How to make primary care rotations more appealing for students [PODCAST]

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“It is time that every health profession school specifies their criteria for optimal teaching primary care practices and for the training that would optimize their students’ experience. It is time that we, as primary care physicians, advocate for the resources necessary to expose ourselves and our students to the best that primary care has to offer — and, in doing so, provide the best possible care to our patients. We deserve that, as do our students and most importantly, our patients.”

Russell Phillips is an internal medicine physician.

He shares his story and discusses the KevinMD article, “Flip the axis: primary care rotations.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show we have Russell Phillips. He’s an internal medicine physician, and he co-wrote the KevinMD article “Flip the axis: primary care rotations.” Russell, welcome to the show.

Russell Phillips: Thanks so much, Kevin. It’s great to be here.

Kevin Pho: So we’ll get into the article in a little bit. First off, briefly share your story and journey to where you are today.

Russell Phillips: Sure. I’m a primary care general internist, and I went into medicine really intending to do primary care. I loved the relationships with patients that you have an opportunity to make and maintain in primary care. I did rotations when I was a student in family medicine, and I actually worked in a diagnostic clinic at Stanford, where we sort of helped primary care physicians who were having trouble making difficult diagnoses, sometimes, with patients. I ended up training at Beth Israel Hospital in internal medicine, where they had a primary care residency, and I went on to do a general medicine fellowship program. I have done research for many years, was the division chief at BIDMC in primary care and general medicine, and then, starting in 2012, I directed the Center for Primary Care at Harvard Medical School.

Kevin Pho: Wonderful. And like you, I’m an internal medicine primary care physician myself, and I’m sure we’re going to have a vigorous conversation in terms of how we can keep primary care thriving despite the many challenges and obstacles that it faces. So you co-wrote this article, “Flip the axis: primary care rotations.” Now, for those who get a chance to read your article, just walk my audience through it. Share the story of why you decided to write it.

Russell Phillips: Sure. What we wrote about, really, is the experience that our students are getting in primary care, and trying to address the question of why it is that many students come into medical school thinking that they might want to do primary care but unfortunately leave deciding they want to do something else. One of the factors that’s associated with staying in primary care is really the experience that our students have in primary care. Unfortunately, many of our students have experiences in practices that are not well organized, often have some level of dysfunction, are staffed by primary care physicians who are to some extent burned out and unhappy in the field, and are immersed in a culture that is not supportive of primary care.

The question is really, how can we change that? I think part of the answer is really trying to intentionally change the experience that our students have when they do primary care: making sure that they are in practices where they’re exposed to the best of primary care, where they are precepted and taught by primary care physicians who are enjoying what they’re doing, and who, you know, want to continue doing that and want to see students go into primary care. And I recognize that that’s a challenge. It means that we not only have to find those practices, but sometimes, as medical schools, invest in those practices, because in fact, many times the practices aren’t working well because there just isn’t enough investment in primary care.

Kevin Pho: So the last time I rotated through a primary care clinic as a resident, that was almost 20 years ago. So for those who aren’t familiar with that medical school experience of rotating through primary care, just describe to my audience what exactly that was like. Because for me, I remember it was pretty much one afternoon a week, and this was sometime in the midst of inpatient rotations. You just had to finish rounding, rush off to your primary care clinic, be there by 1 o’clock, do primary care until 5, and then perhaps come back to the hospital and finish your inpatient work. So that was what my experience was. Tell me what it is now, currently, for medical students rotating through primary care clinics.

Russell Phillips: Yeah, so that unfortunately continues to be really the model. I think it also, though, depends a lot on whether you’re in family medicine training or internal medicine training. But certainly, medical students who are rotating through primary care often will be doing it in the context of an internal medicine period when they’re also on the wards in internal medicine, meaning that they’re in the hospital, and they’ll spend a half day in the clinic. They will be rushing down to the clinic, just as you say. They will still have patients who are sick in the hospital, so they’ll be distracted. They’ll be working in a clinic where they’re precepted by somebody who they may not know that well and who doesn’t know them, you know, that well. They don’t really get a sense of the team that they’re working with in the clinic or the resources that are available. And it becomes more of a negative experience than a positive one.

