For years President Andrew Jackson was locked in a battle over Indian lands with a Cherokee chief. NPR’s Steve Inskeep on the history of that rivalry, how it led to the "Trail of Tears" and helped set the stage for the Civil War.
The U.S. is facing a critical lack of primary care physicians, and it’s likely the Affordable Care Act will worsen that shortage. Many worry there won’t be enough physicians to care for the estimated 30 million people set to gain insurance under the law in 2014. And it’s not just an issue of fewer doctors joining the ranks. While 20 percent of Americans live in rural areas, just 9 percent of physicians practice there. But some argue that the way primary care doctors practice is even more important than their numbers. This hour, the first of our new medical series, “Mind and Body,” Diane and her guests discuss the future of primary care medicine.
- Julie Rovner health policy correspondent for NPR and author of "Health Care Policy and Politics A-Z."
- Dr. Sumi Sexton partner, Premier Primary Care Physicians in Arlington, Virginia. She is also assistant professor of family medicine at the Georgetown University School of Medicine and an associate editor for the journal "American Family Physician."
- Elizabeth Wiley national president of the American Medical Student Association
- Dr. Fitzhugh Mullan Murdock Head professor of medicine and health policy, George Washington University School of Public Health and Health Services.
MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Today we begin a brand new medical series. We're calling it "Mind and Body" and we start appropriately enough with the role of primary care physicians. The U.S. faces a critical shortage of family doctors, but many medical school students are choosing to specialize.
MS. DIANE REHMJoining me in the studio to talk about the future of primary care medicine is Julie Rovner of NPR, Dr. Fitzhugh Mullan of George Washington University and Dr. Sumi Makkars Sexton, a primary care physician in private practice in Arlington, Va.
MS. DIANE REHMDo join us, 800-433-8850. Send us your email to email@example.com. Follow us on Facebook or Twitter. Good morning, everybody, thanks for being here.
MS. JULIE ROVNERGood morning.
DR. FITZHUGH MULLANGood morning.
DR. SUMI MAKKARS SEXTONGood morning.
REHMDr. Makkars Sexton, starting with you, I think a lot of people are confused about the role of the primary care physician. Describe it for us.
SEXTONThe role actually is to be a guide. These days in medicine, it's not about -- and I try to make a point of saying this to my patients. It's not about me telling you what to do or what's best for your health, it's me having the background, reading articles, reading the studies, presenting the information to you, listening to what's going on in your life and then coming to a decision together. So I see it as a guide.
REHMDr. Mullan, how do you see it?
MULLANI think primary care is and should be the basis of any health care system. The generalist function is where we all need to start and the generalist is capable, by most estimates, of dealing with 90 percent of the issues that present day to day for all of us, from minor problems to major new developments.
MULLANThe primary care role is also to refer on when the developments are judged to be more specialized or more demanding of more specific treatments. But it is the basis for our individual health and it should be the basis for our national health in terms of a system that works from a strong foundation up to other kinds of specialized functions.
REHMAnd Julie Rovner, what's happened to primary care physicians in the national system?
ROVNERWell, you know, on the one hand, primary care, the ideas is to have a new paradigm, if you will, for health care where the primary care physician is going to be the coach of a team of professionals who take care of you, your sort of go-to person. When you have something more minor, you'll be seen by a nurse or a nurse practitioner or a physician assistant.
ROVNERWhen you have something more major, you'll be seen by a specialist. But it will be, you know, in the early days of managed care, the primary care physician was your gatekeeper, if you will, and that didn't work out so well. You had to go to the primary care physician to get permission to see anybody else.
ROVNERPeople didn't like that. The primary care physicians particularly didn't like that. There was just too much paperwork involved. But the primary care practitioner is now going to become the critical lynchpin in this sort of new world of medical care.
ROVNERThe bad news, of course, is that primary care still doesn't pay that well and we have, particularly in the United States, where medical care is financed by medical students themselves, the students graduating with hundreds of thousands of dollars of debt. You still get paid much more to be a specialist so there's still this mismatch of students coming out of medical school wanting to be specialists. They get better quality of life often as a specialist and more money.
REHMSo how severe is the shortage now and how severe is it projected to be?
