A physician who knows you and can coordinate your care 24/7 is key to a healthier life. What’s the prognosis they’ll be there to meet society’s challenge?
On his walk to his clinic one winter day, a car came squealing to Dr. Tim Rumsey’s side. Behind the wheel was a frantic husband, and riding shotgun was his wife, her hand wrapped in a tea towel, the tip of one finger sealed in a plastic sandwich bag. Quickly sizing up the situation, Rumsey packed a little more snow around the severed digit, and calmly urged them to continue on their way to the emergency room at United Hospital in St. Paul.
“They weren’t actually patients of mine,” says Rumsey. “But I guess they’d seen me around enough in the neighborhood to know I was a guy they could ask.”
In his years of walking to work through West Seventh Street, a hardworking neighborhood in the shadow of St. Paul’s old Schmidt Brewery, Rumsey has grown accustomed to such unscheduled requests for his opinion. He’s had patients leave their beers at the bar to lift their shirts on the sidewalk and show him the funny-shaped mole or the bruised rib. Others have offered him rides to his office at United Family Practice Health Center, opening their mouths on the way to say “aahhh” or asking his opinion on a lingering cough. The clinic he started three decades ago to reach the uninsured and underserved has merged and grown into a federally qualified health care center, chalking up 45,000 patient visits each year. The place is such a fixture in this corner of St. Paul that many people refer to the place simply as “Rumsey’s,” like the legendary steak house “Mancini’s,” the next parking lot over.
While he is not reimbursed for the time he spends talking to his patients outside of the office or even for the occasional house call he is still known to make to his oldest and most faithful clientele, he doesn’t list these moments as the downside of being a family doctor. In fact, he mentions them as the best part of his life’s work.
“It’s quite a beautiful thing to be taken into people’s lives like that, to hear their stories, and to feel that they trust you to know them,” says Rumsey. “It’s a great privilege to care for people like this. It’s still the best job there is.”
If Rumsey sounds like he’s trying to recruit more people into his line of work, that’s because he is. Across the country, the shortage of primary care doctors is so acute that now one in five Americans is considered “medically disenfranchised.” Even though a growing number of health advocacy groups are pushing the value of the so-called “medical home,” a shrinking number of physicians who can coordinate that care means that 56 million Americans are medically homeless—even though a majority of them have health insurance.
In Minnesota, 18 percent of adults don’t have a primary health care provider. That’s better than in Texas, where 60 percent of adults don’t have one, or in Massachusetts, which recently discovered it didn’t have enough family doctors to get a new universal health care plan fully implemented. Even so, Minnesota’s long-term prognosis isn’t great. Between 2000 and 2004, the supply of physicians going into specialties in Minnesota rose by 129 percent, while the number of primary care physicians—family medicine doctors, pediatricians, and internists—rose by only 20 percent. Nationwide, medical schools have seen a 50 percent drop in the number of graduates pursuing family medicine, and applications to family medicine residency programs have declined for several years running. Though the number of primary care residency slots has dropped in the Twin Cities, there still aren’t enough Minnesota graduates to fill them. Two-thirds of primary care residents in the Twin Cities now come from other states and countries, and they are far less likely to stay here to set up permanent practices.
The trend is so troubling that last spring the boards of Allina Hospitals and Clinics and the University of St. Thomas came together to consider the unusual possibility of creating a new medical school, with the goal of graduating forty new family medicine–focused medical students each year. The feasibility study suggested that the costs of building and staffing a third medical school in the state would be prohibitive (one estimate put the cost at around $40 million a year), and the boards of both institutions voted against proceeding. Even so, observers say that the tabled proposal doesn’t end the debate about how to save the family doctor—instead, it’s only the beginning.
Kathleen Macken, MD, works down the hall from Rumsey, where for the past seventeen years she has directed the United Family Medicine Residency Program, training recent medical school graduates from such local schools as the University of Minnesota, Iowa, University of Minnesota–Duluth, and Mayo and those from much farther away—Harvard, Dartmouth, Brown, Tufts, Tulane, and Notre Dame, among many others. Residents spend three years in this bustling urban clinic, treating 13,000 patients from places as divergent as Somalia and Summit Avenue with everything from strep throat to suicidal thoughts. Macken, who has earned national recognition as one of the top family medicine educators in the country, says the knowledge base needed to deal with such a broad spectrum of health needs over the course of a long life is one of the main attractions of family medicine.
“There is really a magic to it,” she says. “That opening of the human spirit that comes with attending the birth of a child, visiting a patient in the hospital, seeing someone with a depression stabilize, or live through a state of grief, or celebrate their children’s accomplishments. It’s very gratifying being involved in so many stories of life.”
So why aren’t more young doctors choosing to follow her into family medicine?
“Well,’’ she says, turning her attention to a pager that has gone off twice since she started talking. “It’s also like being on a hamster wheel.”