Kevin Pho: All right, so tell me some of your solutions to fix some of these issues, because from what you’re describing and from what I remember, you’re right. It doesn’t seem like the most positive shine that we could put on primary care.

Russell Phillips: Yeah, so I think, you know, the value of primary care is really, you know, things that Barbara Starfield, a researcher, really helped define and demonstrate. She was at Johns Hopkins, and she talked about continuity, comprehensiveness, first contact, and care coordination as being the things that happen in primary care that really bring value to what we do. And continuity is a big part of that. When I mentioned, you know, what drew me to primary care, it was the relationships with patients. I think it’s really important to create opportunities so that students can create those relationships.

So what I actually favor is a longitudinal experience in primary care that really goes through the four or five years of medical school, depending on how long someone is there. I should mention that at Harvard, 80 percent of our students actually are at medical school for five years, often because they’re doing a research project or a master’s within the context of that program. That’s not true everywhere, of course. But what I would love to see would be a continuity experience in primary care.

We do some of that at Harvard, where we have something called the foundational continuity clerkships, where first-year students, in fact in the first few weeks of school, are introduced to a primary care practice. Ideally, that’s the same primary care practice where they will then do their primary care clerkship during their second year. Unfortunately, during years three and four, they move away from primary care, and that’s a real time when we have challenges retaining interest in primary care. But ideally, that clerkship experience would continue through years three and four, so that students are continuing to be engaged and potentially, during years three and four, are not only seeing patients but also engaged in primary care transformation, or at least some aspects of that, through doing quality improvement projects or innovation projects within that primary care practice as well.

Some other important elements, really, are that it should be a heavily curated experience, meaning that we create those opportunities in practices that really show the best of primary care, with intensive team-based work, where there’s behavioral health integration, for instance, where there’s screening for social determinants of health, where there are resources around addressing patients’ social determinants of health, and where there’s also ready access to specialists through things like e-consults. And there are certainly some practices that do all of these things, but not enough, which is why I think it requires medical schools both to think about how they can create this continuity experience and also to help identify and resource practices, so that students really do have an ideal experience within primary care practices.

Kevin Pho: I want to follow up on that, because I think one of the things that you said earlier that detracts from students’ interest in primary care is not having those positive primary care role models. For one reason or the other, those primary care clinicians could be under a tremendous amount of stress and pressure: paperwork, electronic medical records, understaffing, a whole host of issues. So what are some ways that we can give students more of those positive role models? Because, I’m sure, you’re pressured, you’re under pressure, and sometimes it’s not our best face that we give to students in the primary care setting. What are some ways that we can solve that?

Russell Phillips: Yeah, so, you know, key to that is, in some ways, following up on the recommendations of the National Academies of Sciences, you know, one of their committees that met on primary care. The first was really thinking about payment. It’s clear that primary care is undersupported. And when I said medical schools need to invest, it may either be medical schools investing or changes occurring, you know, at a larger level in terms of how we support primary care. But right now, only 5 to 6 percent of the total medical spend goes into primary care. So if you think of, you know, a Medicare patient, who on average spends $14,000 a year, actually, for Medicare, it’s only around 3 percent. So we’re only talking about several hundred dollars going to primary care for the care of an older patient, who often has, you know, very complex needs and needs additional resources, and clearly primary care practices need more support to meet those patients’ needs.

In Rhode Island, for instance, they doubled the investment in primary care, which I think is what we need to do nationally. Nationally, 5 or 6 percent of the spend goes to primary care. It should be 10 or 12. And that will go a long way toward supporting some of the activities that I mentioned, such as behavioral health integration, where we have the collaborative care model for depression, for instance, and social workers embedded in the practice, screening for social determinants, and community health workers who will help address patients’ needs, where we can address equity and social justice within practices. I think all of those things together, to the extent that we can incorporate them into primary care in a really standard way, would improve burnout and sort of address some of the concerns.

The other thing you mentioned is the EHR, which is a huge, you know, sort of issue. We need to have better EHRs available. Right now, what we have are mostly designed around billing, as opposed to team-based care and communication with other providers, and, you know, we just spend too much time entering data. And so, you know, that’s something that needs to be fixed as well.