ROVNERIt's relatively severe now. It's projected to be much more severe as we go forward. Part of that is because you've got all these baby-boom primary care practitioners getting ready to retire. It's not just the baby-boomers themselves who are turning 65, 10,000 a day. You've got a whole cadre of physicians themselves who are going to be retiring and need to be replaced by these physicians in training now.
REHMAnd it's not just the number, is it Fitz? It's where they practice?
MULLANDistribution is a huge problem in primary care and in the system in general. Doctors tend to remain urban. They tend to remain in neighborhoods that are economically better off so we have a gradient in access, a gradient in availability to get the benefits of primary care.
MULLANRural areas are particularly hard-hit. Urban inner-city areas are hard-hit and that is an ongoing national problem that will be exacerbated as we move with The Affordable Care Act towards 30 million more people who will have either Medicaid or subsidized health insurance. These are folks who essentially have been uninsured and as they move into the system, their first stop will appropriately be primary care. This will be a big stressor in the immediate future.
REHMAnd Sumi, tell me the kinds of things you hear from medical students as to why they don't choose primary care?
SEXTONUnfortunately, I think the number one thing is student loans and also I think there has to be adequate support from the medical schools toward primary care. When I was training, I was very interested in family medicine and jokingly, the attendings I would work with would say, oh, okay, so you're going to kill the entire family and just joke, you know, make silly jokes because there was such a push toward, if you were a good student, you were going to go into specialties.
SEXTONYou're going to go into surgery and so we need to refocus that right from the school all the way up.
REHMAnd I gather what happens is that some students who have in their minds that they're going into primary care realize this enormous debt they're going to face and switch midstream?
ROVNERThat's exactly what happens. And even, you know, some students who go into what are considered primary care fields, into internal medicine, end up in some of the sub-specialties, if you will, of internal medicine. They go into cardiology. They go into nephrology. They go into -- or they become things like emergency room doctors, which are not necessarily, you know, which is technically a primary care field, but you can determine your schedule a little bit more realistically.
ROVNERYou know, one of the things that we've seen recently is that you have a lot more two-doctor couples. It used to be, you know, in previous generations, the husband would be the doctor. The wife would be home raising the kids.
ROVNERNow you have, you know, men and woman marrying each other. You've more than 50 percent of many medical school classes are women and you've got two-doctor households and, you know, somebody is going to have to be able to be home with the kids at some point. It's very difficult if you're going to be a primary care physician.
ROVNERYou're on call, if not, you know, every night. If you're in a rural area, you're often on call all the time. At best, you're on call half the time. It's a very difficult lifestyle so you've got a lot of students opting not just for financial reasons, but for lifestyle reasons not to want to go into primary care medicine.
REHMJulie Rovner is health policy correspondent for NPR. She's also the author of "Health Care Policy and Politics A-Z." Dr. Fitzhugh Mullan is professor of medicine and health policy at George Washington University School of Public Health. Dr. Sumi Makkars Sexton is partner at Premier Primary Care Physicians in Arlington, Va. She's also assistant professor of family medicine at Georgetown University School of Medicine.
REHMDo join us, 800-433-8850. Send us your email to firstname.lastname@example.org. Dr. Fitzhugh Mullan, some people say that just adding more primary care doctors is not going to solve the problem. How come?
MULLANWell, we have a challenge in terms of numbers. We have a challenge in terms of distribution and there's no question we need to retool our medical education system to incentivize and legitimate primary care disciplines, primary care specialties in careers.
MULLANBut beyond that, I believe we have an important asset which has been developed over the last half century and that is the nurse practitioner and the physician assistant that contribute mightily already and will be a major element of dealing with particularly the immediate challenge of the oncoming newly-insured.
REHMSo what are you saying, that you're going to train -- in addition to training more doctors, you've got to train more physician assistants and the like?
MULLANYou should know that today practicing in America are almost 200,000 nurse practitioners and physician assistants. They are divided actually between primary care practices and specialty practices and from my perspective, that's good. In both cases, they augment the practices and in the national sense, allow us, or take some of the pressure off, training more doctors.
MULLANThey are more flexible. They are more nimble in the terms of their ability to move and meet needs. And right now, the training in both, for both nurse practitioners and physician assistants, is moving ahead fairly briskly so the output of both those professions will be major contributors.
