The Primary Care Shortage: Symptom of Societal Problems

1. The Primary Care Shortage:Symptom of Societal Problems Nicholas H. Apostoleris, Ph.D.

2. On the presenter�s perspective This presentation will look at the�primary care�shortage from the�perspective of a psychologist who teaches in a medical residency, administers a behavioral health department in a community health center organization, serves as health center director for a Healthcare for the Homeless/Public Housing Primary Care FQHC, and has a practice which focuses on serving homeless adults in an underserved community.

3. Personal viewpoint and opinions I�m not speaking for my medical school, my residency, my hospital, my community health center or any other institution or organization. All errors, omissions, and oversights are my own.

4. The fundamental assumption underlying this presentation We are all of equal value as human beings

5. Some assertions to get things going� Assertion I Primary care medical providers have a greater positive impact on public health than do subspecialty providers (See B Starfield�s work out of Johns Hopkins)

6. Assertion II Subspecialist physicians�are paid more than are primary care physicians, even when controlling for years of training This gap has widened over the past several decades.

7. Assertion III Reimbursement schedules favor specialist procedures over prevention and primary care interventions Depth of knowledge is thereby rewarded, but only in areas where there are reimbursable procedures requiring special equipment, or use of medications�requiring special training. Little or no additional reimbursement for knowledge and skills which improve public health by affecting patient behavior rather than provider behavior. On the contrary, physician interventions which take clinic time but positively affect patient behaviors are often squeezed by �productivity demands.�

8. Current system reimburses for depth of knowledge in areas where there are reimbursable procedures requiring specialized equipment or education.� So the knowledge curve on the left is remunerated more highly, so long as the area under that curve is the right area.Current system reimburses for depth of knowledge in areas where there are reimbursable procedures requiring specialized equipment or education.� So the knowledge curve on the left is remunerated more highly, so long as the area under that curve is the right area.

9. Assertion IV The intellectual challenges faced in primary care equal or exceed those faced in subspecialty care Intellectually, primary care is characterized by: High complexity High need to manage ambiguity and uncertainty Synthetic thinking - Pulling it all together The primary care provider needs to manage considerable uncertainty in managing an often undifferentiated, undiagnosed patient.� Facility with a broad range of diverse fields is necessary to provide good primary care.� There is no way to reach maximum depth, so managing uncertainty is a critical skill.�The primary care provider needs to manage considerable uncertainty in managing an often undifferentiated, undiagnosed patient.� Facility with a broad range of diverse fields is necessary to provide good primary care.� There is no way to reach maximum depth, so managing uncertainty is a critical skill.�

10. Assertion V Medical education in the US is expensive and subsidized Expense is most salient in private medical schools and the subsidy is most salient in state medical schools but both receive public subsidies or support

11. Assertion VI Public dollars fund physician training and theoretically could be tied to funding training which maximizes public health

12. Assertion VII Developing more primary care physicians�is in the public interest, but medical schools (receiving public funding) are producing a low percentage of graduates who pursue careers in primary care

13. Assertion VIII Primary care providers and family physicians in particular are the best trained physicians to care for the complex, multidimensional problems facing the underserved and disenfranchised in a holistic, culturally competent manner

14. Assertion IX Choice of career is affected by multiple factors and no one factor can be assumed to be able to overcome problems with other factors

15. Some career desirability elements Financial considerations � � Lifestyle/workload � � Social Good/Fulfillment � � Status (Income, debt, liability) � �(e.g., call, hours, liability-related worry, productivity requirements) � (Fulfilling personal mission toward prosocial ends) � (in eyes of people important to the individual)

16. Medical Student scenario High functioning �hotshot� 3rd year medical student in US medical school with several options regarding residency choice. This student has rotations which bring her to all the specialties, from which she will choose� In coming up with this scenario, I�m remembering working with super bright, eager medical students who all said they were interested in family medicine but stats show that only about 7% went into FM from that med school.In coming up with this scenario, I�m remembering working with super bright, eager medical students who all said they were interested in family medicine but stats show that only about 7% went into FM from that med school.

17. Decision point - Medical student Financial concerns � Concerns about debt are driving some decisions that income concerns would not have � Growing income disparities in after-tax income with tax structure not serving a leveling function Concerns about ongoing expenses, including liability insurance (especially for those interested in OB) � � Again, tax code can have implications beyond investment decisionsAgain, tax code can have implications beyond investment decisions

18. Decision point - Medical student Lifestyle concerns � Call - Balancing family and work life becomes so much harder when a physician cannot put consistent boundaries around the work time OB??? � Long hours in under-resourced settings � Who is being drawn to the field - who will my colleagues be? Will I ever be competent? � I hear about Call and OB as surprisingly big issues � If the hot shots in med school are going into the subspecialties, this will create its own pull for future hot shots to go in that directionI hear about Call and OB as surprisingly big issues � If the hot shots in med school are going into the subspecialties, this will create its own pull for future hot shots to go in that direction

19. Decision point - Medical student Social Good/Fulfillment � This seems to remain a strength of primary care for med students, even those who value this factor and who do not choose FM.

20. Decision point - Medical student Status � Is status related to the perception of intellectual rigor? Complexity of practicing primary care medicine well is severely underappreciated. Not a high status field from the med student�s perspective. Who has more status, the subspecialist or the family doctor? � �

21. Well established problems Government is fueling the widening income gap between primary and specialty care providers. Much research has demonstrated the public health benefit of increasing the emphasis on primary care. Physicians caring for the underserved are disproportionately family physicians, yet fewer med students are choosing family medicine.