Though primary care physicians are now the most sought-after doctors in health care, regularly leading the “wish lists” of medical employers, the high demand hasn’t helped boost the supply. Some explanation for that may be found in an annual survey of primary care physicians conducted by the recruiting firm Merritt, Hawkins & Associates, which recently asked those doctors where they felt they stood in the medical hierarchy, compared to diagnostic and surgical specialists. Nearly 54 percent chose the answer “second class citizen.” Though 40 percent said they believe primary care will play a “vital” role in the future of health care, 14 percent said they believe primary care will “eventually disappear.” If given the chance to do it all over again, only 40 percent said they would go into primary care.
Perhaps, predictably, much of this job dissatisfaction centers on money. Nationwide, the average base salary for a physician in family medicine is $161,000, while the average base salary for specialties such as radiology, cardiology, and orthopedic surgery, can be two or three times that amount. Tallying up the long office hours, the hospital rounds, and a full spectrum of patient needs, the income physicians make on an hourly basis can be especially disheartening.
Blame for the problem is often attributed to a reimbursement structure that rewards higher rates for the sorts of procedures and tests performed by surgeons and other specialists in acute care and less for the cognitive and harder-to-quantify healing that takes place in primary care settings. While some medical historians suggest that the system was put in place in the advent of Medicaid in 1965, others say it started several centuries earlier, sometime around 1216 A.D. That was when Rome issued a papal edict banning priests from drawing blood—and leaving surgery to the barbers.
“Since then, we’ve always paid the barbers, and we’ve never paid the priests,” jokes Macaran Baird, MD, professor and head of the department of family medicine and community health at the University of Minnesota Medical School. “We have a long history of paying more for procedures than for [the less invasive] forms of health care—the healing, the listening, the laying on of hands.”
In real terms, says Rumsey, it translates this way: “Say you’re a GI [gastroenterologist], and you do a half-hour colonoscopy on a patient, and you get paid maybe $500 to $1,000. Here, we can do an hour-long visit with a schizophrenic patient who’s suicidal and you get about $185. I don’t have anything against GI docs, but that’s just how the system works.”
While senior physicians may be secure enough in their careers, or close enough to retirement, to be inured to such inequities, medical students with loans to pay off may not have such a luxury. Consider, for instance, that proposed cuts to Medicare will reduce payments to physicians by 10 percent starting this month and by as much as 40 percent over the next nine years. During that time, the American Medical Association predicts the costs of running a practice will increase by about 20 percent. [Note: At presstime, physician groups were lobbying Congress to turn back the proposed cuts.]
“The overall rate of reimbursement is going down and it’s just getting to a critical point now,” explains Peter Dehnel, chief of staff at Children’s Hospitals and Clinics of Minnesota and medical director of the Children’s Physician Network. “You have these young, energetic, highly skilled and smart people coming out of medical schools, but they’re reading the same headlines and asking, ‘Do I want to go into a situation where there’s not a good future?’ ” After all, half of the graduates of public medical institutions leave with over $119,000 in debt, while medical school students at the University of Minnesota, the second-most-expensive public medical school in the country, now face an average total loan bill of more than $140,000.
“So here you are, you’re twenty-four or twenty-five, you have all of that debt just for that education, plus living costs, plus whatever you owe on your undergraduate education. And now you’re saying, ‘What kind of doctor should I be?’ ” says Daniel Foley, vice president of medical affairs of United Hospital in St. Paul. Little wonder a recent survey of med school grads found that 32 percent say that debt level had influenced their choice of a specialty.
Another influence has been a shift in the culture of medicine. Many current family medicine physicians came of age in the 1960s and 1970s, when creating access to quality health care was part of the political movement of the times. “I went into medical school believing health care was a right, a human right, and that’s why I chose family medicine,” says Macken. Though she finds that many of her residents are moved by the same ideals, they may not owe their career choice to a compatible cultural movement.
“Another trend, I believe, is that we have a culture now that encourages increasingly focused intellectual pursuits,” says the U of M’s Baird. “Being a generalist [as family physicians have to be] is almost countercultural.” Against the high debt load and the high bar of simply getting into medical school, many may feel the pressure to get the highest yield from their investment.
“There’s an incredible amount of pressure to specialize,” agrees Lisa Holland, a third-year resident at United Family Practice Health Center, who grew up outside of St. Cloud and graduated from the U and medical school at Dartmouth. Almost the entire state of New Hampshire is designated as a partial shortage area for primary care physicians, but, she says, “when I would tell [professors and faculty members] that I planned to go into family medicine, the attitude was, ‘Why would you want to do that?’ ”
Regard for family medicine has always been higher in Minnesota, where primary care has been essential to the rise of the HMO and an emphasis at the U of M. In the thirty-five years between 1971 and 2006, the U has trained more than 1,150 family physicians, more than any primary care training program outside of the U.S. military’s. While an estimated 17 percent of U graduates go into family medicine—more than twice the current average of 8 percent of all medical school graduates—that percentage is about half of what it was as recently as a decade ago, when almost a third of all U of M med students went into family medicine.