MULLANRight now, 200,000 nurse practitioners and PAs and about 700,000 physicians, so already more than 20 percent of our day-to-day clinical workforce are non-physicians, that is PAs and NPs.
REHMHow much training do those nurse practitioners and physician assistants need when you compare it to a general practitioner, Sumi?
SEXTONWell, I had four years of medical school and then three years of residency training and that was a very closely-supervised time. We actually have a physician assistant working in our office and she's amazing. We love working with her, but we closely -- and she's very responsive, but we closely monitor how she sees patients and how everything is going in the office.
SEXTONSo I think that the way that the training is going in these other fields is fine. I just think that I get a little bit concerned when I hear about independent practitioners not necessarily working in an environment with other physicians.
REHMDr. Sumi Makkars Sexton, we'll take just a short break here. When we come back, we'll open the phones for your calls, questions, and comments. Stay with us.
REHMAnd welcome back. Joining us now from her office in Sterling, Va. is Elizabeth Wiley. She's national president of the American Medical Student Association. And I gather, Elizabeth Wiley, you are actually Dr. Wiley.
DR. ELIZABETH WILEYI am. Thank you for having me.
REHMWell, congratulations to you. Fitzhugh Mullan was telling me about your extraordinary background. Tell us what you've done. You're not even, what, 30 years old and you've already done what, Teach for America. You've had a Fulbright scholarship. You've gone to medical school. You've now taken this one year off to head up the American Medical Student Association. Wow.
WILEYWell, I think you've summarized it pretty well.
REHMI'm impressed. Okay. And you have just made the decision to pursue primary practice medicine. Talk about the factors that you considered before making that decision.
WILEYWell, for me I came to medical school pretty interested and committed to primary care. Based on my experience as a middle school teacher in Detroit I'd really seen kind of firsthand how a lack of access to primary care sabotaged my students' academic achievement. And so, you know, when I came to George Washington I really sought out a lot of opportunities at some of the community health centers, the unity clinics in Washington, D.C. and was really able to see what's possible in primary care.
WILEYBut I think, you know, to echo some of the points that were made earlier, the issue of student debt and the sort of student loans has certainly been a huge part of the decision in my mind. I graduated in May with more than $300,000 of debt. And it's really hard to make a financial decision to take a significantly lower salary and see a future with that lower salary as, you know, I think about, you know, maybe having a family and sort of this financial future for me. And so I think that that's certainly been a huge consideration.
WILEYI also would echo the points about the culture of medical education as medical students. The faculty members that we're exposed to tend to be the subspecialists and, you know, there very much is that culture that -- you know, that if you're a successful student at a U.S. medical school that you should be going into a subspecialty and that primary care is really looked down upon in a lot of instances.
REHMSo how did your professors respond when you said you were going into primary care?
WILEYWell, I tend -- I guess my experience on clinical rotations was to tend not to talk about it with a subspecialist because you hear comments like, you know, you're too smart for primary care on rotations. And for me at least I sought out mentors like Dr. Mullan, you know, very successful primary care physicians who really encouraged me.
REHMSo you're faced with $300,000 in debt. How are you going to manage your student loan debt on a primary care physician salary?
WILEYWell, I think programs like the National Health Service Corp are really critical to incentivizing students like me and enabling students like me to go into primary care. So I'm very much, you know, hoping to join the corp. to benefit from some of the loan repayment programs and the public service loan forgiveness program that President Obama initiated or championed a couple years ago.
REHMBut Elizabeth, you've got to be pretty dedicated to pursue this path in the face of not only the challenges presented by some of your own professors but also by this $300,000 debt hanging over your head.
WILEYWell, like I said, I mean, having seen sort of firsthand, you know, how important primary care is and, you know, having come to medical school to really serve patients and to, you know, try to work to address some of those access issues, for me it's a clear choice. And I hope that more medical students kind of see it the same way in the...
REHMIs that why you’ve taken this position this year?
WILEYIn many way, yes. It's, you know, really been an honor to represent physicians in training and to really speak to many of these issues. And the need to address the primary care shortage and to incentivize us and enable us to make the decision to pursue primary care.
REHMElizabeth Wiley. She's national president of the American Medical Student Association. Thanks for joining us.
