A social movement to save primary care [PODCAST]

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We welcome family physician Michael Fine alongside insights from medical resident Fatima Khan. Join us as we delve into the transformative journey of the Scituate Health Alliance, spearheaded by Michael, and its pioneering approach to community-based health care reform. From the challenges faced to the triumphs achieved, we uncover the power of collaboration, innovation, and advocacy in reshaping the landscape of primary care.

Michael Fine is a family physician. Fatima Khan is a medical resident.

They discuss the KevinMD article, “Primary care for all Americans: What the U.S. health care system can learn from Scituate, Rhode Island.”

Mentioned in the episode: Primary Care for All Americans (https://primarycareforallamericans.org/)

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Michael Fine, and we welcome Fatima Khan. Michael is a family physician, Fatima is a family medicine resident, and we’re going to talk about primary care for all Americans, what the US health care system can learn from Scituate, Rhode Island. Michael and Fatima, welcome to the show.

Michael Fine: Thank you for having us.

Fatima Khan: Thank you so much.

Kevin Pho: All right. So I’m just going to ask you briefly, Michael, to reintroduce yourself, and Fatima to briefly share your story. So Michael, why don’t you go first?

Michael Fine: Sure. Great honor to be here. I’m a family physician. I spent a bunch of time in public health. I’m an author. I’m a past director of the Rhode Island Department of Health. And I’ve had the opportunity to be at almost every major table in health policy in the United States. And one of the things I’m going to tell you is that there is nobody in charge, and the cavalry isn’t coming.

Kevin Pho: Fatima, why don’t you briefly introduce yourself, share your story.

Fatima Khan: Hi, I’m Fatima Khan. I’m a family medicine resident at Jamaica Hospital Medical Center. My background is in practicing in a resource limited but patient rich population, so the ethos of primary care for all Americans, it echoed with me deeply, and I wanted to be a part of this so that we can ensure that primary care reaches all Americans, just like any other essential service.

Kevin Pho: All right, great. We’re going to talk about this article and use it as a jumping off point, primary care for all Americans, what the US health care system can learn from Scituate, Rhode Island. So Michael, why don’t you lead us off? Tell us what this is about.

Michael Fine: Sure. Well, Scituate, Rhode Island is the only place in the United States we know of where every person is guaranteed access to primary medical and dental care. That’s kind of an amazing accomplishment by itself, and that’s what the piece is about. And then the article talks a little bit about primary care for all Americans, and I want to explain why that’s an important transition.

If we were to provide primary care to all Americans, we are short 200, 300,000 primary care clinicians. The shortage is overwhelming, and almost nobody understands how deep it is.

What we’ve learned from the DPC movement is that the ideal patient panel is something like 500 patients. That has changed because of the EMR, because of the proliferation of both new drugs and new treatments and new recommendations. Now many, many, many more things for people to keep track of than back in the day when I used to take care of 3,000 people, and some of our colleagues have, still taking care of those numbers.

But that change, the shrinkage of the ideal panel size, hasn’t been accompanied by training more clinicians. And we are down to 43 percent of American adults having a robust primary care relationship, which means 57 percent don’t have a primary care clinician.

In order to make up that difference, we have to magically and tremendously multiply the number of people we’re training, both in medical school, nursing school, PA school, and get them through good, meaningful residencies so they’re ready to practice.

And the thing that’s really scary is that, like I said in the beginning, nobody’s in charge. There’s nobody thinking out how we’re going to increase that number. Which is where primary care for all Americans comes in. We are organizing clinicians and the public around the country to build local and state work groups, so that we get people figuring out and focusing on how to quadruple the number of people we’ve got in training.

But the problem is, we’re up against $750 million of lobbying from people who want to keep things the way they are. And the only way to get around that is to build this social movement involving everybody, involving clinicians and others, but often led by clinicians because we’re the experts with the attitude. Involving everybody, so that we get policy makers at the state and national level to really focus on this critical need.

Kevin Pho: So Michael, it sounds like we’ve been talking about the primary care shortage, especially on KevinMD, for almost decades now. If you were to distill it to one root cause, or the most important root cause of the many, what would you say is the major reason why there is such a shortage of primary care clinicians?

Michael Fine: Because nobody’s in charge. I mean, very simply, we know how to address this.

