By Mary Flynn, California Health Report
Primary care doctors have an increasingly significant role in health care reform. More and more, medical systems are focusing on creating what’s known as a “medical home” — a doctor or clinic who oversees and coordinates all of a patient’s health needs — a move intended to reduce costs and improve health by providing preventative and well-managed treatment.
Within these medical homes, primary care physicians are expected to play an increasingly important role. And with a looming shortage of primary care physicians, lawmakers and medical experts are scrambling to come up with ways to increase the number of primary care doctors.
Some health industry observers say it will be impossible to train and pay for the number of primary care doctors that would be needed if California, and the nation, were to extend the current way of doing business to the millions of new patients who will gain insurance coverage under the federal Affordable Care Act. But even if dramatic changes in medical practice reduce the need for more doctors, those changes won’t make the problem disappear. More doctors will still be needed.
There are about forty family medicine residency programs in California that produce approximately 300 family doctors a year, Contra Costa Health Services Residency Program Director Dr. Jeremy Fish testified in a March 14, 2012 hearing before the California State Senate Health Committee.
But that’s not enough to meet the increasing demand, he added. “We may have to look at trying to double the number of programs to try and meet that kind of demand.”
Creating more residency programs for training primary care doctors would likely help increase the number of doctors in the areas where the programs are created. That’s because there are two predictors – where a trainee grew up and where he or she completed their residency – that most often determine where a doctor will practice, Fish said.
Fish considers the program he directs in Contra Costa County, where residents undergo a unique training program, to be a model for other family medicine residency programs.
A recent study conducted by the Commonwealth Fund, a private foundation that works to improve health systems, recently ranked the county-operated Contra Costa County Regional Medical Center and Health Centers among the nation’s top health care systems, and it appears that the county’s Family Medicine Residency Program may be one reason for the medical system’s success.
The program is located in the diversely populated Contra Costa County, which includes urban underserved areas like Richmond and North Richmond, but also sees rural farm workers in Antioch and Pittsburg. The program prides itself on its commitment to working with underserved populations, and its applicants are medical students who share that vision, Fish said.
Sergio Urcuyo is one such resident. Now in the third and final year of his residency in the Family Medicine Residency Program, Urcuyo realized that he wanted to care for the most vulnerable populations as an undergraduate working at a county hospital.
“I sort of found an internal mission in taking care of the underserved for as long as I emotionally can,” he said. “I think it’s really rewarding in ways that are kind of hard to articulate. The appreciation felt, and just knowing how down and out some people are when you help them, it makes it more worthwhile somehow.”
Like his colleagues, Urcuyo bypassed a higher-paying career as a specialist in favor of primary care based on something he discovered about himself in medical school.
“The primary care doctors in particular – the family doctors – seemed to be the ones that focused the most on treating people like people and like patients,” he said. Urcuyo added that he thought many medical systems depended too much on referring patients to specialists, and “treating people like organ systems” was an unfortunate byproduct of this practice.
But he was impressed with the Contra Costa Residency Program. “This is a really special place – it’s a place where there’s a culture of learning.”
One important aspect of the program is that it is community-based, meaning the residents work embedded in community clinics and health centers. In comparison, Fish said, most residency programs have a single clinic that the residents work in, and it’s usually located next to the hospital.
“We wanted our residents to get training throughout the county, so they could get exposure to a wide variety of communities, not just from Martinez (where the Regional Medical Center is located),” Fish said.
“It allows for a more diverse training setting,” He said, referring to the county’s population of both rural and low-income urban residents, many of whom are people of color. “A lot of research is showing that there are ethnic varieties and variabilities that you need to learn about and get trained in, in order to take care of certain populations.”
Fish gave the example of how treatment of congestive heart failure and high blood pressure has different treatments in African American patients than in White patients.
“And that’s beyond just the obvious cultural sensitivity issues that come up,” he said. “If you train within a population, obviously you gain a lot of experience working with populations and then can understand the cultural differences of communication about illness and diseases.”
Another feature of the program is that the training model allows for only one resident per attending physician (fans of medical TV shows may be familiar with the typical ‘duckling’ model, where a group of residents follow around one attending physician). This allows each resident to get more in-depth training, while the attending physicians get a sense of their strengths and weaknesses, Fish said.
“We work very, very closely with our faculty here,” Urcuyo said. “We developed these very close mentorship relationships that sort of foster our skills as physicians and our skills as physician leaders.” Following his graduation this year, Urcuyo will remain in the Contra Costa system.
A third component of the program that leads to its graduates’ success is that residents receive a wide variety of full-spectrum training, Fish said. Residents train on a variety of common procedures, such as skin biopsies.
“[You would] have to refer to a dermatologist to have that procedure done, which in our view, increases costs and increases the hassle factor for the patient,” Fish said.
“We can kind of do one-stop shopping for basic, common care,“ he said.
Fish and his associates believe they can increase access to care through these methods, by shifting away from the current system – that of specialty care, where a patient sees a different doctor for each condition – towards a patient-centered medical home.
“We think it’s that improved integration and communication and teamwork that really begins to get the health benefit for the patients,” he said.
While it seems that the solution to California’s problems for physician distribution is for every county to create a primary care residency program similar to the one in Contra Costa, unfortunately, it’s not that easy. Budget restraints play a big part.
“Funding for residency programs is a federal action,” Fish said, “It’s all through Medicare that pays for graduate medical education, so it makes it hard for the states to put the money where they need it the most.”
To funnel more money toward graduate medical residency training programs, the California Academy of Family Physicians and the California Medical Association began working with Senator Hernandez, the chair of the Senate Health Committee, to introduce Senate Bill 1416. The bill would create a Graduate Medical Education Trust Fund in the State Treasury. The state Legislature would appropriate the moneys in the Trust Fund to fund grants to graduate medical residency training programs.
“California is leading the way in trying to find creative ways to create a funding pool so new programs can be built where the need is the greatest instead of where there’s already systems in place,” Fish said.
“I think that’s a game changer as far as getting the training where the need is the greatest,“ he said.