January 2006 | Back to Table of Contents
Cover Story
Retooling Family Medicine
By Amy Snow Landa
In November, HealthPartners cracked the foundation of family medicine in the Twin Cities by announcing plans to close its family medicine residency at Regions Hospital and West Side Community Health Services in St. Paul at the end of June. It is the oldest such program in the Twin Cities, dating to 1972, and was, at one time, one of the most sought-after residencies in the country.
Announcement of the decision on Nov. 22 stunned the program’s 26 residents. “I was shocked, like everyone else, and then saddened,” says Michelle Tomes, M.D., a third-year resident in the program. “I thought we were holding our own.”
But the program wasn’t. Recruiting problems and the clinic’s financial turbulence had created a “perfect storm” that spurred its closure, says Carl Patow, M.D., M.P.H., executive director of HealthPartners’ Institute for Medical Education. In July, HealthPartners had transferred the assets and operational responsibility of the clinic where the residency is based to West Side Community Health Services, which provides low-cost health care at 20 clinic sites in St. Paul. The spin-off was just the latest in a series of destabilizing changes to hit the residency. Previously, the program had experienced leadership changes and faculty resignations. By the time the transfer was finalized in July 2005, residency positions had been cut from 12 per class to six, part-time preceptors had been laid off, and half the faculty had departed. The transfer also meant the clinic lost its electronic medical record system, which was licensed by HealthPartners. So physicians and staff had to go back to using paper.
Despite this series of blows, faculty physicians say they didn’t expect the residency to close. “We had been on a down curve, but were on our way back up,” says Rob Wagner, M.D., who graduated from the program in 1987 and joined the faculty in 2001. The program had already signed four interns to begin residencies in July 2006, and faculty felt proud that they were able to continue providing high- quality education to their residents despite the program’s difficulties, he says. “We were actually quite hopeful.”
Marianne Clinton-McCausland, M.D., who has directed the Regions Family and Community Medicine Residency since September 2004, says the faculty is working to assist 14 first- and second-year residents in finding positions in other residency programs.
The Regions closure has added to the sense of unease among Minnesota family physicians that the residency infrastructure is growing increasingly fragile. Already, the number of family medicine residency positions available in Minnesota had dropped in 2005 from 96 to 80, and the number of filled positions declined from 69 to 65.
Even residencies that are planning to maintain their current number of positions in 2006 say it’s become noticeably more difficult to attract applicants.
The Duluth Family Practice Residency, a community-run program affiliated with the University of Minnesota Medical School, had to step up recruitment efforts after the residency made only four matches in 2001 and 2002 for 10 available positions, says program director Thomas Day, M.D. “Now we’re recruiting as far east as Philadelphia and as far west as Salt Lake City.” And he’s having to sell the program at eight schools rather than the three at which he used to recruit. So far, the program hasn’t resorted to offering signing bonuses or free housing, which many of its competitors in other states are doing. “We talked about it, but we decided we’d rather have someone who is committed to our program than someone who wants $10,000 to play with,” he says.
At Mayo Clinic, the residency continues to match well but has seen its number of applicants from U.S. medical schools decline significantly this year—from about 50 to the low 30s, says program director Robert Flinchbaugh, D.O. On the other hand, the number of international applicants has shot up.
Allina’s United Hospital program also plans to maintain its current number of positions this year, says Dan Foley, M.D., Allina’s vice president of medical affairs. “But our people are always nervous because we’re just not seeing as many students talk to us about the program.”
A Tougher Sell
The struggles of family medicine residency programs are not just a Minnesota phenomenon but are part of a national trend that has caused deep concern and a measure of soul-searching within family medicine about what is needed to start the pendulum swinging in a more positive direction.
In 2004, seven family medicine organizations released the Future of Family Medicine report, which warned that the declining number of students choosing a career in family medicine had reached “near crisis proportions.”