And then in addition to investment, it’s also how we’re paid. We need to move to value-based payment so that we really are off fee-for-service as sort of the mark for how we’re paid, because fee-for-service leads to a focus on RVUs, which often focus on low-value, short visits, when I actually think we should be taking care of, especially in internal medicine, patients with complexity. And I think if we were able to do that, that also would address some of the burnout that we feel from, you know, seeing 20 patients a day, often for things that we don’t need to be seeing them for, but chiefly because it generates RVUs for the practice, and we’re really focusing on patients where we can make a difference. So, you know, all of those things have to happen as well to address, you know, some of the larger concerns that you just mentioned.

Kevin Pho: We’re talking to Russell Phillips. He’s an internal medicine physician. He co-wrote the KevinMD article “Flip the axis: primary care rotations.” Russell, I want to talk about the role of advanced practice providers. A lot of primary care practices across the country have trouble recruiting physicians, and then they hire physician assistants and nurse practitioners to fill that primary care role. Medical students come up to me, and they see this, and they say, “Why should I go into primary care when I may be replaced by an advanced practice provider?” So to those medical students who ask you that question, what do you say?

Russell Phillips: That’s a really good question, Kevin. I think the role of advanced practice providers is really key to the function of a primary care practice. In my mind, they can also do many of the things that the primary care physician is right now spending time doing, which will offload the primary care physician, again, so they can focus on patients with complexity, for whom they are best trained to care through their care of hospitalized patients and their rotations through heart failure clinics and things like that. That way, the primary care physician can spend time really thinking about diagnostic challenges, which for most physicians is one of the enjoyable and fun things about practice; can problem-solve for patients with advanced heart failure and advanced lung disease; can spend time consulting with specialists when need be; and can also be involved in practice leadership and practice transformation.

We will always have challenges in caring for patients through new things, new needs of patients. So, you know, an example is COVID, where we had to totally reinvent what we did. There are going to be other things coming along, which won’t be pandemics, but things like the aging of our patient population, that will require transformation. We need medical students who are trained in innovation and transformation to serve as physicians in primary care to help lead that.

And advanced practice practitioners can, in the meantime, be doing a lot of chronic care management, management of patients with straightforward hypertension and diabetes, and, you know, often, you know, preventive care. You know, we know from a recent study that was done that it takes five hours a day or so to do the care of our patients with chronic disease just by itself, and there’s no way that there’s sufficient time in a primary care physician’s workday to be doing that all themselves. And there’s no question that advanced practice practitioners can’t do just as well as primary care physicians. So we should really be shifting that work to them so that we in primary care can take on some of the more challenging tasks. That’s not to say that advanced practice practitioners sometimes don’t have a role in that as well, but they can certainly take on much of the work that’s done in primary care. There’s more than enough work to go around. So I would say to the student who is thinking about going into primary care that they will not be displaced, but rather they will be supported by advanced practice practitioners.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Russell Phillips: Yeah, so I would first say that primary care, for me, has been an incredibly rewarding specialty and experience, and I can’t imagine doing anything any differently. You know, the opportunity to care for patients over a lifetime has been just incredibly satisfying, and again, I just can’t imagine doing anything else. I am so supportive of students who want to do this work.

You know, we also know that primary care is among the most high-value work that a physician can do. Some of the work that we’ve done in the Center for Primary Care has actually helped to support some of Barbara Starfield’s earlier work. We’ve shown that the density of primary care physicians, more so than any other physician, correlates and is associated with life expectancy, and we’ve shown that if there are insufficient primary care physicians in an area, there can be up to a year drop in life expectancy. For that reason, primary care is considered a common good, meaning that, you know, it’s something that everybody should have access to.

So I think the first message is that, you know, primary care is a great field. There’s wonderful opportunity. The second is that the value of primary care is, you know, undisputed. And then I think the third message is really that medical schools need to recognize the social value of primary care as a common good and be really, you know, focusing on how it is that they can turn out more students who are focused on primary care as a career goal, and support those students through their clinical experiences so that they leave medical school still wanting to focus on primary care.

Kevin Pho: Russell, thank you so much for sharing your time and insight. Thanks again for being on the show.

Russell Phillips: OK, thanks so much, Kevin. That was great.

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