Audio posted, 1/20/15. Story broadcast on New England Public Radio 1/22/15. Text updated 2/3/15.
Remember the grandfatherly doctor who makes house calls and treated three generations of the same family, nursing them through everything from skinned knees to cancer?
For the most part, that Norman Rockwell ideal is long gone, and replaced with busy group practices that usher through patients in 15-minute increments. But even that model is struggling. There simply aren’t enough primary care doctors, period. So when the Affordable Care Act passed in 2010, the government included money to train and inspire a new generation of primary care doctors.
For the past year, New England Public Radio followed such efforts in western Massachusetts and elsewhere. We’ll meet a group of doctors-in-training as they weigh this major career decision, while trying out the profession first-hand.
Meet The Residents
The High Street Health Center sits upon a hill in one of Springfield’s poorest neighborhoods. Boarded-up apartment buildings line the narrow streets, groups of twos and threes hang out on corners.
And inside this community clinic, owned by Baystate Medical Center, the hallways and waiting room are filled with coughing or sniffling patients, many speaking Spanish, some on crutches, some without any obvious ailments.
Behind two more locked doors, in the staff backroom, one 29-year-old doctor – a second year resident – is having a particularly bad summer morning. Katie Jobbins is on the phone, waiting for emergency services to pick up.
“Hi, this is Dr. Jobbins calling from High Street Health Center,” she says. “I have a patient over here who is actively homicidal and suicidal, who I’m going to send to the ER.”
Jobbins has known this patient for a more than a year. The woman struggled with chronic psychiatric issues and was doing better for a while. Jobbins updates her nurse on this latest visit.
“This is the worst I’ve ever seen her,” she says. “She’s been a little off occasionally when she doesn’t take her meds right or things like that, but I’m afraid she’s going to hurt herself.”
Jobbins has never had to commit a patient to the hospital for a mental health crisis. She has to feel her way through the paperwork.
“If she’s homeless do I just write homeless?” she says out loud, going through the form. “Designated physician? I’m the designated physician. Do I do this part or does the hospital do this part?”
A few cubicles over, Dr. Donielle Sliwa, a 32-year-old resident, sits in front of her computer and logs into her medical chart, waiting for her patients to arrive.
There’s a 30 percent no-show rate here, so the clinic tends to overbook.
“If everyone comes it can be very busy, a little bit overwhelming, a little bit stressful,” she says. “But then sometimes you have days where half your panel doesn’t show up.”
On today’s schedule, Sliwa notices the name of a patient who was supposed to have an appointment the week before – but he’d shown up 30 minutes late, “and I had to make the decision to not see him, given the patient load that I had.”
The man hadn’t been to a doctor in three years, so she expected he’d have a long list of questions for her. And he’d shown up just before her first afternoon off in weeks.
“But it’s hard because a lot of our patients have barriers to getting here, whether it be transportation or child care or whatever,” Sliwa says. “And you feel guilty sometimes saying no. I don’t always say yes, and I don’t always say no.”
And on an evening shift one town over, Dr. Sara Tischer examines a 30-year old named Kevin.
“Deep breath,” she tells him, as he obliges, and then coughs. “Try again.”
Kevin is uninsured. He came to this free clinic in East Longmeadow, where Tischer volunteers as part of her residency, because his cough won’t go away.
“I went out for a basic walk and I just thought it was allergies,” Kevin tells her. “Then it got worse and worse to where I couldn’t breathe. Everything from chest up just felt like it was shutting down.”
“That sounds exactly like how I’ve been feeling,” Tischer replies with a laugh. “When did all of that start?”
Unlike many of Tischer’s cases, Kevin’s is pretty straightforward. She recommends Ibuprofen for inflammation, “but mostly rest and fluids, unfortunately. The things we all know about.”
“That we never can get?” he laughs.
“Exactly,” the doctor replies with a smile, as she walks out the door. “Alright, I’ll be back, Kevin.”
Baystate’s Push For Primary Care Through Specific Residency
These young doctors are in the middle of their residency at Baystate Medical Center, a hospital affiliated with Tufts University Medical School. They’ve completed four years of medical school – so they’re already MD’s – and are now in the hands-on part of their training.