Nationally, the number of available family medicine residency positions has declined every year for the past eight years—from 3,262 positions in 1997 to only 2,761 in 2005.
That trend is expected to continue, according to Perry Pugno, M.D., M.P.H., director of the American Academy of Family Physicians’ (AAFP) graduate medical education division. “There will probably be about 40 fewer positions offered this year than we had last year, based on what we’ve been advised by a few programs that are closing,” he says.
Even with fewer slots being offered each year, many programs still have trouble filling the smaller number of positions. Nationally, the Match fill rate has fallen from 90.5 percent in 1996 to 82.4 percent in 2005, according to the National Residency Match Program. Even more startling, perhaps, is that less than half of family medicine residency positions nationwide—only 40.7 percent—were matched by graduates of U.S. allopathic schools in 2005, down from 72.6 percent in 1996.
Despite fewer residents in family medicine, the current supply of family physicians overall remains in relative balance with demand, according to the AAFP. The exception is in smaller to mid-sized communities, where there tend to be shortages of primary care physicians. But recruiting of family physicians has definitely slumped, according to Merritt, Hawkins & Associates, a national physician-search firm that saw a 28 percent decrease in search assignments for family physicians between 1997-98 and 2003-04. Other specialties, such as radiology, saw increases during that period.
One bright spot is that a high percentage of University of Minnesota medical school graduates continue to choose family medicine as their specialty. The proportion has stayed fairly consistent during the past five years at about 19 percent to 20 percent, according to Macaran Baird, M.D., chair of the department of family medicine at the university. Family medicine remains one of the top two career choices of graduates, along with internal medicine. He also notes that the university ranks second in the nation in the amount of family medicine research funded by the National Institutes of Health.
A particular hot spot for family medicine is the University of Minnesota Medical School in Duluth, which tends to select applicants with a strong interest in pursuing rural primary care—especially family medicine—and then works hard to sustain that interest. “We try to keep the fire alive,” says Ruth Westra, D.O., M.P.H., who chairs the family medicine department at the University of Minnesota’s Duluth campus.
One way the Duluth program does that is through a preceptorship program that matches students with a rural family physician and sends them out for a series of four three-day visits to follow the doctor throughout the day. The idea is “to expose students to family docs who are happy doing what they’re doing, have good colleagues, are getting paid well, and live in a wonderful community,” says James Boulger, Ph.D., who directs the preceptorship program. “That’s the kind of thing that really acts to reinforce students’ interest in family medicine.”
The effort has paid off. More than half of practicing physicians who started medical school at Duluth are now in family medicine, compared with 11 percent nationally; nearly 65% practice in Minnesota; and more than half practice in communities with populations under 30,000.
Blueprint for Family Medicine
Recognizing the need for dialogue about where family medicine stands today and where it’s headed next, seven family medicine organizations, including the American Academy of Family Physicians, launched an initiative in 2002 called the Future of Family Medicine. Its goal was “to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment.”
The organizations commissioned independent research firms to conduct a national study, and used interviews and focus groups to solicit the views of family physicians as well as patients, payers, residents, students, and other clinicians.
The result was the Future of Family Medicine report, published in 2004, which was billed as “a compass and a call to action” for those concerned about the specialty.
The report attempts to guide family physicians toward a new model of care that better meets patients’ needs but also retains the discipline’s core mission of “continuing, comprehensive, compassionate, and personal care provided in the context of family and community.”
The new model of care outlined in the report includes several elements: a patient-centered team approach; improved access to care; advanced information systems, including an electronic health record; redesigned, more functional offices; a focus on quality and outcomes; and enhanced practice finance, which includes securing more equitable reimbursement as well as increasing practice efficiency to boost margins. The report notes that a number of family physicians are already putting components of this model to work. “However, few, if any, have designed practices that integrate all of these elements.”
Reimbursement is a main issue in implementing the model. Within the current fee-for-service system, the model would increase compensation 26 percent for prototypical family physicians who maintain their current number of work hours, according to the results of a financial modeling exercise that was used as part of the project.
