By Ishani Ganguli
JAN 12, 2011
Provided by Kaiser Health News
This is part of a KHN occasional series, First Person.
Ganguli (Katherine Lambert)
The clinic starts at 5 p.m. sharp with a team huddle in the conference room. A black plastic tray of stale bagel halves and crusted cantaloupe sits on the table, remnants of a breakfast meeting, but despite our medical-student hunger, we focus on the task at hand.
At 5:15, patients start to arrive. Their paths have been carefully choreographed from waiting room to exam table, lab to social services. Our schedules, through vigorous debate, have been set to five-minute time slots and annotated in flow charts. The first- and second-year medical students take blood pressures and interview the patients. The senior students finish the exam and present each patient’s case — from poison ivy to possible kidney failure — to the supervising doctor, using practice guidelines printed in our thick orientation packets.
Other students fill in as patient coordinators, social workers, and lab directors, while the research and quality assurance team tracks data on patients’ health needs and wait times. The M.D./MBA candidates in the group designed the clinic’s business model with the goal of self-sustainability, but for now, we simply do our best to take care of our patients.
Each Tuesday evening, the internal medicine practice at Massachusetts General Hospital lends its facilities to Harvard Medical School’s new student-faculty collaborative practice — the Crimson Care Collaborative (CCC). Medical schools across the country have similar student-run clinics, some decades old. More than a chance to play doctor, the clinic is a hands-on lesson in practicing primary care, the sort that forms the cornerstone of the “accountable care organizations” or “patient-centered medical homes” encouraged by the federal health overhaul law.
This evolving conception of primary care requires doctors and other primary health care providers to work in teams and to be creative about how they deliver care. Lawmakers have come to realize that it is critical for both improving our nation’s health and saving our wallets. Now medical training needs to change in kind.
My initial regard for primary care when I entered Harvard Medical School has been distorted by frustrations I hear from practicing doctors and the not-so-subtle lure of a “lifestyle career” alternative, my putative reward for being smart and working hard.
Yet when I spend time at the Crimson Care Collaborative or at the primary care clinic that occupied my Wednesday afternoons for a year, I am reminded of what draws me to this field — patients like the soft-spoken college student who came to see us at CCC because his volatile digestive tract made it hard for him to go to class, let alone work his two side jobs. The diagnosis was potentially life-altering, and it was our job to piece together his story, to explain what we were thinking, and to arrange for him to get the lab tests and the colonoscopy which ultimately showed (thank goodness) that his condition wouldn’t require lengthy hospital stays and could be treated, with close attention, through outpatient visits.
This is what makes primary care interesting — relationships with patients, the intrigue of new diagnoses, and the challenge of coordinating and optimizing care.
Ganguli during her rotation in Guatemala.
We know that the US health care system needs more primary care doctors as the number of practitioners entering and staying in the field dwindles and the number of patients increases — more than 30 million are expected to get insurance through the new health care law.
Last September, the American Association of Medical Colleges predicted that “there will be 45,000 too few primary care physicians — and a shortage of 46,000 surgeons and medical specialists — in the next decade.”
In response, since 2000 nearly two dozen new medical schools have opened or are being planned, for the first time in decades. The health overhaul seeks to entice more medical school graduates to fill these roles by redistributing unused residency training spots to primary care and offering new programs to repay the loans of graduates who work in underserved areas. Researchers at the George Washington University School of Medicine and Health Sciences have even introduced a new ranking system for medical schools based on fulfilling the so-called “social mission,” which includes producing a certain number of primary care doctors.
But reducing the primary care shortage to a problem of supply, demand, and geography misses a critical point: that answering the nation’s workforce needs means more than mass-producing more doctors and nurses; it requires training practitioners who can deliver the kind of care our country requires.
For one thing, the benefits of loan reduction programs are quickly lapped by the margin of hundreds of thousands of dollars in income that specialists gain each year. A better way to encourage medical students to enter primary care is to make it more fulfilling to practice, and not just by adjusting payment structures (though this is important). The key is to expose future doctors to primary care early and to teach the skills needed by all doctors (but especially those in primary care): teamwork and a dynamic understanding of health care systems.
Historically, these skills have been given short shrift in medical schools.
I had little formal exposure to my future health care colleagues throughout medical school; I had no idea, for example, what physician assistants did and how they trained. I only found out when one morning in my third year of medical school I asked a physician assistant joining us for morning rounds because I was curious and frankly, embarrassed by my ignorance.
As I moved between rotations in surgery, pediatrics, and neurology, my charge was to fit in. So it was hard not to adopt the half-joking superiority over other specialties espoused by some of the residents and senior doctors with whom I worked.
I’d hear hospitalists deriding hastily written patient notes from emergency medicine doctors, and those emergency doctors griping about primary care doctors who sent their patients to the emergency room without having seen them first. There were perfectly good explanations for brief notes and unscreened referrals (in short, lack of time), but loyalty to my team-of-the-moment had to trump my sympathies with other fields, so I was wary of speaking up. At the same time, while I called the doctors I worked with my “teammates,” I had little idea how to make the most of these relationships or what to do if they went sour. But as my friends in business school tell me, this may be a teachable skill.