Most residents at Baystate are in the internal medicine program – a broad term that covers specialties like cardiology or gastroenterology or dermatology. But Tischer, Sliwa and Jobbins are part of a specialized track – one that’s expressly designed to create more primary care doctors. Michael Rosenblum is a residency director.
“If you get people before medical school and even at the beginning of medical school, there’s a huge interest in primary care,” says Rosenblum. “The vast majority of medical students want to develop relationships and see patients over time. And then we see that kind of peter off.”
In part, he says, because of their training. In traditional residencies, students spend most of their time inside the hospital. But Baystate’s primary care track is steeped in the clinic experience. It was launched in 2011 with funding from the Affordable Care Act, which made shoring up primary care one of its central tenets. After all, as more people get insurance, they need first-line doctors to act as gatekeepers to the medical system.
“When we look at really highly functional systems, you need to have a really strong core of primary care doctors to be the base of this pyramid,” Rosenblum says. “We as in the country don’t have that, and I think we struggle with that.”
Workforce surveys consistently suggest that primary care is in trouble – too many doctors are leaving the field, and too few are in the pipeline to enter. Already, the government counts a shortfall of 8,000 primary care doctors. By 2020, the Association of American Medical Colleges estimates a shortage of 45,000.
“So really our goal from the get go has been to turn people on primary care, and to turn the ship in the other direction,” Rosenblum says. “Takes a long time to turn a ship, though.”
Last year, when I started following this group of new doctors, 12 were in various stages of Baystate’s primary care residency – compared to 54 in the general internal medicine program. This is not surprising. An NYU study found that the number of students choosing to train in primary care declined by 50 percent between 1999 and 2008. Most choose to go into specialties.
So who will be left on the medical frontlines for the next generation? And can new programs like Baystate’s fill out the ranks? The hope is that giving new doctors a taste of front-line medicine will whet their appetites for the primary care profession – and that the profession itself will become more appealing. But as these residents know, there are no guarantees.
‘I Was The One Who Was Always Talking Longer To Patients’
“What room is she in?”
A few minutes after Katie Jobbins sends her suicidal patient to the emergency room, a nurse tells her the next patient has arrived.
Since she has two other patients waiting already, Jobbins asks if another doctor can take the appointment, but then remembers that this patient “only wants to see me. That’s why she was booked with me. She only trusts me.”
Jobbins wants her patients to see her as their personal liaison with the health care system. It’s just today is a bit nuts.
“We’re taught how to deal with the basics,” she says, “but there are days where you’re going to be very frustrated and overwhelmed with something very complicated.”
She gathers herself and goes in to the exam room, coming out a few minutes later to talk to the nurse again.
“I think it’s pain today,” Jobbins says. “I mean, she’s crying in the room she’s in so much pain.”
And by now, there’s another patient waiting.
“Normally, I’m really on time,” Jobbins tells me. “Problem is, I saw my last patient second because I wanted to get her taken care of and bumped her up. But normally I’m not this far behind!”
Katie Jobbins has wanted to be a doctor since she was an athletic, accident-prone teenager in Hampden, Massachusetts. She had a close relationship with her own
pediatrician — a kind man, she recalls, who wore a toy koala bear on his stethoscope.
“I broke all of my fingers once when I was in middle school running onto the tennis court with a racquet in one hand and a bottle of water in the other,” Jobbins says. “He just looked at me and kind of shook his head and laughed and said, ‘Okay, what did you do now?’”
Her closest friends studied the humanities. Jobbins stuck with math and science. After four years of med school, she started training as a surgeon. She liked the idea of infiltrating a male-dominated field, as well as its straightforward approach to medicine.
“It made sense to me,” she says. “You had a problem, you fixed it, you take it out.”
But after two years of mostly gallbladder removal and blood vessel surgeries, Jobbins noticed something about herself. While the other surgeons tried to spend as much time as possible in the operating room, “I was the one who was always talking longer to patients, or I was having family meetings.”
Finally, it hit her – she wanted to be their point person, their care coordinator, their primary care doctor.
“I like establishing relationships with people and getting to know them outside of what their medical diagnoses are,” Jobbins says. “I like to be involved in the community where I’m from and I like to laugh a lot too, so I try to make my patient’s experience not something that’s a dreadful one when they come to the doctor.”
