—or a patient—in a way they had perhaps not thought about it for some time.

In the big hallway in the convention center (this was Texas, so the hallway was indeed big), conference organizers put up lip charts and invited docs to scrawl their responses to three key questions. People in politics and policy circles are so busy drawing up models and plans and simulations for health care reform, they sometimes forget what the docs may have to contribute. So here are some of their answers from those flip charts, a peek into the minds of caregivers who care.

What if we told you a program in North Carolina reduced Medicaid spending in one year by close to $244 million while improving care? The N.C. program offered primary care doctors a $3 per-patient, per-month payment to manage the patients on top of the usual fees for clinic visits. It also organized a multi-disciplinary team of medical personnel to assist the patients. The result: doctors spent more time with patients, coordinating treatment for chronic conditions and reducing hospitalizations. The overall quality of care improved.

The Patient-Centered Primary Care Collaborative (PCPCC)-a broad coalition of business leaders, policymakers, primary care physicians, and other stakeholders is looking carefully at success stories like North Carolina's to see how our whole health care system can redevelop our primary care infrastructure to control costs and improve quality in our country. After all, there's a reason it's called primary care.

More bad news for those of us who plan on getting old some day. The Institute of Medicine just released Retooling for an Aging America: Building the Health Care Workforce which reminds us there are not going to be enough doctors and nurses to deal with the geriatric needs of the 78 million baby boomers who start reaching age 65 in 2011. The authors said Medicare, Medicaid, and other health plans should pay higher rates to encourage more docs to learn about geriatrics. It also recommended training for family members and other aides who do a lot of the heavy lifting (literally and metaphorically) for the elderly. In many parts of the country, it noted, dog groomers and manicurists are required to get more training than the people who take care of our seniors.

"We face an impending crisis as the growing number of older patients, who are living longer with more complex health needs, increasingly outpaces the number of health care providers with the knowledge and skills to care for them capably," said committee chair John Rowe, professor of health policy and management, Mailman School of Public Health, Columbia University, New York City.

Tired of waiting for Washington to fix health care, doctors across America are doing it themselves. I just attended a conference in Dallas where hundreds of physicians exchanged ideas on how to improve the quality of care they deliver, make their clinics more efficient—and rediscover the joy of practicing medicine. In future posts, we'll touch base with some really smart and dedicated people we met there and highlight specific innovations that got our attention—new ways of reaching hard-to-serve populations, managing chronic diseases like diabetes, involving patients in their own care, new twists on "shared visits."

We may not be able to tamp down diabetes in America but at least our skin will be flawless.

For a variety of reasons —including money —lots of young doctors choose fields like dermatology and plastic surgery instead of internal medicine, geriatrics and pediatrics. As we tackle national health reform, we need to make sure we put primary care back on center stage.

Two influential physicians, Joel S. Levine, chairman of the Board of Regents, American College of Physicians and Christine K. Cassel, president and CEO, American Board of Internal Medicine, chimed in about the "upside down" health care system and distorted incentives in a letter to the editor of the New York Times today. They were responding to the recent story, "For Top Medical Students, Appearance Offers an Attractive Field."

"The fact that so many medical students are choosing lucrative specialties like dermatology over internal medicine should be a clarion call that our health care system needs an overhaul," they wrote, noting that primary care docs can't hope for the $2,000-an-hour fees that a physician can reap on a cosmetic procedure.