In health care, like fashion, what goes out of style has a way of working its way back in. When I trained as a doctor in internal medicine in the early 1980s, I chose a residency in community-based primary care. Back then we were told that community-based care, which focuses on the environmental and social causes of ill health, such as the effect of poverty or the lack of healthy food options, was the wave of the future.
During my three-year residency, I spent plenty of time in the hospital. But unlike many of my internal medicine colleagues who trained almost exclusively in a hospital setting, save for a limited rotation through a community clinic, the bulk of my training took place in community clinics.
Working in the community taught me the importance of learning about the complete lives of the individuals and families I treated. I grew to understand that the reason a patient may show up at the clinic was an asthma attack, but that the asthma was produced by impoverished living conditions and a lack of safe and clean housing that so many of us take for granted. As I reflect on my career — and the choices I've made — I realize how much my training influenced my awareness of what patients want and need from us as physicians and from the larger health care system.
Today, like skinny ties, community-based care is back in fashion — in large part because the type of care that hospitals deliver has changed. Hospitals, these days, tend to handle the sickest patients (with the exception of moms delivering babies). Patients who are hospitalized end up staying for shorter and shorter durations.
The vast majority of care in the American health care system occurs outside the walls of a hospital. As a result, according to the Center for Studying Health System Change, only 13% of physicians now practice in hospitals, while in California, of the more than 1.3 million people employed by the health care industry, slightly more than 50% were employed in ambulatory settings: about 30% in hospitals, and 20% in nursing or residential care facilities.
Yet despite the fact that the community is where most of our future doctors will spend their careers, academic medical centers, which train the lion's share of new doctors, continue to churn out residents trained in . . . hospitals. This disconnect is all the more frustrating when you consider the chronic shortage of primary care physicians in the United States. The recent expansion of Medicaid, as part of the Affordable Care Act (ACA), has only accelerated the urgent need for more community-based primary care providers, not just physicians.
Case in point: Most incoming medical students at the University of California, San Francisco (UCSF), are interested in the PRIME-US program. PRIME-US, which first began at the University of California, Irvine, in 2004, is a nationally funded, five-year primary care training program in underserved communities. (PRIME-US stands for Program in Medical Education for the Urban Underserved. Students apply for entry once they are admitted to a UC medical school.)
I recently heard from a UCSF medical student that 8 in 10 of the 150 incoming medical students at UCSF are interested in joining PRIME. But the program has only 36 openings each year (scarcity could be another reason why so many students covet a spot!). The mismatch between supply and demand for these spots has ripple effects downstream: Many of those students who don't get in end up in other specialties, which is a shame, as we desperately need more bright primary care doctors.
As a young doctor, primary care training in the community enables you to become a change agent. By learning how primary care works, in a setting where the primary care physicians are often full-time, you have the opportunity to be there for patients when you are needed. You witness the importance of building relationships with patients and families over time, to begin to see yourself as part of a team making sure the right thing happens, rather than someone who drops in for a few hours and leaves, with no connection to what happens the rest of the time.
The good news is that thanks to the ACA, residency programs now have an incentive to start primary care residencies in community clinics. As a result, programs are springing up around the country. The funding for primary care is a great cause for optimism. But, of course, the primary care of the future can't just be about physicians — patients get better, more affordable care when physicians are part of a team. High-performing systems have nurse practitioners and physician assistants that maintain their own panels of patients, with physicians available for consultation, and medical assistants trained to do preventive care and health education.
It's a similar model to the one I was fortunate enough to learn in 30 years ago, and is more relevant today than ever. I guess some things never do go out of style.