On a clinic shift in late summer, resident Sara Tischer does her best to put a five-year-old and his worried mother at ease.
“Can you believe all these people came to see your rash?” Tischer says playfully as she enters the exam room.
Tischer is among several doctors playing medical detective for an unexplained rash. The boy good-naturedly pulls down his pants to show a patch of raised, red bumps on his behind.
“He hasn’t had any other medications?” Tischer asks the mother, who says no.
After a few minutes, Tischer’s team decides this actually goes beyond primary care; they refer the family to a dermatologist. “You stumped us!” she tells the patient with a laugh.
At 38, Sara Tischer is older than most of her fellow residents. She grew up in Iowa, intrigued by the ocean, and thinking she’d become a marine biologist. She got work in research after college, but something was missing.
“I was often sitting in a lab by myself,” she says. “And I really wanted to keep the science because I’ve always loved science, but I wanted to do something that had more social aspects involved as well.”
She entered med school, where she considered going into neurology or psychiatry, but she always felt pulled towards primary care – thanks in large part, she says, to her role models.
“A lot of the physicians that I worked with, who are doing primary care, loved what they did,” she says. “And they were really passionate about it.
But there weren’t a lot of primary care residencies in 2011 – the government funding for them was just ramping up – so she applied for general residency at Baystate. So happens the directors were just getting their new program off the ground.
“In the middle of my interview they said, ‘Oh you’re interested in primary care. Hey, do we have a deal for you!’”
‘A Monkey Could Practice Primary Care’
Most doctors I’ve met going into primary care talk about their sense of social justice. They want to work for underserved communities. Or to fill a critical need. It’s rare to hear people list the superficial trappings of the job as a driving factor. And that’s not surprising, Tischer says, given what they hear about the field.
“In medical school, the biggest thing that comes up is money,” she says.
A 2014 survey by the Medical Group Management Association found the average salary for a primary care doctor is about $190,000. That may sound like a lot – but consider that some have debt near a quarter of a million dollars. Meanwhile, they see their colleagues in cardiology or hematology, after a couple more years of training, making at least twice that amount, sometimes up to $500,000 or $600,000.
“I try to remind myself, I didn’t go into this for the money to begin with,” Tischer says. “But I think there are other people that maybe could be swayed into doing primary care, but they’re swayed away from primary care because of the challenges for paying back your loans.”
The Affordable Care Act included new loan forgiveness programs for primary care doctors – and it expanded the National Health Service Corps, which subsidizes debt in exchange for working in underserved areas. But in the minds of many doctors, that doesn’t erase what feels like a gross inequity – one largely caused by a healthcare system that rewards procedures over conversations, and a pay scale that’s determined by a panel made up almost entirely of specialists.
“We see students choosing careers in radiology that’s traditionally been high paying,” says Russell Phillips, who heads Harvard University’s Center for Primary Care. “Or orthopedics, anesthesia and dermatology.”
Students actually talk about those specialties – whose letters start with R, O, A, and D — as the ‘Road to happiness.’
“Not necessarily because the work is more fascinating or more rewarding,” Phillips says. “But really because there’s a revenue opportunity.”
Dr. Eric Churchill – an instructor at Baystate – says he moved out of New York City because he felt he couldn’t live on his primary care salary in Manhattan.
“I remember going to a lecture in medical school about various specialties,” Churchill says, “and realizing at one point what the benefits of selling out would be.”
That’s when he heard about a dermatologist who cut down on her hours to have more flexibility, “but of course her salary really suffered. So as a part-time dermatologist, she was only making four times what I make as a primary care doctor.”
And he met an internist working overtime on hospital rounds, “but just because he doesn’t have a leaded flexible tube he can stick up someone’s backside, he makes a third of what GI doctors [gastroenterologists] make.”
But perhaps even more discouraging is what the money disparity says about the status and prestige of primary care.
“Here are these type A competitive people that have been at the top of their class like since kindergarten,” says Gina Luciano, who co-directs Baystate’s primary care residency. “They tried to get into the most prestigious colleges. It’s always very competitive, very competitive, very competitive.”