REHMAnd Julie Rovner, I mean, this is just not a good situation.
ROVNERNo. And one thing that we really ought to add, everybody talks about how, you know, you're going to add 30 million people under the Affordable Care Act, and goodness, what's going to happen to the primary care. It's not like the people who wrote this law didn't realize that. There is an entire section, entire title of the Affordable Care Act that looks at workforce issues, that pledges money to workforce issues to boost primary care. And some of that was what Elizabeth was talking about.
ROVNERThere's a large expansion of the National Health Service Corp. which has for decades now helped young doctors who agree to go into primary care, either pay for scholarships for medical school or repay their loans after the fact. So that will be the -- and I believe there are a number of people who will be taking advantage of that again to go into underserved areas, to go into in primary care. There are other loan repayment programs that are expanded in it so many more incentives for young students to go into primary care, many more incentives to increase the number of people who are teaching primary care.
ROVNEROne of the other problems, particularly in nursing and in nurse practitioner programs and in physician assistant programs, there's many more people who want to do it than there are people available to teach them. So there needs to be more money for people to actually train the people who will become primary care providers. So that is all envisioned as part of the Affordable Care Act.
ROVNEROne of the issues though is that unlike many other pieces of the Affordable Care Act which were automatically funded when the law was passed, most of the education provisions were not. They will need to be funded through the regular appropriation process. That is something that congress has been not happy about doing.
REHMAnd here's an email from Jeremy. "Please talk about how technology can extend the reach of primary care physicians into rural areas. If only we could figure out a way to get around some of the restrictions placed by regulations." Dr. Mullan.
MULLANWell, primary care is an information rich field. It is a field in which has been suggested the physician functions as guide. And the guide has to be based on good information, information about the patient that's easily retrievable, information about lab tests, exams that have been done elsewhere. And with that information the primary care physician can be a critical guide, a critical gyroscope for the health of the patient. But that's technology dependent. So everything from the electronic medical record to handheld devices that will enable quick access are key.
MULLANIn rural areas where distance is an issue, where consultations and information exchange from the regional hospital to the local clinic are key, we stand a leap ahead in terms of the potency of primary care. So it's not just one doc out on his or her own struggling with what the patient told them today. So I think it's an important frontier.
REHMAnd Dr. Sexton, I gather your office is one of the first to use electronic medical records. What kind of difference has that made?
DR. SUMI MAKKARA SEXTONIt's made a huge difference. Before we started our practice -- and one of the reasons I actually wanted to start the practice was the environment we were working in great colleagues, really bad medical record system. And I think my patients would think I was flaky sometimes because the chart wouldn't be anywhere to be found. And I consider myself to have a pretty good memory but I can't remember every detail about the last ten visits.
DR. SUMI MAKKARA SEXTONSo when we decided to open the practice I said, I will not start a practice without electronic medical records. So I feel that we were one of the first groups in the area are doing it. the down side of that -- I love it. It's been a great asset in seeing patients. The down side is the investment that we made several years ago -- ten years ago when we started the group. Now there are continued advances that we have to continually pay for. So here I thought I was making a one-time investment. Well, technology gets old and my wallet gets empty.
REHMJulie, talk about that.
ROVNERYeah, that -- well, obviously, you know, technology keeps moving forward and, you know, medical records...
REHMYou've got to keep upgrading.
ROVNER...you've got to keep upgrading and everybody needs to be what they call interoperable. You've got to be able to keep upgrading to be able to communicate with everybody else. In rural areas though the one thing we didn't talk about here was telemedicine, which is something that's been a great achievement. And I think that's probably what the listener is referring to. There are...
ROVNERThat's right. And there are issues with regulations across state lines, across -- people with licensing. But telemedicine has been a great advance in a lot of very remote areas where doctors and patients can communicate literally, you know, via Skype, via various other remote connections. But you've got privacy issues to worry about. You've got regulatory issues to worry about but it can be a huge way for people in remote areas to connect with practitioners who may be far away.
REHMHere's an email from Marion in Louisville, KY. She says, "You all seem to think more primary care physicians are desirable but the U.S. population is aging. Older people tend to have more and more complicated medical problems. Studies have shown that complicated patients do better and cost the system less when they are taken care of by specialists who know the conditions and medications better." Is that true, Julie?