“It’s still the most popular specialty,” says Baird. “But not nearly at the numbers we need to see.’’ The American Academy of Medical Colleges has recommended a 30 percent increase in first-year medical student enrollment by 2012, in part to meet the growing need in primary care. Though there are now 31.2 family physicians for every 100,000 Americans, the American Academy of Family Physicians says we need 41.6 doctors for every 100,000 patients.
But even if those goals were met and Minnesota trained more family physicians, there’s no guarantee they’d stay. “We’re not just competing [for good doctors] locally anymore,” says Foley. The medical marketplace is national now, even global. (Last year, twenty-eight of the seventy-eight first-year residents in family medicine programs in Minnesota were trained at foreign medical schools.) And while Minnesota still ranks among the best states in many indicators of quality health care, when it comes to recruiting and keeping family doctors there are other factors that may hurt more than the long winters. For instance, The Health Research Group of Public Citizen, a national nonprofit public interest group, recently ranked Minnesota in the top ten of all states when it comes to providing health care to Medicaid patients, giving the state high marks for the wide scope of services offered and generous eligibility provisions. But one criteria that hurt Minnesota’s standing was our nineteenth-place ranking for reimbursement, and the fact that we pay primary care Medicaid providers significantly less than what their Medicare counterparts receive. At the same time, Medicare reimbursements, which are based on a regional cost of living equation, pay substantially less in Minnesota than they do in other parts of the country. “If you’re a young doc, you can see that Medicare pays me half as much in Minnesota as it does in Florida and Texas and California,” says Foley. “You start looking at other things, other places.”
Factor in other capital costs—such as the current push for electronic medical records—and it’s easier to understand why formerly independent family practice groups have been merging lately with larger health care systems. For instance, in the northern suburbs, Columbia Park Medical Group merged this fall with Fairview Health Services, while Allina and Crossroads Medical Centers, in the southwest metro, were in discussions about a merger at presstime. Allina Hospitals and Clinics recently closed its merger with St. Paul–based Aspen Medical Group. In 2005, Aspen’s eight clinics reported revenues of nearly $81 million and expenses of $83 million.
Foley says these recent consolidations remind us that health care “is also a business, and unless you can run it efficiently and make the numbers work, you’re out of business.”
Given the dismal forecast, the question emerges—do we really need family docs? After all, you can get your blood pressure checked at Target, your strep throat cultured at Cub Foods, and all the symptoms and side effect warnings a hypochondriac could ever dream of on the Internet.
In spite of all these choices—or maybe because of them—a great majority of patients would prefer to seek initial care from a primary care physician rather than a specialist. A review of studies from Johns Hopkins University found that adults with primary care physicians had 33 percent lower costs for their care and were 19 percent less likely to die from their conditions than those who saw a specialist. An increased supply of primary care physicians in a population is also associated with lower rates of death, Medicare expenditures, and hospitalizations. Not only that, family physicians play a critical role in lifestyle changes that can prevent the onset of preventable conditions such as heart disease and type 2 diabetes. Considering that more than 300 baby boomers turn sixty every hour in this country, the potential savings of this kind of preventive care could really add up.
“I’ve had patients who said, ‘I stopped smoking because you told me to,’ or ‘I stopped driving because you said I shouldn’t,’ or ‘I started volunteering because you said it would be good for me,’ ” says Macken. “It’s a little overwhelming sometimes, the power you can have in your patients’ lives. But I can also tell you that going into the hospital room of someone who is in severe pain or frightened—if that patient knows you, you’ve just given them something that’s better than any pain medication. There’s a palpable relief in the room.’’
The health benefits of having a so-called “medical home,” a place where the physicians and medical staff actually know your name and your story, may explain why IBM employees in Denmark say they are so much happier with the health care they receive than their counterparts in the United States. Primary care there is given a higher priority and patients spend more time with their physicians during visits and can schedule appointments more easily. These findings prompted IBM, which spends $2 billion a year on health care for its more than 300,000 employees, to join the Patient-Centered Primary Care Collaborative, a collection of large companies and health care groups campaigning to shift our health system to the primary care model.
A similar push is gathering speed in Minnesota. During the last legislative session, an alliance of physician groups, health care providers, and policymakers introduced the “Healthy Minnesota” bill, a sweeping health care reform plan that included a call for universal coverage for all Minnesotans by 2011. Though the bill didn’t survive the session, one piece of the plan that still has legs is a proposal to create a medical home model for adults and children on medical assistance programs. This summer, the state will start with a handful of pilot projects to determine what happens when primary care physicians are established as a patient’s “first point of contact 24/7.”
