Medical Schools Blamed for Primary Care Shortage

OHSU acknowledges that it could do more to prioritize family and rural health
The Lund Report

This is the second story in a Lund Report series on the shortage of primary care in Oregon. For Part 1 click here.

November 19, 2009 -- Dr. Lisa Dodson doesn’t have time to criticize how medical schools prioritize primary care. The associate professor at Oregon Health & Sciences University’s department of family medicine was honored as the Oregon Family Doctor of the Year at the May 2009 annual meeting of the Oregon Academy of Family Physicians.
 
The distinction recognized her commitment in encouraging students to pursue primary care practice. But between teaching at OHSU and practicing in small towns across the state like John Day and Elgin, Dodson is finding moments to air her grievances.
 
“I don’t think people here at OHSU are focusing on primary care as much as they could,” she told The Lund Report. “We talk about it a lot as if it were quote ‘primary,’ but we don’t always act on that principle.”
 
OHSU School of Medicine Dean Dr. Mark Richardson agrees that the university could improve its commitment. “OHSU can always do more to focus on primary care physicians,” said Richardson, who sees the main barrier to better primary care training coming from low federal funding. He hopes that the national health care debate will result in more allocation.
 
Dodson counters that university deans are biased against broad-based learning, and no amount of funding would change medical education’s basic thrust toward specialties.
 
“The money is part of it, but there are ways to get the money for primary care if the attitude is right,” Dodson said. “In the current mindset, we’re left with dwindling resources and a bunch of competing interests.”

Residencies Make the Difference

 
Dr. Fred Matthies, professor emeritus of UCLA’s medical school, wishes all students still interned in various fields of primary care such as the typical program from which he graduated at the University of Chicago in 1953.
 
“Some people said, ‘What’s the point of going to a research university if you’re just going to be a country doctor,’” Matthies said. “I’m afraid they just don’t get it.” He points to OHSU as a school that graduates less than half to primary-care residencies.
 
The school’s public relations department boasts that 43 percent of graduates pursue primary care residencies, compared with about 30 percent nationally. “Our numbers are better than the national average, but not as good as schools that make it their mission,” Dodson said.
 
“Their official attitude is that they encourage, but Oregon could be a true pioneer in closing off some of those specialty slots,” Matthies said.
 
Dodson would love to see a directive pass in the Oregon Legislature mandating OHSU to produce a certain number of primary care physicians per year. “The key thing is to select the right students,” she said.
 
Richardson doesn’t think that a state like Pennsylvania, which has identified Health Professional Shortage Areas that give benefits to schools and physicians to practice certain types of medicine, is on the right track. “It’s my belief that focusing on the number of physicians [to meet a quota] is a mistake.”
 
In response to Dodson’s claim about specialty mindset, Richardson says that the public will have to get used to primary care by nurses or medical assistants as being of equal quality in most cases. He’s looking to OHSU’s Department of Family Medicine for research into medical home models for the long-term. “As long as we are focused on that patient-physician transaction, we will fall short.”

Financial Debt

 
Baker City physician Chuck Hofmann’s first priority is to reduce the educational debt that can run into the hundreds of thousands for physicians going into primary care. He’d like to see Oregon prioritize its incentive programs for newly graduated primary care physicians’ debt relief. “There’s enough blame to go around,” said Hofmann, a member of the nine-member Oregon Health Policy Board who graduated from OHSU in ’78. “It’s not just a primary-care shortage, it’s a healthcare shortage.”
 
Medical schools like OHSU are a symptom of a larger problem, critics concede. They do not believe medical schools are actively causing the primary-care shortage, but still fault the education system for complacency. “The schools are really trying to survive in the sea change of the anti-tax movement, and even while I was at UCLA, the administration closed a family-practice wing,” Matthies said.
 
Rather than focusing on fixes for the short term, some advocates see an attitude in medical students that will take a long time to turn back around. “The nature of the workforces has changed, more than who the medical schools want to recruit,” Hofmann said. “You’re still looking at seven years before you get your first primary-care doctor even if you change the rules.”
 
Dodson believes that true believers in primary care would stop making excuses for themselves. “I think the deans and other so-called advocates all believe that there should be more funding for primary care and rural health, but they don’t always put their own money where their mouths are.”

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