Healthcare faces the challenge of a primary-care shortage
Tasha Wilbert-Starks is a prime example of how early exposure to science, math and the medical sciences helps grow a doctor and, in Wilbert-Starks’ case, a primary-care physician.
A fourth-year medical student at the University of Arkansas for Medical Sciences, Wilbert-Starks is set to graduate in May with an MD and a master’s in public health and begin her residency. She said the inspiration for her choice to enter primary care was the late Morris A. Jackson, MD, one of UAMS’s first black graduates and the Wilbert family physician in Little Rock. “Growing up, when I thought of a physician, it was always my family doctor. He was such a wonderful man,” Wilbert-Starks recalled.
Ensuring that there are enough family physicians to be inspirations in the future and to care for tomorrow’s swelling number of patients is a challenge for medicine today, yet leaders in academic medicine, as well as the president of the American Academy of Family Practitioners, said there are promising signs that primary care is – albeit slowly – growing in popularity with young medical students.
It can’t happen soon enough. AAFP projects a shortage of 40,000 primary-care physicians in America by 2020, a figure that’s exacerbated by the nation’s aging population. Should some provisions of the federal Affordable Care Act come to fruition, more than 32,000 additional Americans are expected to have health insurance coverage by 2019. However, noted Glen R. Stream, MD, a family practitioner in Spokane, Wash., and AAFP president, insurance coverage and access are two different things – and that’s the crux of the challenge. In Mississippi, for example, half the state’s licensed physicians practice in just 12 of the 82 counties, and half the counties don’t have even one obstetrician/gynecologist. Insurance coverage doesn’t fix that problem. What needs to happen, Stream said, is pushing more primary-care physicians into the market.
“A Supportive Environment”
Stream called on medical schools to tweak their entry processes to target students interested in primary care, particularly in rural and underserved areas, and to create “a supportive environment” for primary care. “In a lot of academic institutions, family medicine is looked down on, quite frankly,” he said. “We need to be nurturing rather than stomping out that interest during their medical school education.”
Stream also challenged medical schools to grow the number of primary-care residency training spots. An insufficient number of such residency opportunities are creating a “bottleneck in production,” he noted.
“I absolutely believe that the healthcare reform debate really highlighted how important primary care is,” Stark continued, and the patient-centered medical home concept puts family practice at center stage. He expressed optimism that pilot projects with the Center for Medicare and Medicaid Innovation will result in some workable solutions regarding coordinated care for patients and proper alignment of incentives to better reward primary-care physicians. It’s estimated that a specialist may make $2.5 million to $3 million more over a career than a primary-care physician, and that economic disincentive is another reason medical students are shying away from family medicine.
Acknowledging that the challenge is daunting, Stream said that’s no reason not to strive for increased numbers of primary-care physicians and a less expensive, more effective system. “We’ll just get further behind if we don’t start now,” he said.
What Med Schools Are Doing
Wilbert-Starks credited undergraduate research opportunities and a program called Summer Science for Undergraduates, which exposes students to the curriculum of a first-year medical student and offers chances to shadow physicians, with keeping her focused toward a medical career.
Her third-year rotations in medical school helped her realize that she enjoyed the variety of primary care. Then, a family-medicine rotation in Helena, Ark., cemented her future. “I realized that I enjoy the rural setting, and Arkansas has so many rural areas that opportunities are basically unlimited,” Wilbert-Starks said. “Also, there is such a need. I have been blessed to be trained here, this is home and I really want to give back to the communities of Arkansas.”
That’s music to the ears of Daniel A. Knight, MD, chairman of the UAMS Department of Family and Preventive Medicine. Asked what kind of medical student is attracted to family practice, he replied, “I think it’s somebody who wants to give back and help and somebody who is very person-oriented – they want to know the whole person and not just their disease. They enjoy talking to people and enjoy a lot of variety.”
To nurture students just like Wilbert-Starks, Knight said his department is recognized by the National Committee for Quality Assurance as a Patient-Centered Medical Home – and at the top level, which is level 3. Such programs focus on optimal use of health information technology and care management to achieve efficiency. “That shows that we’re committed to reforming how care is delivered, and we’re trying to get the students interested in that, he said.
“Family medicine is the foundation of our healthcare, and I think that’s not been recognized over the last few years. I think there was a great backlash against gatekeepers and managed care, and that has probably led to some of the downpush on primary care over the last years,” Knight said. “But it’s being re-recognized as a necessary part of our system. We’re working more in teams these days to improve the lives of the physicians who will be operating in these teams.”
At the University of Mississippi Medical Center, the concept of “grow your own” is taken to heart. UMC only accepts Mississippi residents as students. “It seemed logical that if we had a state pool of applicants capable of going to medical school and being physicians that we would give that resource to individuals in the state,” explained Loretta Jackson-Williams, MD, UMC’s associate dean of Academic Affairs. “There’s never a question about who we are investing in. We’re investing in the citizens of the state with state funds to provide a medical resource for the state.”
Jackson-Williams echoed the concern of AAFP’s Stream that a future family-practitioner shortage could hinge on a lack of appropriate residencies. “That is a much bigger concern for us,” she said. “We need to really work on that side and develop residency opportunities.”
To feed the pipeline of future primary-care physicians, she pointed to the Mississippi Rural Physicians Scholarship Program as a success story. Established in 2007 by the Mississippi Legislature after extensive grassroots work by the Mississippi State Medical Association and the Mississippi Academy of Family Physicians, the program identifies promising science scholars and puts them on the path to medical school while they are undergraduates. Then they receive $30,000 annually to pay for their medical education.
Janie Guice, the program’s executive director, said, “Mississippi has a long list of worst firsts, and it’s compounded by the fact that we have the fewest physicians per capita of any state. … This program was designed for the early identification of rural students who aspire to go to med school and then return home to care for the people they’ve grown up around. All the national research supports the notion that those from small towns are the ones most likely to choose to practice there because it’s a lifestyle choice.”
The program’s criteria, she said, recognize that rural Mississippi students “face some cultural barriers” to medical school; some small Mississippi high schools don’t even offer advanced-placement math and science courses. Yet 18 such students are chosen annually during their sophomore year based on their history of volunteerism, work ethic, good faculty evaluations, good grades and “a real missionary zeal” to care for people, Guice said.
During their junior and senior years, they enjoy “medical encounters” in the five primary-care fields – family medicine, obstetrics/gynecology, pediatrics, general internal medicine and med-peds – and help preparing for the MCAT. Upon completion of residency, they must enter a clinic-based practice in a rural community for at least four years. For students who planned to practice at home anyway, the program is “a blessing from heaven,” Guice said.
The program started small, with 10 scholars, and Guice said, “The pipeline is really starting to flow. We have six in residency, and two will complete their training this summer.”
Guice has become a one-woman evangelist in Mississippi on the importance of primary care availability in a community, and she speaks frequently at meetings of local civic organizations and government agencies. She encourages them to lay out a welcome mat for young physicians casting about for the right community in which to hang their shingle. She said data from 2008 show that when a community picks up a new primary-care physician, the average economic impact is $2 million annually, creating up 35 new jobs. In some counties, the impact is estimated to be as high as $7.5 million a year. “At that point, that physician becomes a two-legged Toyota plant,” she said. “It’s human nature to go where you feel most welcomed, and that’s my message to these small towns that are seeking to grow.”
It won’t solve all the problems America’s healthcare system faces in the coming couple of decades, but it sure is a start.