ROVNERNo. I think what they found is that the coordinated care is best. You need one person in charge and that's the idea behind these medical homes that are being discussed now, that there needs to be a physician in charge and coordinating all the care. Yes, when you get older you do need specialists but you need somebody who knows everything that's going on. And that person is -- ought to be a generalist who's got sort of some ideas -- or the quarterback, if you will, of this team.
REHMYou've mentioned medical home. What does that mean, Dr. Mullan?
MULLANThe medical home is a concept that has been with us for some time, although in the last decade it's really leapt forward. And the concept here is moving beyond the idea of a personal physician who has envisioned it as a given human being available presumably all the time to a setting in which there is a designated individual physician or clinician. But where there are other health care team members, nurse, nurse practitioner, nutritionist, social work, in a setting that's integrated and collaborative where information is readily available. And that this is the ideal for patient care.
MULLANMoreover it is a much more -- a better business unit in terms of managing the cost of the care to the individual and the system.
REHMDr. Fitzhugh Mullan. He's professor of medicine and health policy at George Washington University School of Public Health. And you're listening to "The Diane Rehm Show." Let's go to the phones. First to St. Louis, Mo. Good morning, Mary, you're on the air.
MARYI listen to your show every day and...
REHMThank you so much.
MARY...this one is of particular interest to me. I'm a retired nurse after 50 years. And I was a nurse practitioner for 15 of those years. And I am a strong advocate for primary care. And I listened to all the things that your group has had to say about it and I believe in it. I believe that nurse practitioners do play a part, but that nurse practitioners should work in concert with physicians and be supervised by those physicians, too.
REHMIt sounds as though she agrees with everything you've said, Dr. Sexton.
SEXTONThank you. Thank you.
REHMYes, indeed. All right. Thank you for all you've done, Mary. I hope you enjoy your retirement. To Falls Church, Va. Good morning, Chris.
CHRISGood morning, Diane. Thanks for taking my call. I appreciate it.
CHRISWhat I wanted to say was there is a group of doctors out there already who are uniquely situated to be generalists or primary care physicians but they're not allowed to practice in 35 of the states. They've gone to medical school, they're experts in nutrition and preventative medicine but they are not allowed to practice. They're nature path -- I happen to be one of them. I have a practice in Falls Church.
CHRISAnd the reason that I say that is because a lot of what these great doctors are doing is treating people who potentially have nutritional solutions. For example, if you have somebody with type II diabetes or some of the cardiovascular disease, you know, if you're going to treat them for 40 years that's going to take a lot of doctors, a lot of medicine. But a lot of these can be fixed with nutritional solutions. Not everything though. And I think any nature path would tell you that. I mean, we can't solve everything. And then when we need the medicines and when we need the doctors that's when we can send them there.
CHRISSo a blend between a doctor who is an expert in nutrition but can also manage, you know, basic medicines and be able to order labs would be an amazing solution.
MULLANI'm not an expert in nature paths or naturopathy but I am respectful of the work that is done. I think the challenge when we talk about a physician or a doctor or medical practice is what is the span of competencies that we expect, and have individuals been trained in that full span? And when examine tested do they have a knowledge base that's acceptable in that span? That is the basic question.
MULLANI don't know the curriculum of naturopathy, but if doctors of naturopathy reach that level of competency, it's clearly something that ought to be considered.
ROVNERYou know, this goes into an issue, and I think the call before goes to this too. You know we have sort of a guild system, if you will, in the medical profession. It's been very difficult for medical professionals to work together, which is what obviously, as Dr. Mullan was saying, you know, is the -- what we need to work towards in the future. Doctors are worried about midlevel practitioners, the -- particularly the nurse practitioners and the physician assistants working without enough supervision because they say they don't have enough training.
ROVNERAnd then there becomes the issue of are they just encroaching on their salaries? You know, there's been long time -- you know, decades-long fights between MDs and chiropractors, and MDs and doctors of osteopathy and it -- you know, it gets -- some of it become economic and some of it becomes, you know, literally do you have enough training. And it gets very difficult for the lay person to be able to differentiate between who's actually -- you know, how much of this is legitimate, are you qualified to care for me and how much of it is are you protecting your own piece of the economic health pie?
