Idea Lab: Primary Care Crisis
More than 66 million people live in regions of the United States that have a shortage of primary care physicians. Learn what Harvard Medical School is doing to help by watching this video or reading about the new Harvard Center for Primary Care and join the conversation below.
What do you wish for the future of primary care? What solutions do you recommend to tackle the primary care crisis in the United States?
Use the comment form below to submit your thoughts.
This morning we reviewed the recent SGIM Forum publishing the news of your new center and rejuvenated interest in developing primary care.
Though there may be many disagreements and misunderstandings about what primary care does, the evidence speaks for itself: properly implemented primary care systems are the key to improving population health, and moving the health statistic needle in the right direction. When citizens always know where to begin a journey/query, and do so with a coordinated, comprehensive system with continuity, they live better and longer.
The trouble in the United States has been that getting this established in an accessible way for all citizens has run aground time and again. When it looked as though managed care would do it, the gatekeeper model failed. In our fee for service model, with diminshing re-imbursement and increasingly specialized procedure oriented demand, we see dis-enfranchized primary care physicians who feel they have on means to influence the rusty noisy furiously spinning wheel of practice that is professionally unsatisfying, of low quality, and marginal efficiency. So yes, it is time we join together and find a better way.
Hats off to you and your leadership. We will watch carefully for opportunities to collaborate as we develop our programs here at Central Michigan University College of Medicine, founded with the stated purpose of graduating doctors who will practice in underserved areas, with burgeoning unmet needs that includes primary care.
For now, it would be nice to hear a voice other than two opposing parties discuss the Affordable Care Act in terms that resonate with patients and doctors. Perhaps that would be a good goal matching your timely entry into becoming champions of this important cause.
Sean Kesterson MD
Associate Dean Clinical Affairs
Central Michigan University College of Medicine
I hate to spoil the party, but primary care is NOT where it is at. There is way too much knowledge in medicine these days to have PCPs trying to manage complex cases. It is a disservice to patients! Primary care is boring: how many colds, UTIs and pap smears can one handle in a week; how much energy is spent refilling meds; finding the right fax number for the correct pharmacy; how much cajoling for a patient to get a colonoscopy can be done and should it be? It is way too much work for way too little money. One of the commenters said it best: many of the diseases people have are caused by lifestyle choices. PCPs have no control over those choices. It’s a lot of wasted effort.
Rachel, I think the growing challenge that people are right now rising to face is – how can primary care affect patients’ health behaviors and wellness? Ultimately lifestyle choices are up to the patient, but we cannot give up on trying to find the best ways to motivate people to make those choices. I just read an article in the New York Times about how people who get genetic tests are more likely to do things like sign up for a colonoscopy than make lifestyle changes ( http://www.nytimes.com/2011/01/18/science/18tier.html?scp=2&sq=genomewide%20direct-to-consumer&st=cse ). This isn’t something we should give up on – it’s an exciting frontier, and as far from boring as you can get!
well even thougn im only ninne iu think majority of the harvard med grads are going to be the ones chosen to go to the remote locations right now in my health class i just learned dilerma is also caused by tape worms. most doctors are cardioligist while im planniong to be a pedatric imunization ( yes i do have a huge vocabulary for a nine year ol din florida)
Develop a healthcare-themed professional, social network. Make it like Facebook but specifically for healthcare. Use a national comprehensive database, once it’s been digitalized, to create and inform a profile for doctors and patients, (whether for short term or long term purposes). Create a community and culture of care where conversations can start before arriving at the brick and mortor and continue meaninfully and conveniently after leaving. Give some additional consideration to the concept of a care facility as a dynamic and devoted set of relationships among people not just hallways and rooms. Make people, not places, the priority.
Hi, my name is Kaylyn Crawford,
I am in the 9th grade. I support the health care bill but, i think that there should be some major revisions. First off, national health reform is very difficult to achieve without fully understanding the unique situations of each citizen. I think the ideal national health bill would include set the guidelines for the federal health care sector (and/or a basic foundation of) and include unique plans for the people to choose from based on their personal preference/situation. This type of plan would allow for a general consensus of citizens and also not deplete the benefits that have already been received. If the health care bill is sent back to congress, republicans main goal should not be to put down the bill but to revise it so to be in the best interest of the people.