So when they get into residency, she says, they want to stay on the up escalator. “And you have all of these mentors that are telling you, ‘you could do cardiology, you could do critical care.’ It feels really good that here are these really prestigious things to go into in medicine. It’s hard, I think, to be swayed from that.”
Dr. Andrew Morris-Singer, who runs the advocacy group Primary Care Progress, calls this the “hidden curriculum” of medical education. And not always hidden very well.
“There’s also explicit statements like, ‘You’re too smart to be a primary care doctor.’ ‘This is a dead field.’ Or my favorite, ‘A monkey could practice primary care. Why would you do that?’” says Morris-Singer. “So it’s a whole range of things, but the basic admonition is: ‘Hey, it’s a waste of a medical education.’”
A Primary Care Dream, With A Twist
“So he came today concerned for STD’s…”
Donielle Sliwa is treating the patient who hasn’t seen a doctor in years. As expected, he showed up with a host of problems, not all of them medical.
“He was absent from the clinic for a year and a half because he was incarcerated for breaking and entering,” Sliwa tells her advisor, Luciano, in the clinic’s backroom. “But otherwise doesn’t use any tobacco, doesn’t drink alcohol, smokes marijuana occasionally.”
She and Luciano are trying to figure out what the man needs. Luciano suggests a battery of tests for sexually transmitted diseases.
“This is your chance to treat,” Luciano tells her. “You don’t know if this person is going to be able to come back.”
Later, Sliwa reflects on the variety of cases she treats. “I think the attractive thing about this environment is that the patients are really interesting,” she says. “And I’m really terrified of being bored. I like always being challenged.”
As a young child in Belchertown, Massachusetts, Sliwa was scared of her pediatrician, but gradually she grew intrigued by what he did. By the time she finished college – as an anthropology major – she knew she wanted to become a physician.
“I sort of imagined myself as this small town doctor where I took care of horses or something in my spare time, because my practice was right in my house, people came to me and I made house calls,” she says. “I know that’s an antiquated view, but that’s what I like.”
Working at the High Street clinic is not like that. Sliwa enjoys the relationships with patients, but says it can be hard to work with a highly stressed, low-income population.
“If they are engaged and involved, I think it can be very rewarding,” she says. “But sometimes when people access care intermittently, and perhaps aren’t always compliant with going to the lab or picking up their medications or taking them regularly, it can become very discouraging. You kind of wonder why you’re putting so much of your own energy into it.”
By this time, Sliwa was in her second year as a primary care resident. She’d recently spent a month working at a clinic in the Himalayas, which she said opened her eyes to the diversity in the human experience and in healthcare. She was especially impressed at how rural clinics were able to fashion together screenings for cervical cancer using a vinegar-like acid.
When she returned to Springfield, she came to a big decision. Primary care is not for her. She wants to go into oncology.
“When I am interacting with cancer patients, when I’m treating cancer patients, there’s just something inside of me that’s different than when I’m treating other types of patients,” says Sliwa. “It combines spirituality, it combines religion, science, long term partnerships.”
Sliwa’s colleagues in the primary care program say they were not entirely surprised by her decision. But that hasn’t stopped them from giving her a hard time.
“Anytime she says something that we think is very ‘primary care-ish’, we say – ‘Really? Are you really going to go into oncology?” says Sara Tischer with a laugh.
“We joked around and said, ‘We’re gonna put you a room and make you listen to what you’re saying until you realize you look more like a primary care,'” says another resident, Hector Guzman.
“They do tease me quite a bit, actually,” says Sliwa. “Sometimes they call me a traitor to the primary care program. I do get a little bit sensitive sometimes and then they sit me down and say, ‘You know that we are just kidding with you.’”
“In my mind, she’s still doing primary care – but with a more oncologic twist to it,” says Luciano. “So I don’t feel like I’ve lost her at all. I just feel like she’s doing something very creative with what we’ve given her over a couple of years.”
‘I Don’t See It As My Role To Hoodwink Them’ Into Primary Care
Medical practices have gotten creative filling the primary care gap, relying more on nurse-practitioners and physician assistants. But healthcare leaders say it’s still important to get the more highly trained doctors into the pipeline. The problem is, the typical structure of medical education seems to work against the primary care pitch.