Additional changes in reimbursement—such as paying for e-visits and chronic disease management—would boost compensation further while also improving care and reducing overall health care costs.
The report also contains a warning: “Unless there are changes within the broader health care system and within the specialty, the position of family medicine in the United States may be untenable in a 10- to 20-year time frame.” —A.S.L.
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Confronting the “Big Elephant”
But many family physicians say they’re convinced that lower net incomes in family medicine are translating directly to lower interest among medical students, particularly those carrying large debt loads when they leave medical school. Nationally, the median debt for graduates of public medical schools hit $115,000 in 2005—$15,000 higher than in 2003 and more than five times the median in 1984, according to the Association of American Medical Colleges.
The connection between income and specialty choice is the “big elephant” in the room, Westra says. She says income disparity is undoubtedly one of the factors that causes some medical students who start out with a passion for family medicine to end up choosing another specialty. “We know that it happens.”
Baird agrees. “Even though the surveys actually refute the idea that debt is influencing decisions, that doesn’t match reality in anyone’s common sense,” he says.
But income disparities among specialties aren’t only a consideration for medical students, they’re also a major concern among practicing family physicians, who say the current reimbursement model fails to pay them appropriately for providing high-quality, comprehensive health care, particularly for patients with chronic conditions. According to Medical Economics’ annual income survey, median compensation for family physicians, internists, and pediatricians was about $150,000 in 2004, whereas the median was $215,000 for ob/gyns and about $300,000 for urologists and noninvasive cardiologists.
The reason for the gap is that the health care reimbursement system generally rewards fragmentation, high-tech wizardry, and procedure-oriented medicine, say family physicians, which runs counter to family medicine’s mission of providing holistic, patient-centered care that emphasizes communication and consultation between patients and providers.
“It’s not uncommon to have a patient with 20 different problems and 12 different medications; but we don’t get paid for being their medical home and coordinating their care,” says Dawn Blomgren, M.D., medical director of Northwest Family Physicians in Crystal. “We might have to look at everybody’s notes and coordinate, but unless we have a specific diagnosis that someone else is not getting paid for, we could spend 30 to 45 minutes and not get reimbursed. Yet someone can sit and do cataract surgery over and over again and get paid three times what we do.”
Income stagnation and lack of reimbursement for managing patients’ care has fed into a broader sense of frustration among some family physicians, says George Schoephoerster, M.D., who practices at CentraCare Health System in St. Cloud and is president of the Minnesota Academy of Family Physicians. “I think many of us feel burnt out, not appreciated, and not well paid for all that we do relative to other physicians,” he says.
Schoephoerster, who has practiced in St. Cloud since 1982, says he has seen family medicine grow more complex over the years as family physicians acquired more knowledge about caring for patients, particularly those with chronic conditions. But family physicians are also under pressure to do more—to not only be the patients’ “medical home” and manage their care but to practice high-quality, evidence-based medicine at a lower cost, communicate well with the patient, and also try to have a life outside the office. “We’re getting more and more stress from lots of different places,” he says.
Most family docs went into medicine because they wanted to help people, he explains. But the managed care model has corroded their ability to maintain strong relationships with patients—relationships that are at the heart of family medicine. In the mid 1990s, he and others had high hopes that managed care would make them the “gatekeeper” for patients, which would improve care and give family physicians more control and higher incomes. “But it didn’t help at all,” he says. Instead, it gave them less control, didn’t improve income, and got in the way of the doctor-patient relationship. “There were times when I would sit for 45 minutes on the telephone waiting to talk to some nurse in New Jersey to get approval to do some tests on a patient,” he says. As managed care has loosened up, he no longer has to do that. “But I think that’s where some of the bitterness has come.”