I really think the Primary Care is becoming necessary in the modern society. As the cities and towns flowing in our eyes everyday and communities gradually take part in the citzens especially the elderly for their acommodation. Primary Care will take the responsibility for first to save people’s lifes and for recovery after their treatment in hospitals. And GP, the actor in the Primary Care need to treat their patients well and make them feel like at home.
The primary care is a basic health action.Each of ous needs to search the information on protecting health from the daily life.
Armed with those knowledge,we can have a good health.I’d loving in searching the important medical information on Harvard Medical web.Yeah,it’s good for my health.
i live in nigeria and the health care is really bad here. i think it all boils down to corruption. money that is suppose to be spent on these health care are diverted to personal use.we also lack the proper staff training in PHC and the personals tht are there are not properly paided. the world estimated that by 2000, there will be health cae for all but this is 2011. i think the future of health care is in REAL crisis if there is noting done. thanks
Many of the concerns that have been raised by the physicians and other community leaders mirror the sentiments of patients-in order to have healthy patients, there needs to be a stronger relationship between primary care physicians and their patients. After being in education for nearly a decade and working with under-served communities, I am aware of the challenges that patients face in the access of health services. Equally, I am aware that serving as a health care provider, much like a teacher, is and could to lead to becoming a thankless job. However, there are thousands of patients who will benefit from the initial care of a physician. To solve this issue of barriers and access to primary care requires the following: strong advocacy for health policy for all Americans, creating satellite clinics that are strategically placed on school campuses, more of a “hands-on” approach to health care versus a sole concern about paperwork and costs. I remain optimistic that these issues will be solved-as long as there are medical schools that have individuals who are committed to serving the health care needs of our communities. My concerns along with other experiences with health care have ignited my desire to pursue medicine once more.
[...] More than 66 million people live in regions of the United States that have a shortage of primary care physicians. Learn what Harvard Medical School is doing to help by reading about the new Harvard Center for Primary Care or by watching this video. [...]
It is surprising that PHC is a problem in USA ,and a continuos political issue in all Elections . The EMS also is a problem but less discussed . I am looking from outside USA but very well oriented & used to your systems & frankly apply a lot of them throughout my work experience from 1984 till now with the latest updates of CPR . Looking back to my experience ,including 12 years in PHC & 5 years in ER , I think I can participate & give some clues for solid suggestions . First, building a competent PHC or Family physician should be based on three points : Scientific Knowledge , Ethical commitment & strong clinical skills and medical sense together. To acheive this goal & with the expanding knowledge, the internship/housemanship must include 6 mth in surgery,6 mth in paediatrics,6 mth in medicine,3 or 6 mth in OB/GYN . Departing from this station everybody will go to his preference . A Diploma in FM or PHC will be sufficient to send a doctor to GP or PHC settings with a good understanding of his/her role & duties & adequate ethical commitment.
Second, Understanding the levels of healthcare institutions,primary-secondary-tertiary, is important to enable doctors to refer the proper patient to the proper level at the proper time . This will improve the outcomes . Third, the feedbacks will,certainly, strengthens the selfconfidence of doctors & the overall systemic confidence . I hope this will B enough for the timebeing & thanks .
The Primary Care Advisory Group could not have said it better themselves, “underpaid and overworked.” Though a layperson would hope to think that their PCP became who they are for the love and passion they have to treat patients and not for money it would be reasonable to say that PCP’s are not compensated enough for their work. Medical students throughout the United States are not oblivious to this shortcoming, so what incentive does this provide them to become PCP’s after numerous years of hard work in school and debts up to their ears? Within the past few years there has been a rise in utilizing other health care professionals such as Nurse Practitioners and Physician Assistants in primary care offices, why not continue this trend? There are more and more undergraduate students in the U.S. looking to further their education specifically in the healthcare field, so embrace it! Create a degree that specializes in primary care at a physician assistant level but do not limit it to one school. Collaborate with other medical schools to make it one of the fastest growing degree programs in healthcare and at the same time make it affordable. Design a curriculum that emphasizes an education which will better assist PCP’s, enabling them to handle a larger volume of patients with less stress and time yet with care at the highest level possible. Allow other healthcare professionals with years of experience to have this opportunity as well with bridge programs. A wise woman (my mother) once told me to always try my hardest and be the best at what I do but never be afraid to ask for help. Primary care right now needs that help, not only for the overworked and underpaid physicians but for the wellness of our communities.