22. More problems The country needs more family physicians yet FM residencies are under pressure to contract due to poor supply of graduating medical students Even in FM, some residents go into specialty lookalikes (sports medicine, hospitalists, gerontology) The pressure away from primary care towards specialization seems irresistible � yet this trend isn�t in the public�s interest

23. Affecting the most vulnerable Only a subset of family medicine residents are going to be interested in the special challenges and rewards of serving underserved populations

24. Assertion X Change is possible.

25. Assertion XI Those making structural changes will face resistance based on overt and covert interests and rationales

26. Addressing more basic causes However it happened, what are the conditions that permit this seemingly untenable situation to grow, threatening the public health?

27. Looking more broadly for answers Economics Macroeconomic assumptions (the government has a role in shaping the economy and can intervene purposely) Business/Public Health interface Distinguishing public health goals from business and economic goals

28. Silent Cal said�

30. Assertion XII The chief business of America has been business but American world business leadership has declined in many areas while other areas remain dominant. The dominant sectors are fiercely defended by industry and government even when doing so results in inefficiencies. We must look at the business perspective to understand what�s happenedWe must look at the business perspective to understand what�s happened

31. Sectors in which US remains a world leader Entertainment/popular culture Weaponry/Aviation/IT IT/software Higher education including medical education Pharmaceuticals/medical devices and technology

33. Eisenhower in his farewell address, 1961<Consider substituting �medical industrial complex� for �military industrial complex�> In the councils of government, we must guard against the acquisition of unwarranted influence, whether sought or unsought, by the military-industrial complex. The potential for the disastrous rise of misplaced power exists and will persist. We must never let the weight of this combination endanger our liberties or democratic processes. We should take nothing for granted. Only an alert and knowledgeable citizenry can compel the proper meshing of the huge industrial and military machinery of defense with our peaceful methods and goals, so that security and liberty may prosper together. Akin to, and largely responsible for the sweeping changes in our industrial-military posture, has been the technological revolution during recent decades. In this revolution, research has become central; it also becomes more formalized, complex, and costly. A steadily increasing share is conducted for, by, or at the direction of, the Federal government. The prospect of domination of the nation's scholars by Federal employment, project allocations, and the power of money is ever present and is gravely to be regarded. Yet, in holding scientific research and discovery in respect, as we should, we must also be alert to the equal and opposite danger that public policy could itself become the captive of a scientific-technological elite.

34. What was he worried about? That the massive public/private �system� would self-perpetuate, growing ever larger and its growth imperative would have a corrosive effect on its mission of national defense.

35. Not a surprise, but not OK Our health services/pharma/medical technology sector (Big Med?) is now largely functioning on a business model rather than on a public health model. Everybody is happy if there are more highly paid physicians, doing more expensive procedures, generating more profits for the medical industries, and generating grant and patent related income for the universities. Except� The primary mission of this sector should and must be to maximize public health. The mission should and must be to maximize public health.The mission should and must be to maximize public health.

36. �The chief business of Americans�� It�s fine with the IT or entertainment sector, but with the defense and health-related business sectors the primacy of the profit motive is problematic considering the public safety and public health implications that are essential and core to each sector�s mission.

37. What exactly is the mission of a for-profit health care organization? �Profiteering� as unethical obtaining of profits, especially during wartime What would �profiteering� in the health-related business sector mean? Perhaps conducting profit-based business ostensibly to improve, but clearly to the detriment of public health How about just conducting business in disregard of the public health?

38. Why worry about �Big Med?� The worry is that when industries get large enough, their success becomes a public end in and of itself (jobs for the district, etc.) What would the effect be on the economy if people exercised more, ate less (would ADM or McDonalds be happy?), had fewer procedures, got sick less? Good for the economy overall, maybe not so good for the health/medical sector as presently configured (if true, that should be concerning)

39. Solutions must increase the attractiveness of a career in primary care Financial considerations � � Lifestyle/workload � � Social Good/Fulfillment � � Status (Income, debt, liability) � �(E.g., call, hours, liability-related worry, productivity requirements) � (Fulfilling personal mission toward prosocial ends) � (In the eyes of people important to the med student)

40. What to do to help that med student decide to go into primary care? Financial considerations Tie student cost subsidies to decision to work in underserved areas up to and including complete medical school tuition waiver A physician who worked in an area and specialty with low public health impact would be expected to pay the full cost of the education Tightly tie public subsidies to medical schools to the percentage of primary care physicians the schools produce

41. What to do to help that med student decide to go into primary care? Lifestyle/workload OB Optional Attendings never to be heard reminiscing about how much harder it was �back when I was a resident� The primary care visit is redesigned around the centrality of the patient�s behavior as the primary determinant of patient health knowing that more time per visit will be necessary

42. What to do to help that med student decide to go into primary care? Social Good/Fulfillment Explicitly link family medicine with values of egalitarianism Promote �service to society� as a core FM value Promote prevention and primary care as the path to improved public health

43. What to do to help that med student decide to go into primary care? Status Promote primary care as intellectually HARD Following the medical or health home model, promote primary care physicians as care providers and team leaders Status (or stature) through service

44. Time for a fundamental reassessment Critically examine the pay-for-procedure model which is a root cause of the deviation of the mission of healthcare from serving the needs of the public�s health to fueling an industry which necessarily is driven by its own profit demands. Determine the precise level of health care an American citizen is entitled to, then provide it with high quality standards and without regard to ability to pay. High quality primary care would be central to that entitlement.

45. Maybe the core problem is that our society is not acting as if We are all of equal value as human beings

46. Thank you for your time. Nicholas Apostoleris � NHAPHD@gmail.com