When I came through, I was in a cohort of 3,000 people in the National Health Service Corps every year who got to go to medical school for free, and in exchange for that I committed to practicing primary care in a place that was underserved. And then, because we had gone to medical school for free, we felt free to be able to do what we thought was important, which is serving populations.

Now there’s something like 50 people a year getting those scholarships. So we could massively increase the number of scholarships at the federal level. We could create scholarships at the state level. I’m actually old enough to remember when communities used to create scholarships for their own students to go, so they could come back. So communities could do this for themselves, but they aren’t, because nobody’s leading the way.

And then we need to fund a massive increase, a quadrupling, of the number of slots at medical schools. So almost nobody knows that we train 21,000 medical students a year. 63 to 67,000 apply, which means 40,000 don’t get in. And yet I bet, having survived organic chemistry, that of those 40,000, 35,000 would be great clinicians. But nobody’s in charge of making sure that those numbers increase.

And that’s where you need people active in their own states and their own communities, pushing on their policy makers to quadruple the number of slots. There are interesting places in the Caribbean, even for-profit medical schools, that have classes of a thousand. There is no reason that every medical school in the country shouldn’t have a class of a thousand right now, with half of those people committed to practicing primary care.

These are solvable problems, but we have to get everybody together to solve it. And the only people who are going to be able to lead this are clinicians, which is why we need people to join primary care for all Americans and help us figure out at the local level, at the state level, how to make all this work.

Kevin Pho: Fatima, you are a family medicine resident, and obviously you are pursuing that career in primary care. What about primary care resonates with you, and why did you choose that as a field?

Fatima Khan: So I think it would go back to my experience when I was on the other side, as a family member caring for, or related to, people who are diagnosed with terminal illnesses. And I saw what a devoted primary care practitioner did in those circumstances. For example, they could not take away a terminal diagnosis, but the handholding they provided, the comfort they provided throughout the way, to the family, to the patient, that guided my career.

So I knew I wanted to be that doctor holding a patient’s hand even through their worst challenges. Because specialists only get a specific amount of time with the patient. They come in for that one particular thing, then they’re phased out. But your primary care physician is literally that one physician with you from birth to earth, and that is what my way of looking at it was.

So when it came time for me to apply for residency, I knew I wanted to be a primary care physician, and family medicine was the choice for me.

Kevin Pho: And Fatima, among your medical school classmates, could you estimate what percentage of them are pursuing careers in primary care?

Fatima Khan: I can easily say it would be 5 percent or less.

Kevin Pho: Why do you think that is? Why do you think so few want to pursue primary care despite the urgent need, as Michael articulated?

Fatima Khan: So I think one thing that Dr. Fine mentioned already, they came with a lot of student loans, and the pay grade for primary care physicians across the board is not very lucrative. So when someone is walking in with a heavy student loan, they want to make sure that they can get rid of it in the shortest amount of time possible. They do not want to go up until their kids are in college carrying that student loan with them. So that was the deciding factor for many medical students who did not look upon primary care as their choice of residency.

And also the amount of importance in the society that is given to primary care physicians. So while as clinicians we realize the importance, or some people who have had primary care physicians know the importance, many others do not realize that you need a primary care physician to have better health care.

And speaking to that point, there are a lot of things that we as a community still haven’t understood. One of the things is that, if someone receives good primary health care, you have a primary care physician, the chances of you ending up in an ER or in a hospital for a long-term admission, it goes down significantly.

And it’s not just the patients, but even clinicians who are able to provide primary care the way they want to, especially like how primary care for all Americans wants this movement to grow, physicians themselves feel so much better, they feel satisfied. So the physician mental health discussion also gets linked into this.

Kevin Pho: And Fatima, one other question before I move to Michael. So other than the economic incentives, and you mentioned hundreds of thousands of dollars of student loans, what are some other ways medical schools or medical education can encourage more of their students to pursue primary care as a career? So if you take economics out of it, what else can they do to really encourage, because 5 percent is pretty low. So what more do you think they could do?

Fatima Khan: One of the things could be that during medical school rotations and the residencies, they perhaps could get some economic incentive still, if they take up a residency in an underserved area, that would help.

Also providing them with more hands-on experience in perhaps an underserved area, which they would actually get the chance to connect with, instead of just checking off a box or a shelf on their exams. They could actually see what difference primary care physicians are making, especially in underserved areas, and that would inspire them to perhaps take primary care physician as their chosen career.