I totally agree with you. Why waste Medical Student’s time and $ to become PCPs? I can see PAs and NPs are doing great jobs in being the gate keepers of healthcare systems.PA degree is good enough for them to take care of their jobs..Why 4yrs of med sch and 3 years of residency?
I also agree, however, I think the value of a PCP’s superior knowledge base is understated in your response. I agree there is an overwhelming response to eager applicants to enter the health care field and particularly medicine as is obvious from admission data and competitiveness. However, I would propose to take your idea in utilizing physician assistants(PAs) and nurse practitioners(NPs) and take it one step further. Use these qualified PAs and NPs to run the clinic and utilize the more specialized knowledge of the MD-PCP to act as a pseudo-manger for the clinic. Clinics, in effect, would be run as a downsized hospitals where the MD-PCP would be available for consultation with patients when there are situations out of the scope of the PA or NPs. The larger number of patients being assessed and largely diagnosed by the PA and NPs would, in an economical sense, bring more money to the clinic via lager treatment numbers. The MD-PCP would collect a premium on each of his or her NP’s/PA’s producing treatments and diagnosis, which would ultimately decrease the MD-PCP net workload while increasing their net salary. Meanwhile this increases care access to the public without added Health Care expenses to the country or insurance brokers (or whoever is paying) and transfers more money to MD-PCPs which would assist in retaining talented MD-PCPs through better compensation. This model would also appeal to their intellect by only assessing patients that present as an “enigma” or more advanced cases to the PAs or NPs. In effect, this could eliminate a lot of backlog in primary care at least in more urbanized areas where the population could support this model. The “head” physician can even travel to a set amount of clinics within his jurisdiction providing the same hierarchy of care to a broader geographical space.
The primary care shortage must be addressed by providing people the information and tools they need to stay healthy. With less demand for primary care, we would have more than enough providers and money in the system to care for those who need care. The vast majority of illness and disease in the U.S. stems from poor lifestyle choices. If we can teach people how to take better care of themselves and make healthful food more affordable we would have a much smaller problem. Wellness needs to be affordable, accessible and engaging.
My Endlish is not good,sorry^but I want you understand.
When I see the project, I think maybe this is the true medical, and I also want to participate it.Now I am only a medical nursing college students.But in my idea the Primary Care is like this:
1. In China, nursing education is started the primary education at the beginning, but it is because the primary education, that in society have a view that on the nurse will exist a \discrimination\. Everyone feels and now all the nursing students (we are referred to as the \protect life\) because of bad grades was compelled to become nurses. This and you American national condition is different. I know that in America, the nurse is a respected, highly educated, rigorous, kind, clean profession; But in China, the nurse is a were looked down upon, low degree, dead-beating, informal and filthy business. Despite all the 21st century, now of medical school highly educated nurse also many, but people always mention the nurse is think of China nursing education still underdeveloped time, this also makes many intentionally engaged in nursing career students scared to choose this major. Today saw you in the online about the nursing of primary education plan, feel very gratified, hope you continue!
2 me is merely a student, no suggestion, but still hope to mention points. Also do not know whether accord with your country’s conditions.
Every year, summer and winter vacations schools will organize our in-depth community for mass physical census, such as measuring T, P, R, BP etc, for the elderly, still can measure blood glucose for them.
Another during school, we also have the stipulated time into clinical apprentice. Although hands-on few chances, but because we usually stay at school, came to the hospital is very excited, so hope to help patients do some things. Even if the teacher just call we sorting bed unit, lie bits of care, measuring fundamental temperature, visited the wards etc, also very active.
Sometimes we would organize to nearby company for the white-collar explain health knowledge. Like in the long-term face computer to the people who do the work, we will explain how to do exercise for them to prevent cervical spondylosis, etc.
3. For primary care crisis, I think to basically solve this problem, we should grab from children. Let them to this career, believes it can become fairly-tale their future career. I think this point in Chinese is difficult, wish you success. Come on!