“Hello, sorry to interrupt your breakfast…”
A group of residents walks through the hallways of Baystate Medical Center for their daily rounds, checking in on patients in their beds.
“She continues to have pain in her hips,” says one resident as they enter a patient’s room. “Her diabetes is still uncontrolled,” says another.
This is the way most internal medicine residents are trained – on the hospital wards, with specialists roaming in and out to challenge them on medical questions and pinpoint some of the more unusual cases.
“Also, there’s a small pocket of abscess,” says their instructor during one patient visit, “so we should talk to radiology.”
Residents say they become most confident on the inpatient wards, where they get to know specialists better than anyone else. That’s a problem if you’re trying to groom them for primary care, says Dr. Sudeep Aulakh, another Baystate residency director.
“We’re preparing them well and giving them the skills to do one thing,” says Aulakh, “and then thinking that they’re going to be comfortable doing something very different.”
Aulakh says Baystate’s new program is trying to upend this model, as are a number of new primary care tracks across the country, including one based at the Veterans Administration.
In 2011, the federal government gave five different VA health centers across the country a million dollars a year – for five years – to set up new primary care residencies.
“We have silos of education where the physicians do very little primary care in their residency,” says Dr. Joyce Wipf, who runs the new residency at the Puget Sound VA in Seattle, which is affiliated with the University of Washington. “So they were trying to set up a whole new program where our residents spend at least 30 percent of their total training in primary care.”
“A 59-year-old gentleman says he’s had hives on and off for past two months,” explains a resident as she meets with her supervisor, Dr. Mayan Bomsztyk.
“Do they itch?” replies Bomsztyk, as they brainstorm together.
Bomsztyk has only been out of residency for a year. She returned to the VA as an attending doctor after a maternity leave. Bomsztyk now helps train doctors in the VA’s primary care program, where her goal is to give them confidence in the routine of clinic work.
Bomsztyk says the VA is in some ways an ideal place to practice primary care. It’s a closed, managed-care system, so doctors are somewhat insulated from financial pressures. They’re allowed 30 minutes per patient visit, which is relatively long. And her bosses are willing to accommodate part-time schedules for new moms, including breaks for breastfeeding.
“They blocked two pumping times for me,” she says. “So my ten o’clock and my two o’clock patient appointments are blank, which is amazing.”
All this is proof, Bomsztyk says, that you can be a happy primary care doctor – a point that her colleague, Dr. Doug Berger, tries to make with his students as well. But unlike Bomsztyk and others, Berger does not see his job as recruiting them into primary care.
“Once someone is coming to this school and paying for their education at the University of Washington,” Berger says, “I don’t see it as my role to hoodwink them into some specialty that is not going to be satisfying for them in the end.”
And in fact, even in this new VA program, which is designed to win over primary care doctors, residents are still choosing sub-specialties. Some of them say it’s because of the time they spend in the clinic.
“I find it exhausting,” says resident David Levitt. “The interactions are constant and draining in primary care for me.”
Levitt intended to go into primary care when he started residency. But after three years, he’s changed his mind. He enjoys the teamwork more at the hospital than the outpatient clinic.
“It could be that in clinic I’m usually seeing patient back to back to back, writing notes back to back to back, have a lunch break if I’m caught up. And then I do it again in the afternoon,” Levitt says. “Whereas in the hospital there’s more of an ebb and flow to the work, where you do a bunch of work upfront and then maybe it lulls.”
So Levitt is planning to become a hospitalist – the person who oversees basic care in a hospital. His salary will be similar to a primary care doctor, but he will have set hours, and at the end of each shift, he’ll hand over patient responsibility to the next person.
Creating A Practice Where Doctors Want To Work
[Listen to Related Audio Feature, Raising The Stakes For Primary Care]
Levitt says he would consider going back to primary care if he found the kind of private practice that would make him happy, but that’s not what he saw in residency. Across the country, residents often work in urban, hospital-affiliated community clinics where health and social needs are complex, and offices often under-staffed. Since revenue often depends on the number of patients seen, there’s pressure to push them through in 15-minute increments.
“We realized we couldn’t change the student experience if we put them into dysfunctional clinics, led by dispirited faculty who are not enjoying the work that they are doing,” says Russell Phillips of Harvard’s Center for Primary Care.