REHMIs the Affordable Care Act going to make any difference in our approach to those other...
ROVNERIt certainly does move towards the encouragement of health professionals working together in teams. And certainly with things like accountable care organizations it makes it more -- less, you know, every health provider for themselves and more you have to get together and coordinate care.
REHMJulie Rovner, a health policy correspondent for NPR. We'll take a short break here and we've got lots of callers to speak with when we come back.
REHMAnd we are back with many emails. Here's one from David in Dallas. He's just the sort of person who needs to hear from all of you. He's a third-year medical student at a medical school in Texas. He's currently in the portion of training during which he must choose a specialty. He's interested in hearing more of the pros of family medicine with regard to patient interactions and lifestyle rather than the cons of this profession.
REHMDr. Mullan, you and I have known each other, I think, practically all the 33 years I've been on the air. So I'm going to turn to you first because you have been exactly that.
MULLANWell, I'm a pediatrician, which is a primary care specialty, not family medicine, but a close cousin. And the rewards for me have been in the ability to deal across the issues that come to the office and also the ability to know that person over time. I actually did start as a family physician, working in the National Health Service Corps and to be able to see a family in which I delivered the baby, in which I was taking care of the mom, in which the grandpa came in for blood pressure checks was very rewarding.
MULLANNow, the challenge is, are you competent in all those areas and today's family physicians, the pediatrician, I was not as good as I should have been. Family physicians are well trained for care in all those areas. And that's a real reward in terms of how you see yourself. Some people are much more technically inclined and if procedures are what really light them up, then many specialties work around a procedure or two.
MULLANBut I will say that the normal premise that being a specialist is a more complex intellectual challenge than being a generalist, I think, is exactly on its head. Many specialties devolve around certain, fairly limited areas of disease and fairly limited areas of intervention, on which people can become very good. As a primary care physician you don't know what is coming through that door.
MULLANFor some people who have trouble dealing with uncertainty, that's anxiety producing. For those of us who kind of like it and want to greet the human condition and challenge it and take it on as it is, it's very rewarding.
REHMDr. Sexton, from your own personal experience, why do you think it's good to be a family practitioner?
SEXTONFirst I have to say I would do the same thing again and again and again. I love my job. I love my patients. It's what Fitz said, it's the link, it's the bond that you make over time with your patients. I know the entire family. There's something to be said, first of all, in knowing a mom and her baby and the husband and the cousin and everyone. And then having insight, when somebody comes into see me, I already have a foot in the door with what's going on because I'm treating the whole person because I know the whole family.
SEXTONAnd I can't say enough about that. My patients are incredible. I look forward to seeing them and meeting them every day. They give me advice, believe it or not, about local school systems, about fashion, about politics. I've had many an interesting political conversation. I can't say--and I tell students all the time, I love what I do. I love procedures. I love variety. I love the challenge. I wish I made more money, but that's fine. That's not why I went into this.
REHMAll right. And on that money issue, Catherine wants to know whether you would comment on the amount reimbursed by Medicaid for a non-complicated office visit. She says, "A few years ago, when I worked for a family practice doctor, he would receive $8 for this visit. I recall an ophthalmologist who fared slightly better at $11 per visit. With Democrats talking about decreasing fees to providers, who will want to see these patients?
ROVNERWell, of course states decide what they reimburse for Medicaid, but one of the things that the Affordable Care Act did do is for two years, starting next year, primary care services under Medicaid will have to be reimbursed at the Medicare amounts, which will be a substantial increase, I believe, in every state. That's the good news, but the bad news is, A, it's only for two years and, B, if Congress doesn't do something about Medicare rates for doctors they're going to drop 27 percent starting January 1. But in general, there will be an increase in Medicaid rates for primary care for just that reason, to encourage more physicians to take Medicare--Medicaid patients, excuse me, because there will be an increase in Medicaid enrollment.
REHMAnd, Dr. Mullan, you wanted to talk about these teaching health centers.
MULLANWell, the question that always arises is how to do we train, and in a culture, medical students and young physicians, to understand, appreciate and want careers in primary care. One thing that's a clear requirement is to model other forms of practice. So much of medical education takes place in or around the hospital, with all the benefits that has, all of the intensity, but it really doesn't model where most practice takes place.