Surveys show that many students who start medical school interested in primary care do not become PCPs. Early exposure to primary care careers and mentorship, along with meaningful longitudinal experiences can positively influence primary care career choice.
Crimson Care, the new student-faculty collaborative practice co-sponsored by Mass General Hospital, the Stoeckle Center for Primary Care and Harvard Medical School, is a wonderful example of how we can harness student excitement about primary care while improving patient access. Students helped design the practice with close faculty supervision and are involved in all aspects of clinic functioning including administration, quality improvement, laboratory services, comprehensive social services along with clinical responsibilities. The clinical practice is supported through a combination of work RVUs generated from insured patients, from teaching funds allocated by HMS and grant funding.
Student interest in Crimson Care has been overwhelming. What started as a discussion over coffee with one student 12 months ago, grew to 40 students within 2 weeks and now involves 92 participants! Expanding opportunities for students to get involved with student-faculty collaborative practices where they can get hands on experience with primary care delivery and innovation could help increase the pipeline of future primary care doctors while helping to improve patient access issues in the meantime.
As we have co-designed and launched this new practice, I have been impressed with the dedication and enthusiasm of the many students involved. Through the patient relationships they build and the mentorship they gain both from the Crimson Care faculty and from each other, momentum has taken hold. Many of our senior students are applying in primary care fields this year and I suspect this will only grow with time.
The students and I hope that Harvard Medical School will continue to support Crimson Care and help us expand to accomodate all of the students who would like to be involved (128 students applied this year alone!). Eventually Harvard could boast several student-faculty collaborative practices. In the future, as healthcare reform sweeps the nation, Harvard can lead other medical schools to increase patient access for insured and uninsured patients alike while helping to increase interest in primary care careers.
In 2007, the American Journal of Medicine published an article titled “Predicting, preparing for, and creating the future: what will happen to internal medicine?” In response, I wrote the following letter to the editor: I have been a practicing internist for almost 30 years and can see that the practice of medicine has changed substantially. We, as doctors, have not kept up with these changes in both training and the delivery of medicine. These changes have been brought about chiefly by economic, malpractice, insurance, politics, and quality-of-care issues. For good or bad, the practice of medicine has been realigned, very similar to the practice of medicine in Britain. I propose that, rather than a complete revamping of our old training programs, we change the new training programs thusly—replace family medicine programs with a program specifically geared toward training a physician who cares for ambulatory adults. This track would be called ambulatorists. I would propose that the internal medicine track be replaced and be, specifically, training grounds for hospitalists, intensivists, and specialists. This means that ambulatorists would care for outpatients and never go to the hospital. Hospitalists, intensivists, and most sub-specialists would be hospital based. I would suggest then, that students align themselves into either ambulatorists or hospitalists/intensivists/specialists. This means that they would probably spend 2–3 years in family medicine programs that would now be called ambulatory programs geared specifically for ambulatory medicine. Most family medicine programs now are undersubscribed for various reasons. I would suggest that we eliminate from the family medicine programs general surgery, orthopedics, and obstetrics/gynecology because most family doctors, unless they are practicing in a very rural setting, for malpractice reasons do not practice any of these specialties in their daily care patients. If a physician became an ambulatorist in a primary care setting that was very rural, he or she could take electives in these areas.
I realize that this is a substantial change in the training of future physicians, but I think it is better aligned with what we actually do. I also think that quality of care would not be impacted and perhaps be improved, and it would satisfy the various insurances and economic gatekeepers who watch what we do daily.
The numbers of students going into primary care medicine has been dwindling of late and will continue to do so. Perhaps dividing this into ambulatory and hospital care may attract more students, and, by shortening their training, they may be able to recoup faster some of the monies that they have spent on their medical education. I would be very interested in your thoughts concerning this revision of medicine and care by primary care physicians as well as hospitalists, intensivists, and specialists.
I am delighted that once again, a great deal of discussion has developed around primary care medicine. I have been a practicing family physician for nearly thirty years, and I also have some thoughts on the subject. I agree that future primary care physicians will be in short supply because primary care medicine is a grueling, frustrating and poorly reimbursed profession.
I have a different idea about rearranging the education and training of physicians and the delivery of care.