The Center for Primary Care since was created in 2010 with a $30 million anonymous gift. That was following years of criticism that Harvard was ignoring primary care – a reputation Phillips is determined to reverse.
“So it wasn’t a question of just exposing them more to dysfunctional clinics,” he says. “It was really trying to help those clinics to improve and show capacity for innovation.”
The Harvard center sponsors an annual conference in Boston where med students and doctors present new ways to take care of people in a primary care practice. One model gaining traction is a team-based approach to primary care – also called the patient-centered medical home. It may not sound revolutionary, Phillips concedes, but for years primary care doctors worked in relative isolation – in charge of almost all administrative and medical tasks.
“Formerly, the patient would bring in a bag of medicines and I would spend half of my visit going through and checking which medicines they were on,” Phillips says. “Now we have other team members who can assist with those kinds of activities.”
The Center for Primary Care is now putting money behind team-based practices where Harvard students train, including Faulkner Hospital in Jamaica Plain, an affiliate of Brigham and Women’s.
“So Kristin, are you ready?’
Second-year resident Kristin Castillo is preparing for her day’s patients with what’s called the daily huddle. It’s attended by a supervisor, a nurse, a patient coordinator and a medical assistant. They listen as Castillo reviews her charts and chime in when necessary, reminding her of test results or screenings she may have overlooked.
“I’m not sure how current his depression is,” Castillo says about one patient, as the nurse reminds her he’d been screened already the previous week. “Okay, so maybe we can hold off.”
After the huddle, Castillo greets her first patient, a 39-year-old woman with poorly controlled diabetes, which causes pain and numbness in her feet. Castillo uses a soft filament to test her nerve endings.
“It shouldn’t hurt, but I want you to close your eyes and tell me if you feel it,” she tells the patient. After a few minutes of running the filament over the woman’s skin, Castillo gives her assessment.
“You didn’t feel when I was moving your toe as much on this side,” she says, “which makes me concerned there may be more nerve damage to this side because of longstanding diabetes.”
Afterwards, Castillo says she feels good about the visit. On top of the diabetes, she addressed the woman’s fainting spells, weight gain and depression. She gives credit to her team for keeping her efficient. But she’s not ready to commit to primary care after her residency. She’s strongly considering cardiology.
“I’m not certain that folks choose their specialty based on whether a team-based approach is there or not,” Castillo says. “I think people tend to be attracted to specialties based on their interest in the subject, whether it’s an organ system or a disease that excites them.”
And it can be a relief to only have to know about one organ system or disease – and to know it incredibly well. That’s pretty much the opposite of a primary care, where doctors are often asked to take on a lot more than medicine.
Back at the High Street Clinic, Katie Jobbins is reading an email from a patient who’s in subsidized housing – and wants a doctor’s note to get a bigger one.
“It says they need a housing letter for a 3-bedroom apartment, she has a two bedroom,” she says aloud to her assistant. “Do I just email them about what the health condition is?”
Jobbins says she doesn’t resent negotiating these issues; social work is just part of the job. But as primary care doctors are asked to take on more and more duties – from mental health counselor to employment liaison – will that scare the less socially-minded people away from the field?
“Everyone loves it, if you can spend an hour with a patient and really get to sit down with them and get to know them,” says Baystate doctor Eric Churchill. “It’s much less rewarding when you have 15 minutes per patient, and you have to try to cram in everything we have to get done. And on the other side of that, it’s going to be difficult to get people interested into primary care as long as it has less reimbursement and less prestige than specialty care.”
Resorting To Advocacy When The Market Doesn’t Work
Clearly, the healthcare system needs specialists. If you have cancer, you want an oncologist. Epilepsy? A neurologist. And many specialty fields are also in high demand. But without a robust new supply of primary care doctors, who will refer people to specialists? Or encourage healthier habits? Or watch for signs of decline?
That’s what worries Andrew Morris-Singer. He says his mother almost died several years ago because she had no regular doctor.
“She had an atypical pneumonia,” he says. “It didn’t present in an usual way and she didn’t have a primary care provider to take a comprehensive approach to her problems. She ended up on a ventilator for 6 weeks.”
