The U.S. spends $13 billion a year subsidizing graduate medical education. Yet almost all of this money winds up producing the wrong kinds of doctors in the wrong places, with America’s most elite teaching hospitals being the worst offenders.
Thomas-Hemak grew up in a small town outside of Scranton. Inspired by the example of her family’s physician (an old-fashioned doctor named Thomas Fadden Clauss who still made house calls in the snow), she made her way through medical school and then on to Harvard’s combined medicine and pediatrics residency program at Massachusetts General Hospital. She was on her way to becoming chief resident at Mass General, she says, when she was drawn back to her roots, returning to Scranton in 2000 to join her aging mentor in his local practice.
She soon discovered, however, that being a modern-day primary care doctor, especially in a medically underserved area like Scranton, left her with little time to breathe. In short order she found herself responsible for 2,600 patients. “I felt I could never get a cold or take a sick day,” she says. “I felt so far away from Harvard.” She felt frustrated, too, that so many of Scranton’s aspiring young doctors would become discouraged by the lessons they took from seeing how she and her colleagues were struggling. “At the end of the day you take bright, idealistic, and Pollyannaish students and expose them to that, what do you think will happen?”
To work on these problems, she joined a preexisting sponsor of local residency programs known as the Wright Center. From that perch she began building not only a state-of-the-art primary care delivery system based on best practices (recently recognized by the Robert Wood Johnson Foundation for its innovation); she also along the way pioneered a new form of community-based residency training. This model is not controlled by any one teaching hospital; rather, it is a consortium of many providers working in cooperation with each other to meet the full spectrum of the area’s particular heath care workforce needs, with the Wright Center serving as the umbrella group. What this means from the perspective of residents is that they receive training in the full gamut of medical practice, coming to understand its interrelationships and need for integration.
So, for example, Wright Center residents I met with described how part of their training occurred at the nearby Wilkes-Barre VA Medical Center. There they are exposed to acute care medicine, such as the hospital’s brand-new, high-tech cardiac catheterization and electrophysiology suite, and also learn about the particular needs of veterans. This arrangement serves the VA as well, explains its chief of staff, Dr. Mirza Ali, since any residency program that the facility offered on its own would leave residents without any exposure to some critical medical services, like pediatrics, that the VA doesn’t provide.
But the training Wright Center residents receive also occurs in urban clinics, such as the Scranton Primary Health Care Center, and in remote rural clinics in places like Hallstead, Pennsylvania, population 1,303. There, pediatrics, family medicine, and geriatrics are the focus, and residents are exposed to such unique problems as the respiratory diseases that particularly afflict farmers and the rural scourge of prescription narcotic and methamphetamine abuse.
Meanwhile, the program operates as a nonprofit, and as such has to report publicly how it uses any money that flows through it. This brings a level of transparency not found in graduate medical education programs run by private hospitals, as does the fact that different health care providers in the consortium now know what the others are up to. Some funding for the program also comes from an obscure but promising provision of the Affordable Care Act that is specifically designed to build so-called teaching health centers, which are not based in, or controlled by, traditional teaching hospitals or academic medical centers.
So far, despite its hardly glamorous location and its emphasis on the most poorly compensated and least prestigious forms of medical practice, the Wright Center has had no problem attracting residents. This year, it accepted only one out of every ten applicants. It selects according to grades and test scores just like any other residency program, but also looks for evidence of community-mindedness and a willingness to work in teams. “Don’t come if you’re entitled,” says Thomas-Hemak. She says that when she interviews candidates, if they are not at least as nice to the receptionist as they are to her, she knows they will not fit in.
This same philosophy is found at other hot spots of innovation in graduate medical education. Five experimental residency programs sponsored by the VA, in affiliation with local medical schools in other parts of the country, are a good example.
The VA designed these programs specifically to train the workforce it requires to staff its own highly innovative primary care clinics, which are organized into what the VA calls “patient aligned care teams.” Each team consists of a physician, nurse, pharmacist, social worker, and health technician, all of whom work in concert to coordinate not only a veteran’s immediate care but also his or her long-term health and wellness needs.
This model of primary care was pioneered by the VA and is now being imitated in a few places outside the department, where it is most often known as a “medical home.” Yet the VA has found that it can’t just take doctors who have come through traditional residency programs and expect them to thrive in this setting, so it has set up what it calls Centers of Excellence in Primary Care Education, which are residency programs housed in its primary care clinics.
Patient-centered medical education: Pharmacy student Allison Kelleher, resident Arvind Vaudevan, and Wright Center director Linda Thomas Hemak discuss care options with a patient as part of the Wright Center’s new interprofessional model of graduate medical education.
At such clinics, you’ll see a scene unlike any in Scrubs. It’s known as the “huddle.” Instead of a gaggle of terrified residents scurrying after an imperious attending physician on rounds, you’ll see informal groups coming together to tend to the needs of an individual patient. Some in the group will be doctors in residence; others will be nurse practitioners in training. Also in the huddle will be seasoned physicians and nurses, and maybe a social worker. But you’ll have a hard time telling who’s who by the way they relate to one another. The person in charge is whoever has the most to offer in a particular situation. “The goal,” says the VA’s Malcolm Cox, “is to provide an environment in which young people are comfortable, where they learn about followership, not just leadership.”
As with the Wright Center, the VA’s Centers of Excellence in Primary Care Education have been hugely successful in attracting residents. This is true even though the centers are in less-than-prestigious locations. For example, the program in working-class West Haven, Connecticut, is housed in two trailers on the VA hospital’s grounds. Residents from Yale School of Medicine across the river feed into the program, and at least some have specifically picked Yale so they can have access to what goes on in these trailers. Yale’s Web site proudly features videos with residents’ testimonials, while also boasting of Yale’s affiliation with a program that “trains future health care professionals in a team-based, patient-centered care teaching model.”
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