July/ August 2013 First Teach No Harm

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.

By Phillip Longman

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.

wright center
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.”

Phillip Longman is a senior editor at the Washington Monthly and a lecturer at Johns Hopkins University, where he teaches health care policy. He is also a senior fellow at the New America Foundation, where Atul Gawande is a board member.


  • Brian Crownover MD on June 21, 2013 12:22 PM:

    Finally, someone is talking about REAL health care reform, not health care ACCESS reform which the ACA addressed. This review should be mandatory reading for every congressman and especially Pres Obama. For clear insight on the need to reform physician payment which directly impacts specialty choice, read about the RUC. http://well.blogs.nytimes.com/2011/09/22/how-one-small-group-sets-doctors-pay/?_r=0

  • Henrietta McClellan on June 21, 2013 1:18 PM:

    Great article. Am looking for a link to forward to some of my friends on my email list!

  • Denise Shungu on June 21, 2013 3:03 PM:

    Something you almost completely leave out of this thoughtful article is the student loans from the 4 years of medical school and sometimes of college as well. If you would cancel half of the loans for anyone going into Family medicine or whatever the Primary Care is called, you would have many more students who would take that specialty and residency programs would be forced to change because of increased demand.

    My own son who is doing his residency in Primary Care at Thomas Jefferson was able to able to do this because he received a full tuition scholarship to a medical school. His fiancee who had both college loans and medical school loans felt forced to choose a specialty.

  • Bohdan A Oryshkevich, MD, MPH on June 21, 2013 6:10 PM:

    This is a great article. It hits the problem right on the head.

    I would have put a bit more emphasis on the financing of medical education as part of the strategy of acclimatizing medical residents to choosing procedure oriented specialties.

    The Wright Center program is great, but such programs are not likely to produce the numbers of primary care physicians that we need.

    Second, in the process of promoting primary care, we should not demonize specialists. We need them also but perhaps in not such great numbers. They need to be part of the solution.

    Something has to give.

    Bohdan A Oryshkevich, MD, MPH
    New York City

  • Robert C. Bowman, M.D. on June 22, 2013 2:08 AM:

    Common sense indicates specific solutions for primary care and a need for departures from the last 30 years of stagnation. This collaboration has taken a step closer to a specific design.

    Specific preparation for primary care begins as an employee or volunteer in a site focused upon health access.

    Specific training for primary care involves medical school and residency at the health access site.

    Specific primary care result at the current time is seen in 90% of family physicians who resist departure from primary care over their careers - despite adverse policy.

    Hospital and subspecialty preparation and training plus training that is flexible in primary care career result plus national health policy designs fail most Americans in their basic health access needs.

  • Anonymous on June 24, 2013 3:26 PM:

    Why no mention of nurse practicioners are primary care providers?

  • American Association of Colleges of Osteopathic Medicine (AACOM) on June 27, 2013 1:11 PM:

    This article discusses several important concerns surrounding the primary care physician workforce shortage facing the nation. The American Association of Colleges of Osteopathic Medicine (AACOM) agrees with the writer, Mr. Phillip Longman, that the nationwide gap between primary care need and availability is a critical issue and that the need to develop solutions has never been more important. However, we feel that the ongoing efforts put forth by AACOM and its member colleges of osteopathic medicine to address the primary care physician shortage are essential to finding a solution to this crisis.

    In the U.S. today, more than 20 percent of medical students are training to become osteopathic physicians (DOs). While osteopathic medical students may pursue any medical specialty, more than 40 percent of these students enter into a primary care or family medicine residency.

    Currently, there are 29 colleges of osteopathic medicine in the U.S., offering instruction at 37 locations in 28 states, with many of these campuses situated in medically underserved areas highlighted in “First Teach No Harm.” According to data published in the April 2012 issue of Academic Medicine on physician supply in Appalachia, three of the nation’s colleges of osteopathic medicine fall within the top 10 U.S. medical schools supplying the most graduates to the primary care workforce in at-risk counties in Appalachia (as of 2009). These schools are the West Virginia School of Osteopathic Medicine (WVSOM), the University of Pikeville Kentucky College of Osteopathic Medicine (UP-KYCOM), and the Ohio University Heritage College of Osteopathic Medicine (OU-HCOM). Taking this data into account, along with the more than 40 percent of all DO graduates who accept primary care residencies, compounded with the rising total number of osteopathic medical school graduates each year, it is clear that osteopathic medical schools play a key role in increasing the number of medical students entering into primary care residencies, thus are integral in developing a stronger primary care workforce, particularly in medically underserved and at-risk regions.

    Through our advocacy efforts, AACOM strongly supports legislative initiatives that establish and implement innovative and cost-effective solutions to strengthen the nation’s primary care physician workforce. Recently, AACOM endorsed its support of the “Building a Health Care Workforce for the Future Act.” This legislation supports, among other priorities, the expansion of programs such as the National Health Service Corps (NHSC) Scholarship Program, which incentivizes primary care residency training in underserved areas. AACOM also strongly supports the continuation and sustainment of the Health Resources and Services Administration’s (HRSA) Teaching Health Center Graduate Medical Education (GME) Program, which increases opportunities for primary care GME, sets a strong precedent to fund GME outside of the traditional Centers for Medicare & Medicaid Services funding stream, and creates new avenues for training medical residents in community-based, non-hospital settings.

    AACOM and the osteopathic medical education community are dedicated to ensuring a well-trained physician workforce capable of meeting the current and impending health care needs of the nation. For more information, please contact Lindsey Jurd, AACOM editor and communications associate, at ljurd@aacom.org.