I would advocate that physicians be divided into pimary care and specialty training. Primary care would include initial and ongoing care of men, women and children. Specialty care would address complex problems which require much more highly specialized attention provided by physicians trained in the specific area of the problem for the same patients. I am very confident that I am sufficiently educated and trained to provide preventative care and treatment for adults, male and female as well as children, and have done so for years. I do not think that primary care physicians should be trained by primary care physicians, and I think it would be devastating to the quality of primary care if primary care physicians did not receive training in obstetrics/gynecology, general surgery, orthopedics, along with most of the other areas of medicine. I am thankful for the breadth of training I received every day I practice medicine, because it has provided me with sufficient background to know what to look for, how to research a problem, and when and to whom to refer patients. It also has provided me with the knowledge to participate in the patient’s care with the specialist and to have an idea about the quality of care that the specialist provides. There is also inpatient primary care. I practiced that competently for years as well. The economics of the situation and technology separated inpatient and outpatient care. The economics of the situation and advances in technology have resulted in more problems being amenable to outpatient treatment. A much higher percentage of patients who need to be hospitalized have a specialized problem that requires specialty care. “Hospitalists” often function in the role previously played by physicians in training, as facilitators, by writing admission orders, following day to day labs, and interacting with the patient, family and other hospital staff, dictating admission and discharge summaries and thereby relieving a great deal of burden from specialists treating patients in the inpatient settings. (surgeons still use actual surgery residents).
Plenty of specialty care is provided in outpatient settings and more will be provided that way as technology advances.
That takes care of the training issue. The prospects for primary care won’t improve until facility administrators and our subspecialty brethren develop a willingness to share. The healthcare budget is finite. Presently, insurance companies, responding to institutions large enough to control enough business, pay disproportionate reimbursements to facilities and the subspecialists who move the patients through. If two primary care physicians get together and decide not to accept an insurance contract because of inadequate reimbursement and overwhelming administrative hassle, they are breaking the law. When big outfits like the companies named after colors control 50% of a primary care physicians patients, that physician dare not protest poor treatment.
I would like the idea lab to come up with some proposals for equitable distribution of the healthcare budget. If “prestigous” institutions like Harvard would acknowledge primary care physicians as real doctors, even colleagues rather than “ambulatorists” who have no need of training other than a scaled down internal medicine program or glorified extender training program, it would be a start.
Dividing primary care into ambulatorists & hospitalists and medicine/orthopedics/gynecology/surgery-ologists only serves to increase fragmentation and severing continuity of care, not enhance it.
I am a sports medicine family doctor and serve as faculty for family medicine residents in the community down in Texas. I do ambulatory medicine, but also continue to do inpatient adult, neonatal, and pediatric medicine and provide support for obstetrics, in care and in education. I draw upon my training in orthopedics, obstetrics, gynecology, general surgery, and hospital medicine on a daily basis. I feel more capable as a physician having trained in all these various fields and disagree that pushing family doctors out of the emergency room, the labor-delivery room, the operating room, or the hospital for that matter will improve integrated care. Primary care isn’t about the building or the room you’re standing in while you are taking care of the patient. It’s about the needs of the patient first and foremost and whether or not the physician is capable of managing the case in front of them. So, dividing into an inpatient world and outpatient world would only further the gap between the two. What we need to do is elevate the capabilities of the physician, not replace them.
I describe primary care, particularly family medicine, as an applied liberal art. You train broadly, breaking down the body into its most finite elements (age, gender, organ, illness), and then put it all back together with an individual patient in context in front of you. Primary care requires interdisciplinary knowledge and experience: the “big picture” so you can “connect the dots”. I disagree with the previous posts that we should relegate this role to providers less trained than we are, like PA’s and NP’s. Primary care is too complex for that.
The problem in primary care isn’t the building or the room we are practicing in or the simplicity or complexity of the patient. Primary care is variable because the experience, knowledge, and training of the primary care physician is variable. What we need is to improve the education… more support (in funding, in teaching, in mentoring, in reimbursing) in primary care training so that we can give medical students and residents a rich training experience. If we as educators deliver a better product, more students and residents will follow suit.
As Dr. Berman stated, medical students already want to do primary care… they simply get detoured during their training. My hope is that the Harvard Center for Primary Care will take the lead in primary care as it has in much of Harvard’s endeavors.