MULLANCertainly virtually all of primary care practice takes place in the community. So there has developed over recent years a greater emphasis on teaching in community-based settings. And in the Affordable Care Act there's actually a designated teaching health center element, which is funded in a fixed way for five years to fund residency programs -- that's post-graduate training -- at community health centers. Those community health centers will contract with and work with local hospitals for time for the residents to do the hospital portion of the training they need.
MULLANBut the ethos, the strategy, the culture and the philosophy of this new medical practice, this new medical practitioner is in the community dealing with patients' insight too, in their settings in the community.
REHMWill it help with financing?
MULLANThe question of financing community-based training is part of the larger question of how do we finance training in general, which for a set of reasons, a complicated set, are mostly funded by Medicare. And right now the way that's calibrated, it's all hospital focused. So one of the issues in Medicare reform is to figure out how to put more of the training support in the community.
REHMAll right. To Burlington, N.C., good morning, Alexis.
ALEXISGood morning. Thank you for taking my call.
ALEXISIn North Carolina we have a program called Teaching Fellows, where students who are interested in going into education, have their schooling paid for and then they in turn, provide so many years of service to the North Carolina public school system. Does anything like that exist for primary care physicians?
ROVNERAbsolutely. And that's what the National Health Service Corps is and …
ROVNER… and there are several others, as I mentioned, that is expanded in the Affordable Care Act. And there are several other programs for several other types of health professionals.
REHMBut you have to be willing to go where you're sent.
ROVNERThat's right. And you have to be willing to serve in an underserved area.
REHMAnd that is the basis of that program, is it not?
ROVNERYes, it is.
REHMSo there are a lot of people reluctant to do that, even though they want to go through their medical education.
ROVNERI believe there are other primary care programs that will -- there are other loan repayment programs. That's just the largest of them.
MULLANI actually, Diane, started as a National Service Corps physician in New Mexico and then had the privilege of running the program for four years during, actually, the Carter administration.
MULLANIt's a brilliant and very simple solution. In today's parlance, it's community service and trade-off for educational support. And it is focused on where we have our greatest deficit, that's primary care. If you want to be a neurosurgeon this is not the program for you. On the other hand, if you want to be a neurosurgeon (sic), you will be able to pay off your loans quite promptly upon completing your training. But if you want to work in family medicine or general pediatrics for the rest of your career, this is a way to do national service in needy areas and get your loans repaid.
REHMLet's go to East Lansing, Mich. Good morning, Wendy.
WENDYGood morning, Diana.
WENDYThank you so much for taking my call.
WENDYI just love this show.
WENDYI actually work as an instructor in medical school here. And my comment really was -- I agree with everything the panel has said. Loans are a huge problem for our students and I think part of their education is the assumption that they're going to go into specialty. And I myself am guilty of immediately asking these first-year medical students, oh, what area are you going into? And I think that creates a bias. But I think another issue is the general public's perception of primary care. And I'm really not sure what the solution to that is, but I think we need to, you know, elevate our primary care physicians in the general public as well, give them the same respect that we give our specialists.
REHMI think that's such a good point. And you're listening to "The Diane Rehm Show." Is it, in your view, Dr. Sexton, that the general population does not have the same regard for general practitioners as it does for these specialists?
SEXTONIn general, I feel very privileged to work in the setting I work in and I feel very well received by my patients and the community. I would say overall though, it's this, oh, you're a specialist. It's not that there's a lack of regard for primary care, but there may be a little bit more, oh, you had to do a little extra training or …
REHMThat's interesting. So the public needs a good bit of education, Julie.
ROVNERYeah, well, I think it comes from the medical hierarchy, too. I think it rubs off on the public from how the medical profession, you know, it's pretty clear in the medical profession that primary care is the bottom rung. And it's, you know, it's reimbursed at the bottom rung and that rubs off on the public.
MULLANThere are ten medical schools in America today that do not have family practice departments and they're all the elite schools. We did a study on the social mission of medical schools, how many graduates they graduated into shortage areas, how many into primary care, etcetera. And schools like Southern Illinois, schools like Morehouse, schools like the University of New Mexico did sparklingly well. And the brand-name schools that are heavy on research …
REHMWe are talking about Harvard, Yale, Stanford, the like?