Doctors need to be taught not only how to manage teams, but when to let others take charge, said Dr. Robert Kocher, former member of the National Economic Council under President Barack Obama and special assistant to Obama on health care. “We need doctors … who work flawlessly and without ego with nurses, [nurse practitioners], physician assistants …” he said in an interview.
We also need to understand the health care system — not just the history of Medicare, but the ins and outs of billing, malpractice, and quality measures — so that we can effectively work within, and on, this system. Student-run clinics are one way to do this. At the Crimson Care Collaborative, we learned to make real-time improvements in the way we deliver care that would be impossible at a large hospital center. There are plenty of other promising ideas.
Medical students at the University of Texas Medical Branch partner with physical therapy and nursing students in anatomy lab, early in their training. At the University of Pennsylvania, students visit the Wharton School of Business to learn how car manufacturing standards can be applied to health care. At Tufts and Columbia, medical students can enroll in a primary care track in a rural setting that is dedicated to skills like teamwork and quality improvement. Harvard Medical School’s recently announced $30 million Center for Primary Care promises opportunities for students to work with clinicians on practice-improvement projects.
As the realities of our flawed health care system are brought to the forefront, primary care is becoming the purview of trainees interested in a broad perspective of this system and the desire to improve it. If we’re equipped with the skills to do this, I believe more of us will not only choose primary care, but also will practice it better.
Ishani Ganguli is a freelance journalist and a fifth year medical student at Harvard Medical School. She is a member of Primary Care Progress, a Boston-based non-profit organization that promotes innovation in primary care training and delivery.
This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.
Wow, a high, elite Harvard med student has graced primary care with her presence?
LOL give me a break. Who cares. Oh, and with any bet, she’s a commie, she’ll fit in great up in Bahstahn and at the NEJM. Medicine’s finest, right!?
Who the hell gets accepted to medical school let alone makes it to third year without knowing what a PA is and how they are trained?! And what kind of medical school accepts someone who knows so little about the health care system?!
It’s clueless elites like these that make policies that do nothing more than clog up the system.
THIS is why no one wants to practice primary care.
1. You are at best a middle man and at worst a bystander between the patient and the physicians/surgeons that actually provide patient care – aka the specialists. Primary care has been so fractured by specialists that there is not much left. The reason it’s so dissatisfying is because primary care physicians don’t do anything. Either primary care physicians need to stop referring so damn much or give up altogether and let PA’s and NP’s fight over the bits and pieces that are left.
2. The pay doesn’t compare to other fields.
John makes a good point–one I’ve heard from the PCP’s I’ve shadowed. They don’t do anything gratifying and they have little true autonomy. Their practices are focused on the requirements of insurance companies and soon federal law.
I see the best role of physicians trained in primary care in the future being the supervisors of PA’s and NP’s. They will spend more time managing and with the most complex PC issues, while the others take care of simple cases. It’s efficient and I feel like everyone would be happier in the end.
Sandy, I had the exact same response. Why is it a big deal a Harvard med student is interested in primary care?
Wow, I feel like I lost some brain cells reading these comments…
a) EVERY article will reference the author’s background. That’s just simple norm — we want to know where the writer is coming from. So what if she’s from Harvard? Good for her…People at HMS tend to be more intelligent, smarter, and with higher leadership potential than your more average medical school. Kudos for writing about boosting Primary Care, an essential step in improving our healthcare system
b) If you just use NP’s and PA’s to run Primary Care, costs may actually go up. They will be more likely to refer hard patients due to their more limited training (not trying to knock on them). And if more patients go to specialists, costs go up (but not quality).
c) Many students do not know the exact training required to be a PA…can you name all the different flavors of nurses?
I have to agree with several of the comments regarding PCP’s. The future is dim – autonomy has been ground up into pulp and cast into masses of legal paperwork. PCP’s are faced with a future where they exercise no independent thought and develop no meaningful long term relationships with patients. They are being forced to follow protocol in a mind-numbing, disgraceful algorithm of ‘evidence-based medicine’.
Don’t get me wrong. PCP’s are critical and indispensable as front-line managers of healthcare delivery. However, I would be uncomfortable if my wife or daughter wanted to become a PCP – too many headaches, not enough payback.
Future MD’s: let’s all prevent this perversion of medicine by reforming primary care back to its essence: promoting the formation of a solid patient-doctor relationship, the bonds of long-term trust, and an art of healing. Let’s take the steps to prevent insurance companies and lawyers from taking over the human connection that medicine gives us the privilege to explore.
Also – medical school, the traditional MD – may not be avenue to generate PCP’s: perhaps we should increase the responsibility load of PA’s, RN’s, and other health professionals to be the central point of contact for patients in need of long-term, chronic care management.
Also, let’s hope that StudentDoctor mellows out in their blatant and distasteful promotion of an individual based on their institution of study. Touting a medical student at HMS as the symbol of authority on medicine is cheap and makes this article difficult to take seriously.