  • Mark Asplund on July 02, 2013 10:00 AM:

    Great article although it leaves out that it is actually medicare and medicaid that pay for medical students to become actual doctors..

    Not many people realize that is why they are expected to treat medicare and medicaid patient for less. They are essentially expected to "pay back" the cost of their 1/2 million in training.. Anyone who has a mortgage or a car loan that you pay back about 2x the cost

    So any doc's who opt out of medicare and medicaid are breaking their trust with US taxpayers and should be required to pay back in full (interest plus pentalty) or at the very least make this exchange of training for profession a legally binding document.

    We could easily shift the % paid to residents and give family practice docs 80k a year vs the typical 50k in residency and cut the $ to specality providers

  • jim jaffe on July 02, 2013 1:46 PM:

    while most of your subsidiary criticisms are on point, the basic one is flawed. America does NOT face a physician shortage. The ratio between physicians and patients has been improving for years. The ratio between primary care physicians and patients has been also, albeit more slowly. The explosion of walk-in doc-in-box operation gives patients easier access than ever before.

    The only thing a rising physician supply will give us is a larger national medical bill. As Wennberg and others have been documenting for years, enlarging the physician supply simply increases costs without improving health status.

    It makes more sense to let supply shrink and take up the slack with cheaper, but competent folks like nurse practitioners and physician assistants.

  • Atul Grover, Chief Public Policy Officer, Association of American Medical Colleges on July 02, 2013 3:27 PM:

    The AAMC is very disappointed that Mr. Longman did not contact the AAMC for information or comment when he was writing his article. We are writing to clarify a number of important points that his article fails to reflect.

    Read the rest of Dr. Grover's comment here.

  • Ashfaq Khan on July 04, 2013 1:44 PM:

    In this country a primary care physician cannot work without some assistance from a specialist. Mal practice environment potentates this to a greater extent. Non MD/DOs can fill the gap easily on a day to day general practice work. Modern day stethoscope is imaging (X ray,ultrasound and CT machines)making diagnostic decisions on the basis of clinical skills is not the standard of care in USA. We need a balance approach to address the issue.

  • Leena Varughese MD on July 07, 2013 12:11 AM:

    Well-written article from a concerned citizen regarding the state of graduate medical education that explores several areas of problems in graduate medical education. It's important to recognize that great harm comes from the lack of oversight in medical education system and it's a runaway gravy train for major hospitals, where 500k dollars is a conservative estimate of the funding and profitability and value of each medical resident. Clearly, many programs are using the system to enrich themselves, rather than teach residents in residency programs. The program directors do not prioritize teaching residents but utilizes the system to systematically misguide, not teach, and obfuscate appropriate diagnostic information from medical residents. I have certainly experienced this while I was at Mount Sinai Medical Center/ Mount Sinai Hospital in NYC doing Anatomic and Clinical Pathology residency program.

  • BSatiani on July 16, 2013 12:50 PM:

    There is no doubt that the impact of the shortage of all physicians is going to be felt even more with the entry of millions into the elective pool of patients. I also completely agree that throwing more money at the problem without much more accountability from teaching hospitals would be wrong.
    However, the article is simply myopic as Atul Grover implies and denies any impact of specialists shortages. We have documented the upcoming shortages in surgical specialties. Until we have disruptive models of surgical care, with the aging population there is no substitute for these specialists using NP's and PA's. His statement "inflate health care spending by engaging in massive amounts of unnecessary surgery and other forms of over-treatment" is offensive to most specialists who are honest and follow guidelines.I assume primary care physicians have some bad apples as well.
    The best solution for primary care shortages is to not only encourage our residents to enter the field but open up many more NP and PA schools. Much as the author won't like the solution, they are much cheaper to train and can provide the same care to a large percentage of the population. Hence, the entry of CVS/Walmart into the field employing NP's and PA's and now branching into chronic diseases. Why not?

  • Frustrated primary doc on July 16, 2013 6:38 PM:

    1) Documentation is stifling: in order to get paid for the time and effort I put into caring for a patient, I have to document a lot a boat load of information to prove the complexity of the visit I coded for. In addition to the documentation for each visit I get a mountain of forms via fax from insurance companies, drug companies and pharmacies to substantiate the Rx's I write or to tell me to consider a drug from another company, one that gives the insurance company a discount.

    2) Every one want's to abuse the system and it seems the Medicare is putting the burden of policing this on the primary care doc in the way of forms to fill out.

    3) Specialists dump on the primary care doc. A patient gets wrist surgery etc and needs needs his workman's comp form filled out, and the surgeon tells the patient "take it to your primary care doc". Dermatologist does surgery on a patient and if the patient has a problem after hours, on the weekend, has a recording that says, call your primary care doc. Patient's surgeon does surgery on a patient's back and tell him, "my work is done, call you primary care doc if you need pain pills".

    4) Copays are ever higher so patient's want to squeeze ever so much into every visit which goes on longer and longer. But the reimbursement is capped by the coding requirements.

    The time I spend with all this paper work is without reimbursement, yet my nurses want to be paid for the overtime they put in.

    I became a doc to care for people not to push paper or be a Medicare cop or Specialists' scut monkey. And if pushing paper & being a scut monkey paid, I continue but it doesn't.

    I introduced myself to a new radiologist at the hospital while going over X-rays and he asked what specialty I was in, I told him and he responds "oh my god the paper work" My feelings exactly. It is the real reason for the primary care doc shortage. The answer: just as in anesthesiology: one doc who sees a few patients but manages a large team of nurse practitioners and PA's.

    I can't wait to get out. I can't retire, but I'm going to work part time to at least enjoy my sanity.