At about the same time, he was a resident at Harvard Medical School – and learned from an email that the dean had defunded its division of primary care. Morris-Singer joined a petition drive to protest the move, which he says ultimately led to a reversal of that decision.
“And we said this can’t only be possible in Boston,” Morris-Singer says. “This can’t just be a local phenomenon.”
Years earlier in college, Morris-Singer had been a LGBT activist, and it occurred to him the same sorts of tactics could work on primary care. Today, his group, Primary Care Progress, tries to pressure medical schools around the country to put more resources in primary care training and create more leaders in the field.
Every year, Primary Care Progress invites a few hundred medical students, teachers, and others to a forum in Cambridge – which, judging by a recent one, turns into something between a political rally and motivational lecture.
“If you look at how primary care leaders talk and act – ‘It’s not fair we don’t get paid enough. It’s not fair that we don’t have the ability to hire social workers,'” Morris-Singer tells the crowd, mimicking the frustration of doctors. “‘It’s not fair and you with power, please care.’ So that strategy doesn’t work. Being a victim, playing the victim, it doesn’t work.”
Morris-Singer passes the stage off to his right-hand woman, Stephanie Aines, a professional activist, who projects photos of Rosa Parks and Martin Luther King Jr, and links the civil rights movement to the fight for primary care.
“What do we have that they need?” she says into the microphone. “Our tuition dollars fund our schools. They need our money.”
The students brainstorm proposals to take back to their medical schools, like putting more resources into clinic work and creating more primary care tracks. And just to add a bit of energy, students come up with chants – something to do with primary care. One group went for a pun using prime numbers: “2,3,5,7 – C-A-R-E, 2, 3, 5, 7, C-A-R-E, We’re indivisible!”
Corny, perhaps. But there are signs that efforts like these are working, that medical schools are investing in primary care and trying to restore its luster.
Kristin Castillo says she’s noticed a changed in attitude among young doctors since Harvard opened its new center.
“There was a lot of new programs, there was a lot of excitement generated by the people who were hired to be part of that center,” she says. “I’ve seen now there are many more people who are applying to residency with the purpose of going into primary care, whereas that was not the case when I started as a medical student.”
The Affordable Care Act has funded between 300 and 500 new primary care resident slots a year. But putting more resources into training alone will not fix the profession’s problems, Morris-Singer says.
“It doesn’t change the ultimate way that payment for health care services occurs in this country,” he says. “And that approach has always left primary care in the shadows.”
The ACA did include new financial incentives for primary care doctors, including higher Medicare and Medicaid reimbursement, with extra support for the medical home model. The original legislation also created and named a 15-member commission to analyze the physician workforce, but that commission has never met and has yet to be funded by Congress.
After A ‘Struggle,’ Primary Care Takes A Backseat
“I have a candy problem,” says Katie Jobbins, unwrapping a small treat. “They can tell how my day’s going according to how many times I’ve gone in to get candy.”
Jobbins is in a good mood as she looks up her roster of patients. She’s invited me to hang out on her shift on this fall morning. Her first patient is a no-show. The second is one of her favorites.
“So Rosa, how you doing?” Jobbins asks.
Rosa is 59 – she’s recovering from surgery, and just back from vacation. They speak through an interpreter, as Jobbins looks Rosa directly in the eyes.
“How’ve you been feeling? Any chest pain?”
“Si lo tengo, pero poco menos…”
Rosa tells me, through the interpreter, that Jobbins has been a lifesaver over the past year – a year that included a severe bout of depression. And when Jobbins stands up at the end of the visit, Rosa gives her a hug – and a pleading look. Since there’s often turnover among the residents, Rosa is worried she’ll lose Dr. Jobbins.
“She doesn’t want you to go,” the translator says. “No, I’m not going,” Jobbins assures her.
“Porque estoy cosumbrado a ella,” Rosa says. She’s used to Jobbins. “I know,” says Jobbins. “I’m used to you too.”
But Rosa doesn’t yet know what Jobbins had told me earlier that day. Since it had been a few months since our last interview, I asked if she was still planning to become a primary care doctor.
“Actually,” Jobbins says, slowly and with some hesitation, “I decided I’m going to go into cardiology.”
