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    How medical schools consistently cover up their primary care failures

    Andrew Morris-Singer

    The U.S. educational system is doing a woefully inadequate job of producing enough primary care physicians to satisfy future demand, but you'd never guess that if you read the media reports that come out around Match Day.

    It's called the "dean's lie," and Andrew Morris-Singer, MD, and his nonprofit advocacy group Primary Care Progress are out to expose this fallacy that gives Americans a false sense of security that the nation's primary care shortage is being addressed.

    Morris-Singer is a practicing general internist in a patient-centered medical home and former community organizer, as well as president and founder of Primary Care Progress, an organization founded by in Boston by medical students and residents that seeks to "revitalize the primary care workforce pipeline," he says. With 25 chapters across the country, Primary Care Progress provides leadership training to current and prospective physicians and other health providers, and is looking to change how primary care medical education is delivered.

    In the interview below, Morris-Singer sheds some light on the "dean's lie," explains why primary care physicians shouldn't view the expansion of nurse practitioners' scope of practice as an infringement on their turf and how today's physicians can connect with the next generation of primary care practitioners.

    Q: What is the dean’s lie, and how do you think it’ll help primary care if you expose it further?
    
A: Most folks are generally aware that American medical schools have been doing a rather poor job turning out a robust primary care workforce. That's no surprise. Primary care training programs and services have been underinvested in for years. But what might surprise folks is that American medical school deans consistently cover up their primary care failures, regularly overexaggerating the number of medical school students they report graduating into "primary care fields." The problem with this is that it ultimately leaves the lay public with a sense of reassurance that we're on track to fix the primary care physician shortage, when the truth is the exact opposite. If more Americans understand that your average medical school is only graduating one-quarter of their class into primary care (once you factor in the fact that only 20% and 34% of internal medicine and pediatrics residents, respectively, go into primary care) as opposed to the one-third or one-half that some Deans report, Americans will be more likely to call those deans out publicly. (Editor's note: Kevin Bernstein's excellent explanation of the dean's Lie and exhaustive list of media outlets that fall for it is a must-read for those interested in the state of medical education today.)

    Q: What is the responsibility of institutions of medical education in overall health reform?
    A: Clearly our academic medical institutions have a huge responsibility within health reform. Unfortunately, what we've seen from the vast majority has been disheartening. Just as we have a shortage of primary care services that is only projected to accelerate with implementation of the Affordable Care Act, the primary care output of most medical schools continues to be anemic.  Less than 25% of grads go into primary care. Additionally, despite the fact that hospitals engaged in residency education get about $500,000 of taxpayer dollars to train the average resident, they continue to steer this funding towards supporting new hospital-based specialty residency positions and away from primary care residency spots. We need to fix both of these challenges fast. Academic medical institutions must  pitch in to help create a reformed healthcare system like all of the other healthcare stakeholders. And we’ll know they’ve decided to step up once they begin to turn out the primary care workforce this country so desperately needs.

    Q: We hear a lot of reports that primary care doctors are among the most disillusioned types of physicians, yet you think primary care’s future is bright. Why?
    A: Values have changed. When I'm in meetings with policymakers and payers, and they're no longer talking about "generalists" or "specialists," but rather "comprehensive-ists" and "partial-ists," it's clear that the folks who pay for care are interested in buying something new. They're no longer interested in paying for episodic, fragmented, late "sick" care. Rather, they want their populations' health managed. They want robust, up-front, patient-centered primary care that keeps people healthy and out of hospital beds. That's a profound shift in values on the part of payers, that undoubtedly makes us primary care providers the ‘bees knees’ right now. 

    Q: There’s a lot of talk around the country of expanding nurse practitioners’ (NPs) scope of practice to include some primary care work, but physicians’ societies are usually opposed to it. Should they be opposed to it, in your opinion?
    A: I think it's fair to say that your average primary care physician feels like they are drowning under the mountains of work now necessary to provide comprehensive services for our rapidly aging and increasingly complex patient population. And a huge proportion of that work is not the best utilization of our specialized training, nor is it terribly fulfilling. By "sharing the care" with other members of the care team and apportioning responsibility for certain domains of care and subsets of patients to NPs, physician assistants and other "team-extenders,” we'll not only be able to more effectively practice at the top of our skill set, but we'll be able to get the job done for all of our patients. Supporting the expansion of NP's scope of practice shouldn't be seen as a threat to our "turf.” Rather, it's part of a larger effort to unshackle physicians from a delivery model that hasn't worked for providers, patients or payers.

    Q: What does Primary Care Progress offer to the practicing primary care doctor in the trenches?
    A: In addition to highlighting some of the most refreshing and exciting things occurring to improve how primary care is being delivered, Primary Care Progress also offers the practicing primary care doctor an opportunity to connect with the next generation. Today’s medical students and residents spend less than 1/3 of their time in the outpatient setting. The little bit of time they are in outpatient, it's frequently in dysfunctional academic clinics that almost seem like they were designed to destroy interest in primary care careers. Trainees need to hear from frontline physicians about challenges, as well as opportunities. And we're finding that trainees' enthusiasm is inspiring to these clinicians working in the trenches.

     

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