Hi, I go to school with the author and these comments are ridiculous and cruel. Besides the title (which I’m sure she did not write herself), what exactly do you hate about this article? It’s very informed and thought-provoking, and it’s helping to draw attention to the problems PCPs face. Is there anything more YOU can contribute, besides shooting her down?
Ishani is very passionate about what she does, and her writing is good as hell. Did the nay-sayers even read the article?
This is such a self-aggrandizing article I dont’ know where to start. Give me a break. Some liberal loser obama-ite wannabe wants to do primary care, and we are supposed to what, bow down? Gag.
Since when does going to a good school make you an elitist, seriously stop make that connection and the article was very well written and does raise some very important issues about the future need for PCP.
i had Bsc in health science & had 4.6 years work experienced
i want scholarship in MD
I see no thought provoking material, just what everyone knows being rehashed in a pompous, holier than thou manner. We have a shortage of primary care doctors? Really? Whats worse is that the writer claims that one of the main reasons our health care system is broken is because doctors are too arrogant to allow other health care professionals to work in collaboration with them? Seriously? Who is the one who gets crapped on when something goes wrong? Perhaps this is an issue of liability rather than arrogant doctors.
Doctors working collaboratively?
Yeah right.
Just look at the responses to this article.
The problem is that most doctors have this “holier than thou” arrogance about them that prevents them from ever taking a step back, admitting their wrongs, recognizing their way is not the only way, and allowing someone else to take lead.
Until this attitude stops all together, medicine will be what it is. And leave politics out of it. If you don’t view medicine with liberal eyes you don’t belong in it. Medicine is the last hope for true equity and freedom – a field that encourages equality between all people. As doctors you should fight for life-saving services for people of all walks of life, from the cracked out homeless nutcase in the street to political leaders. And in my opinion charging people for healtcare provision is inhumane and disgusting. Doctors are the servers of the community not millionaires. If you want a fat paycheck go into accounting or software development. But don’t tell me you “want to save lives” if that comes at a cost to the people.
Healthcare should be the responsibility of ALL people which means the government needs to overlook it, and all people need to pay for it. Sorry. That is the only “true medicine”.
The arrogance and self-importance in this article is astounding. A “compelling” mission? Oh please.
Give it up. HMS may have great hospitals, but the med school itself is a liberal cesspot which breeds this kind of elitist attitude; May we all be saved from the hell on earth known as OBAMACARE, which is a solid HMS project for the masses.
Anon, you are hilarious. Are you a real doctor yet? If so, please feel free to work 80+ hours the rest of your life, have no personal life, get paged constantly, and while you’re at it- and give the rest of your money away. Because according to you its your job to pay for everyone else’s healthcare and take care of entitled crackheads who want food/a place to sleep/Klonipin while paying no taxes and having way more free time than you do. Unfortunately that is more common than you think. Sorry to break it to you. Have a nice career in what is primary care with the majority of the “underserved”.
I’ll keep my lifestyle specialty.
“Doctors are the servers of the community not millionaires”
Really? Your average medical school is asking 35-40k a year for tuition (often you pay extra for housing, fees, books, etc). Stretch that out for four years and add on more for visiting programs, matching, interviews. Don’t forget the average debt of 20k that many undergrads have coming into medical school.
Put the autonomy issue aside, go be a FP after swallowing 200K + debt (don’t forget interest) and enjoy being a server of the community. There’s no wonder why the top paying specialties are becoming more competitive every year. Radiologists are keen enough to know the definition of the term, enslavement.
Why is it that every time someone says, “if you want to be rich, don’t be a doctor, be a (insert accountant, computer programmer, ) when in reality, those occupations all pay less?
The only way to be rich in the multimillionaire sense is be a successful entrepreneur or a top salesman, or both.
The rich software developers are all entrepreneurs. The rich computer programmers are all entrepreneurs. The rich accountants banking a million a year with bonuses are top salesmen, partners of firms (entrepreneurs).
I find it fascinating that any counter argument against the typical conservative view gets deleted by the mods. Such a fair and balanced website. Lol
Thank you for this frank description of the real atmosphere surrounding physician choice of specialty. All the theorizing about health policy won’t help us deliver better care without hearing the real concerns of the people that make it happen.
This was terrible.
I hope this “experience” will help the students continue to pad their resumes so they get get into the most competitive dermatology or plastics residency…..
.
Does anyone remember this article from former Harvard graduates. I’m sure they both would have volunteered:
http://www.nytimes.com/2008/03/19/fashion/19beauty.html
After noting the importance of preventive medical care despite the often “humdrum” nature of the conditions treated, Mr. Hocker said that “these things that are so important don’t compensate well enough,” and cited “lack of respect for what they do” in a field “viewed as easy because anyone can get into it” as a reason doctors might hesitate to go into internal medicine. He had earlier said that in specialized fields like his own, dermatology, “you know you are valued and your input is valued in the hospital.”
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