MULLANAnd the like, exactly. All rated at the bottom. They did not do well in terms of addressing this national need of profound significance.
REHMHere's an email from Shiva, who says, "As a foreign medical graduate, I have a slightly different perspective. I feel many of my friends who are graduates of American medical colleges carry a sense of pressure to choose a specialty that will pay more so they can clear loans and get on with life. And who doesn't want to have a comfortable lifestyle after you've spent such a large part of your life getting an education. It is unfortunate that the incentive is monetary and not altruistic motivation, which I," says Shiva, "believe should be a prime motivator." Julie?
ROVNERWell, it's not just altruistic. I think what's really unfortunate is that medical students can't decide, based on what it is that they want to do. I think as we've been discussing, you know, it takes a different kind of personality to be a primary care practitioner than it does to be an interventional radiologist. I mean, you know, as Dr. Mullan was saying, it's what lights you up as a person. I mean, we now have these different specialties in medicine that take different types of people. And yet medical students are making these decisions based on things other than, perhaps, how they would like to spend their careers.
ROVNERAnd that's the part that's really unfortunate. If it were more equal, if they could just decide what they want to do based on what they would be good at and what they want to do and how they would want to, you know, to spend their medical careers, that might be a little bit better than having them--then deciding do I need to do this because that'll be the easiest way to pay off my loan or do I need to do this because that's the way I'll be able to have a family and go to my kids soccer game.
ROVNERAnd I think there are ways now with some of these, you know, programs, where you can pay off your loan or some of these perhaps medical homes where a doctor could be a primary care doctor and maybe also have a life that we might be able to work these things out.
REHMYou know, I was just recalling all those older television programs where they had one doctor was the leader in the community.
REHMThat was it, Marcus Welby.
MULLANAnd Northern Exposure.
REHMAbsolutely. Dr. Kildare in "The Hospital." I mean all these gods to whom we looked up, but even these small practices, Dr. Sexton, now barely existing because people are going to larger hospitals, larger practices where they feel they can get everything they need, one stop shopping.
SEXTONSure. I think there's something to be said about the patients that choose a smaller practice. First of all, we've created our own medical home. And I just wish there were more resources out there for us, but we are one of the first groups to do electronic medical records. We started doing same day, next day scheduling, right from the get go. We've collaborated with psychologists in the area, have had psychologists come to the office to do group therapy for our patients. We do some nutrition counseling. And we are constantly looking at ways to improve patient care.
SEXTONAnd the value of the small practice is, there are three partners, we talk about it, we say that's a good idea, let's make a change, let's do something. There's no bureaucracy, no red tape, nobody telling us what to do. We send out surveys. We get feedback from our patients. And the problem is, this is a dying breed. We need small groups that can make changes and then we need to have the resources for those groups to continue to make those changes and meet the needs.
REHMWhat kinds of resources are you talking about?
SEXTONFor example, as I said, we had done electronic medical records, but now, to apply for meaningful use, there are more hoops to jump through. And we've been dying to do electronic communications with our patients. We want to have a web portal, but in order for our business to afford a web portal, we'd practically have to charge our patients for it. We don't want to do that. It may come down to that, but I'd like to be able to communicate. I'd like for the insurance company to pay for communications between me and my patient.
SEXTONBut instead, you know, I'm only incentivized to have them come into the office because that's the only way the insurance company is going to pay. They don't pay for the hours of paperwork or the phone calls that you do. And I'd want to spend more time with my patient and do whatever it takes. They've taken their precious time to come see me in the office. Why should they have to come see me two weeks later just because I only had 15 minutes today? It's a waste of their time. It's a waste of my time.
REHMAnd that I fear has got to be the last word. And what a passionate word it is from Dr. Sumi Makkars Sexton. She is a partner at Premier Primary Care Physicians in Arlington, Va. Dr. Fitzhugh Mullan, professor of medicine and health policy of George Washington University School of Public Health, and Julie Rovner, health policy correspondent for NPR. I hope we have enticed some young people to go into primary care. Thank you all.
MULLANThank you, Diane.
REHMAnd thanks for listening all. I'm Diane Rehm.
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