She knows this comes as a surprise. She says the decision didn’t come down to the reasons most people cite for avoiding primary care – salary, workload and prestige. Jobbins didn’t even mind the paperwork and the arguing with insurance companies – like many other doctors her age, she accepts that’s just part of medicine today. No, she says, she just really likes working with the heart.
“It was a big struggle,” she says. “I really do love doing primary care, and I think I’m going to miss a big part of that. And I know there is a huge need for good primary care doctors out there, but I wanted something a little bit more than that too.”
Like doing intensive care and spending more time in the hospital, she says. Ironically, as a cardiologist, she’s still likely to take on many of the primary care duties of her patients – because there won’t be enough primary care doctors.
“You know, when the patient comes in and say they have uncontrolled blood pressure and diabetes,” she says, “you’re going to have to address both those things.”
Jobbins says Baystate’s program did all it could to groom her in primary care. It prepared her for both the chaos and the rewards of outpatient medicine. So she was nervous telling her advisors that, after three years on a primary care track, she’d be getting off.
“Because I was afraid, that, again, you don’t want to let people down.” But in the end, she says, “they were all very happy for me and thought it was a good fit.”
She’ll stay on for one more year as a chief resident, and then compete for a fellowship in cardiology. She can’t be sure she’ll get in.
“I would happily be a primary care doctor if cardiology didn’t work out for me,” she says.
‘I Didn’t Realize How Busy I Was Going To Be’
If a doctor like Katie Jobbins – who’s so committed to patient relationships and preventive care – can’t be convinced to stay in primary care, how does that bode for the field in general? And this – just a few months after her colleague Donielle Sliwa made a similar decision.
It means advocates for primary care have their work cut out for them. Baystate promoted its primary care residency at conferences and medical schools. After a round of interviews, they offered slots to four people. Only one chose to come. This, despite a national innovation award the hospital won for its clinical program.
“It was disappointing,” says co-director Gina Luciano. “I think we would have loved to have filled our class. It’s just really hard to recruit residents to primary care.”
The Affordable Care Act did include new financial incentives for primary care doctors, including higher Medicare and Medicaid reimbursement, and extra support for what’s called the medical home model. But that money expires this year, and few expect the Republican-led congress to renew it.
The ACA also created a commission to analyze the physician workforce, but that commission has never met and was never funded by Congress.
Meanwhile, Baystate has sent into the world one graduate of its primary care residency: Sara Tischer.
I called Tischer shortly after she started her new job at a private group practice in northeastern Connecticut, and asked for an update.
“So things are going well,” she says. “They’re being very kind to me. They’re ramping me up slowly.”
She chose this job out of three offers she got out of residency. She is the newest doctor in the practice, and the youngest by 20 years. Before she even started, patients were calling the office to get an appointment.
“Of course, in a small community like this, when people find out that a new physician is coming to town, word travels like wildfire!” Tischer says. “But I was really shocked. I didn’t realize how busy I was going to be.”
Since most of her patients have been waiting a long time for a doctor, their problems tend to be complex – chronic diseases and conditions that have long been ignored. It’s daunting, she admits. But she says her new colleagues are doing their best to protect her from early burnout.
“They’ll say things like, ‘Hey, isn’t it your afternoon off? What are you still doing here? Go home!’”
Tischer’s aware that people are watching to see if she sticks it out in the field – unlike a friend of hers from medical school, who got through one year of primary care in the real world before throwing up her hands and taking a fellowship in infectious disease. But Tischer says she’s confident that won’t be her.
“I think you have to remember that the grass is always greener,” she says. “There are problems in every specialty. I’m definitely in it for the long haul.”
“The Path to Primary Care” was supported by a fellowship from the Association of Health Care Journalists and the Commonwealth Fund.
Listen to the follow-up feature on NEPR, “Raising The Stakes For Primary Care,” here.
Read a companion article by Karen Brown in The Boston Globe here.
Corrections: Text was changed to reflect the following: Andrew Morris-Singer was a resident at Harvard Medical School, not a medical student. Baystate’s internal medicine residency has room for 54 residents, not 66. 1/15/15.
UPDATE 5/25/2015: Katie Jobbins has changed her career plans again. She now plans to stay in primary care.