One of my first primary care patients as an intern was Mr. S., a 65 year-old fast-talking, salesman-type. He had a deep tan and a strong golf game. On our first meeting, he asked about my favorite Scotch, and told me he drank three glasses of Talisker every evening with a cigar (in addition to a half-pack of cigarettes per day). I listened, energetically nodded my head (we were developing rapport, I thought), and glanced over at the reminders on my computer screen. He was due to have an abdominal aortic aneurysm (AAA) screening ultrasound. I explained the test, and told him I would be in touch with the results.
Negative for an AAA, the report showed an incidental finding of a heterogeneous appearing liver. When the results came back it was late in the evening and I did not know how, or whether, to act upon this finding. UpToDate (Waltham, MA) provided little guidance. So I placed a liver e-consult with my clinical question. Within a few days I received a note in my in-basket from a hepatologist recommending several lab tests to risk-stratify the patient and, if they were negative, to follow-up with a dedicated liver ultrasound in one year.I am fortunate. My primary care clinic is at the Veterans Administration (VA) Hospital in West Haven, where teaming and innovations in primary care are commonplace and allow me to better care for patients. I connect my complex patients with uncontrolled diabetes to the team pharmacist, who sits rights across the hall and has done a fantastic job of tweaking insulin regimens and meal plans to fit each individual’s routine. An Operation Iraqi Freedom veteran shared daily experiences suggesting depression and PTSD, so at the end of our medical visit I walked him across the hall to meet our team psychologist and link in to the mental health clinic. A patient with frequent heart failure exacerbations now logs his daily weights in our tele-health system, enabling me to see how well he is titrating his diuretic dosing as planned in our prior clinic visit. My work is all done under the guidance of a faculty preceptor who is smart, innovative, enjoys teaching, and most importantly, appears to enjoy his job. This type of environment ought to be commonplace in resident clinics. If it were, I suspect more residents would maintain or develop a passion for primary care.
As residents, we have learned that primary care is the foundation of a high functioning health system. But if trainees are to choose to specialize in primary care, we should have experiences that are educational and inspiring. However, many of my fellow residents at other academic centers are working in under-resourced and chaotic practices, and are being taught by tired and burnt-out primary care professionals. In organizations less progressive than the VA, payment policy or institutional priorities fails to provide sufficient dollars to build out the teams needed to adequately staff patient-centered medical homes. Tertiary academic medical centers, that most often prioritize tertiary specialized care, may devote fewer resources than most to primary care teaching practices.
Residents in these practices may routinely learn about primary care from practitioners who work without the support of multidisciplinary teams. Exposure to primary care practices, although well intentioned, may paradoxically lead trainees away from primary care and towards specialty training. As stated recently by the American Academy of Family Physicians (AAFP): “No matter how inspiring a curriculum, exposure to dissatisfied or disgruntled physicians negatively impacts primary care career choice.” It is not surprising that only 20% of internal medicine residents choose careers in primary care.
How might we transform resident practices as we are doing at the VA? First, residents need to work in teams, as we do in the rest of our training, and to do so, primary care practices need to be staffed appropriately. No one would consider running an operating room without necessary staff, but it seems primary care does so all the time. For a patient-centered medical home (PCMH), optimal staffing is close to 4.25 support staff to one full-time provider, compared to 2.68 currently. With this staffing level, PCMH transformation has improved staff satisfaction. For residency practices, an additional case manager may be needed due to the infrequency of resident clinics and the complexity of patients often cared for by residents.
Most importantly, the “teamlet” model advocated by Bodenheimer, where a primary link exists between the primary care provider and a medical assistant, may be a preferable model for teaching “homes” that train students or residents. In this model, the medical assistant staffs the provider at a 1:1 ratio, and is available during clinic sessions to address gaps in care, health behaviors, and, depending on training, other roles as well. The medical assistant knows how to navigate the system, and can perform tasks such as obtaining prior authorization for urgently needed procedures, or providing triage to other members of the care team. The VA model in West Haven incorporates this concept, providing a single point of contact for both patients and trainees to help navigate a complex system.
Transforming academic teaching practices to meet the needs of trainees is not simply a matter of adding staff. Previous work by a team at the Center for Excellence in Primary Care at UCSF has identified six principles for transforming academic residency training (see Table 1). Most are aligned with my primary care experience at the West Haven VA. Although creating long blocks to provide continuity improves resident satisfaction with their primary care experience and may lead more residents to choose primary care careers, my own program has short alternating primary care blocks. To create teams and operationally excellent clinics, added staff was essential to the VA transformation.
If the VA is able to accomplish these changes and staffing, it seems reasonable to expect that tertiary care training centers can do this too. For the sake of our trainees and their primary care experience, faculty who work in academic teaching practices that are under-resourced must advocate for the needed changes. While improving primary care experiences during training will not persuade every medical student and resident to enter the field, it will not deter them either, and that would be a good place to start.
Adam T. Phillips, MD, is an Internal Medicine Resident at Yale-New Haven Hospital.
Russell S. Phillips, MD, is Director of the Center for Primary Care and the William Applebaum Professor of Medicine and Professor of Global Health and Social Medicine at Harvard Medical School.