Creating a New Look
Despite the difficulties facing family medicine—fewer residents, inadequate reimbursement, the strictures of insurance companies—family physicians say they remain passionate about what they do. “It’s not as glitzy as some specialties,” says Clinton-McCausland. “But I believe deeply in my heart and soul that what I do as a family physician is critical to the health care of our country.”
At the same time, family physicians say they recognize the need for change and would welcome it—both within family medicine as well as within the overall health care system. The “new model of care” outlined in the Future of Family Medicine report (see “Blueprint for Family Medicine,” p. 31) appears to have broad support among family physicians in Minnesota.
Moreover, family physicians are already changing their practices, where possible, both in response to the changing health care environment and in an effort to better meet patients’ needs as well as their own.
One way they’re doing that is with information technology, which family physicians view as an essential tool for managing patient care. Electronic medical records are increasingly common, although by no means universal. Many family practices in Minnesota are still in the process of implementing EMR systems and some have yet to begin.
Camden Physicians in Maple Grove plans to adopt an EMR in 2006-2007, says medical director and family physician Richard Gebhart, M.D. Implementing an EMR is time-consuming and expensive, particularly for smaller practices, he says, but he hopes it will lead to more efficiency and improved quality of care. Camden Physicians also is participating in several pay-for-performance projects, where health plans reward providers for achieving certain patient outcomes. But without an EMR, the paperwork is extremely time-consuming for staff, he says. “So we may have earned $100,000 [from pay-for-performance], but we may have spent $100,000 trying to get this data. And we have to think that an EMR would simplify that.”
Other practices are using additional IT tools, such as online health questionnaires that patients can fill out prior to their office visit, and are giving patients the opportunity to communicate with physicians via e-mail.
Physicians at Family Medicine of Winona have been exchanging e-mail messages with patients since 2002. “I get a lot of e-mails from patients who are going to come in for their annual exam and they want to get their lab done and they’re requesting that I order that for them,” says William Davis, M.D., who has been practicing in Winona since 1976. He gets about four or five messages a week and thinks that will increase over time. Many of the e-mails come from “snowbirds” who go away for the winter and discover they’ve run out of medication and need refills, he says. E-mail also allows him to stay in touch with patients who have moved away from Winona but come back periodically for care. “Also, I have one family where the children live in Alaska, so we exchange e-mails about what is going on with the parents. If they have concerns, they can e-mail me, and I can report back to them.”
Davis says having patients fill out the online health questionnaires before their visit gives him more time to talk with them about their physical, emotional, and social needs. He has found information technology to be a positive in his practice. However, some family physicians fear that computers put a “box” between the patient and physician and may interfere with doctor-patient communication.
Other changes affecting family medicine also produce mixed feelings. On one hand, family physicians generally have more control over their work hours than they used to, now that solo practices are rare and most group practices allow doctors to rotate the responsibility of taking call. But some physicians worry about whether this sets up too many barriers between themselves and their patients.
There is also some concern about the growing number of family physicians who are no longer doing obstetrics or hospital visits as part of their scope of practice. The trend is more evident in urban communities than rural, and is mainly a response to those functions being taken over by specialists. But some physicians say it has shaken family medicine’s sense of identity. “If you cut out those two things—ob and hospital visits—you get a whole different spin on what family medicine is,” Westra says.
Family physicians say their challenge is to continue remodeling the elements of their practice that need updating yet still retain their core mission and values.
Despite the tremors within family medicine and the larger shifts in the bedrock of the health care environment, some things still remain solid, such as family physicians’ commitment to patients and their optimism about the future. Rob Wagner, who will lose his faculty position when the HealthPartners residency closes in June, nevertheless sounds energized when he considers his options. His dream, he says, is to start his own clinic—“from very humble beginnings”—with an electronic medical record and an outstanding staff. “I just think it’s possible to do it right,” he says. “I don’t want to make a killing. I just want to do it really well.” MM
Amy Snow Landa is a freelance writer in St. Paul.