Kevin Pho: So Michael, one thing that you mentioned earlier was that if medical schools could accept a thousand people they would, right? Because there’s so many potentially great doctors who are rejected from medical school. But as you know, the limit isn’t necessarily the medical schools but the amount of residency slots, and that’s controlled, I believe, by the federal government in terms of the funding. So is it just a matter of money, throwing more money at the issue, increasing the number of primary care residency slots, so more of these students can pursue careers in primary care?

Michael Fine: So it’s actually a matter of leadership. So residency slots are controlled by ACGME, and the way that works is, they decide how many slots each hospital will get, each hospital that’s a training program, and they fund those slots, but they leave it up to the hospital to decide how they’re going to assign the slots by specialty. And so hospitals do what’s in their economic interest. They want to train orthopedists, because that’s what they’re going to use to make money.

It would be relatively simple from a regulatory perspective, complicated from a political perspective but simple from a regulatory perspective, to have ACGME require that 50 percent of all graduate medical education funding be devoted to training primary care clinicians. It’s like flicking a switch.

But in order for that to happen, there has to be a groundswell of support for it to happen, because the hospitals are going to resist it. So that’s where we need people involved, and people kind of speaking out and speaking up. And unfortunately it’s going to take somebody to organize that social movement, and that’s why we’re doing what we’re doing, to get that movement organized, so people focus on the public health importance of making sure there are enough primary care clinicians.

Kevin Pho: So Michael, you talk about a social movement, and there is certainly more work to do, and I think you’re doing a wonderful job in not only articulating a need for primary care but doing something about it. So give us an example of how your social movement has moved the needle in the past, in terms of addressing that dire need of more primary care clinicians.

Michael Fine: Well, we’re just getting started. I mean, primary care for all Americans kind of got started formally in December, and we run a process every two weeks, we run a kind of community building Zoom, we have speakers and we have activities, and we’re involving now hundreds of people. That’s the good thing. But it’s just the beginning.

Where we have to go is that we have to get local work groups started in every zip code, and we’re going to be there to help organize and facilitate those people once they step up and say they’re interested. So this is taking the Scituate, Rhode Island model, where there has been a local work group of volunteers that’s been meeting together every month for the last 25 years to make it happen. Our job is to make sure there’s one of those local work groups in every neighborhood and community in the United States.

And at the same time, we’ve now got four statewide work groups, where people are working in four different states trying to figure out how to advance the agenda.

Now, one thing we know is that there’s no one-size-fits-all solution. Each neighborhood, each community needs to figure out how to do this best for itself, understanding its own culture, and each state is going to do it differently, and do it in a different way for itself.

Our job, as we see it, is to get everybody to put their eyes on the prize. And the prize is making sure that everybody who lives in the United States has a primary care clinician and primary care practice where they are known, where they are connected, and, as much as possible, where the clinical staff and the administrative staff look like the population that’s being served, so people feel that connection, that love.

And so we take that, and part of the aim is to take students from those communities, get them to health professional school, and then give them what they need to come back and practice in the communities from which they come.

Kevin Pho: And for those listening interested in finding out more, just Google primary care for all Americans, and the website will come up as the first result, and it’s PrimaryCareForAllAmericans.org.

So I am going to ask each of you just to briefly share some take-home messages to the KevinMD audience. Fatima, why don’t you go first?

Fatima Khan: The take-home message would be, primary care for all Americans is as essential as electricity or gas or any other essential service that you can think of. And it’s in the best interest of not just the patients but also the clinicians. It would be for the best of the entire community, and that’s why we should pay more attention to it.

Kevin Pho: And Michael, we’ll end with you, your take-home messages.

Michael Fine: Pretty simple. The cavalry isn’t coming, there’s nobody in charge but us. Primary care clinicians are already heroes, they’re already doing what it is that must be done. But in order to fix the nation’s problem, in order to help us provide primary care, this essential service, to everyone, we need every clinician to step up and pay it forward, help us be part of what we’re doing, and lead the way.

Kevin Pho: Michael and Fatima, thank you so much for sharing your perspective and insight, and thanks for coming on the show.

Michael Fine: Thanks, Kevin. Thanks for the opportunity again. Thanks for what you do, bringing our community together.

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