While this notion may sound similar to the “gatekeeper” role family docs were expected to play for HMOs decades ago, George Schoephoerster, a family physician in St. Cloud and president-elect of the Minnesota Medical Association, says there’s an important difference. “The physician as gatekeeper worked for the insurance companies,” he says. “In the medical home, the personal physician works for the patient.’’ Instead of being a barrier patients must hurdle to reach a larger array of health care options, family physicians in medical homes could function as highly trained health care system experts who also understand a patient’s unique history.
“Why is it better to have a family doc taking care of Grandpa with his heart problem than a cardiologist?” asks Schoephoerster. “The reason is that it’s not just a heart failing, it’s a patient with a failing heart, which is a different kind of issue. What happens when the silos of medicine attack a patient? They take care of a specific [problem], and if that’s not done in the context of the patient’s history, it leads to things being done more than once, things that don’t make sense.”
Asking primary care doctors to coordinate this care may seem paradoxical, considering that there aren’t enough of them to go around, but many supporters of the medical home believe the model could actually rebalance that equation. A new emphasis on the importance of primary care could make family physicians feel less like they’re at the bottom of the medical hierarchy. And a different form of reimbursement—perhaps monthly payments for coordinating the care of patients over the long-term—could relieve some of the financial pressure family physicians feel now.
“Our goal is to improve the health of our patients,” says Jeff Schiff, MD, the state’s medical director of Minnesota Health Care Programs, who adds that raising the status and the job satisfaction of primary care physicians could be a welcome side effect of the medical home. Three years ago, the Minnesota Children with Special Health Needs Section at the Minnesota Department of Health received a federal grant that included organizing and facilitating a learning collaborative that now includes twenty-one primary care physician–led teams to develop and implement medical homes for children and youth with special health needs in their community-based clinics. “What we’re hearing from them is that this is a more satisfying way to practice medicine,” says Carolyn Allshouse, who coordinates the project for the health department’s community and family health division. “They’re able to provide the kind of care that they went into medicine for in the first place.”
“If we can get beyond the mode of churning patient visits and get involved in caring for patients over time that will be something that will attract skilled physicians,’’ says Schoephoerster. “You need the best and brightest, and that would be one way to do it.”
If the medical home model takes off, it will have the help of a strong foundation of programs in Minnesota already in place. The Rural Physicians Associate Program, a nine-month elective training program offered to third-year medical students at the U, has become an internationally recognized model for introducing med students to the world of family medicine. “That program has a huge positive influence,” says Baird, noting that since its inception in 1971, 80 percent of its 1,000-plus graduates have gone into primary care, the majority in Minnesota.
The University of Minnesota Medical School’s Duluth campus has also been effective at seeking out what Foley calls the “young Marcus Welby types”—students from small communities who have seen first-hand the important role family doctors play in delivering health care. More than half of UMD’s med school students go into rural primary care.
Residency programs, like the one at United Family Practice Health Center, may also play an important role in attracting family doctors to the Twin Cities and keeping them here. So do financial incentives such as the state’s loan forgiveness programs for primary care physicians who spend a few years in rural or underserved urban areas.
But saving the family doctor might also mean making family medicine a little more family-friendly. The New England Journal of Medicine recently estimated that it would take a family physician eighteen hours every day to provide all the chronic care treatment and recommended preventive care for an average population of patients, an overwhelming workload by any standard. “Doctors of my generation and previous generations worked sixty- and seventy-hour weeks, but the doctors of today see the toll that takes on families and they don’t want to be on call every moment,” says Foley. Already, physician recruiters are responding with job offers that include fewer weekend rotations, more flexible scheduling, and even two physicians working more reasonable hours, to take the place of one physician nearing burn-out.
“We talk a lot more than we used to about balance and having a real life outside of work,” says Rumsey. “You don’t want to be the doctor who is beloved by the community, but who never makes it home to see the soccer game or the school play.”
To model a more balanced life to the young doctors with whom he works, Rumsey tries hard not to come in on his days off—though he doesn’t always succeed. He fills notebooks (forty-five at last count) with stories his patients tell him about the history and great characters of West Seventh Street. He plays guitar with his band, The Rhythm Pups, at least once a week, singing Bob Dylan and Neil Young covers at the pub down the street. After eleven years, he’s also found time to complete his second novel, which he has titled Walking to Work. His first novel, Pictures from a Trip, centered on brothers who set out from St. Paul in search of dinosaur bones. Though it was received with some acclaim and a nod from The New York Times when it was published twenty-three years ago, Rumsey is careful to note that his new book is not a sequel about another vanished species.
“It’s about a family doctor,” he says. “And I don’t think we’re dinosaurs yet.”