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Where Have All the Doctors Gone?

• January 09, 2012 • 4:00 AM

Communities with more primary care doctors enjoy better health, yet those physicians are a dying breed. Here is what some schools are doing to combat the looming shortage.

Technically, all Judy Sweet needs is a blood pressure test. In most doctors’ offices, this would be an in-and-out visit. Sweet’s doctor, however, never rushes her patients. Mary Elizabeth Sokach is a primary-care provider based in Exeter Township, a rural Pennsylvania community about 15 miles west of Scranton. When Sokach walks into the room, she greets Sweet like an old friend, then examines her closely. She asks when Sweet last had an eye exam. (“She’s a phenomenal artist, so we have to keep her hands and her vision going,” explains Sokach.) And she talks to Sweet about sleep and pain management.

Working alongside Sokach is a medical student named Adam Klein. Sokach kneads her fingers along the back of Sweet’s neck and invites Klein to do the same. “There’s tension in the right?” asks Klein. Sokach nods. She’s deduced that Sweet has muscle spasms, the source of years of nightly pains and sleep problems. A simple prescription should end all that discomfort.

Sokach works out of a converted house within earshot of the Susquehanna River; she has spent her life in Exeter. Her practice emphasizes primary and preventive care, and close attention to patients. But medical schools are turning out fewer and fewer doctors like her. Most schools operate under a century-old model that’s better suited to producing specialists than primary-care providers.

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This is an ominous trend. Numerous studies show that communities with a high number of primary-care providers per capita have lower medical costs and better health outcomes. By contrast, according to a 2004 analysis of Medicare data conducted by researchers at Dartmouth College, a large-market presence of specialists actually lowers care quality. The Association of American Medical Colleges estimates that the United States is on track to have about 90,000 fewer physicians than it needs a decade from now. Half that shortage will be concentrated in primary care.

To help stave off the looming shortfall of physicians, existing schools are expanding and new schools are opening. In 2002, there were 125 allopathic medical schools in the United States. (Allopathic physicians are the ones with M.D. after their names, as opposed to osteopaths, naturopaths, etc.) Today, there are 134. Another nine schools are in development and applying for accreditation. In the 1980s and ’90s, by comparison, only one new medical school opened in the United States.

That’s why Mary Elizabeth Sokach has a medical student working with her today. Sokach is a faculty member — and Adam Klein is a student — at The Commonwealth Medical College in Scranton. It’s a new medical school that’s been funded partly by the state, and partly by Blue Cross of Northeastern Pennsylvania, which has seen health-care dollars leaving the region as people seek care elsewhere.

Commonwealth is part of a cadre of medical schools that are trying out new models of education in hopes of producing more physicians who will stay and practice medicine in their immediate communities. Simply by virtue of being new and free of traditions, these schools are better able to innovate, according to Valerie Weber, the chair of Commonwealth’s Department of Clinical Sciences.

In the newer schools, interacting with patients and examining social factors that influence health are central to the curriculum. Faculty members are prized as much for their skills in the classroom as for their skills in the research lab. It’s a nontraditional approach intended to produce highly traditional doctors — physicians devoted to their communities. What policymakers and health-care experts are now waiting to see is: Will this really work?

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To fully understand the link between medical schools and sophisticated hospitals — to understand medical education at all — you need to go back to Abraham Flexner, an educator who conducted a detailed study of American and Canadian medical schools for the Carnegie Foundation in 1910. Flexner visited all 155 medical schools in the United States, and what he found was an appalling number of ill-equipped and exploitative institutions that simply churned out diplomas. Many medical schools didn’t even require a high school education. Quackery flourished, and marginal doctors flooded the market.

To counter what he called the “over-production of uneducated and ill trained medical practitioners,” Flexner suggested a template for medical education that has since been adopted nearly universally: two years of classroom instruction in basic sciences followed by two years of clinical work in a sequence of specialties. To ensure that instruction would be anchored to institutions with proper scientific standards, Flexner recommended that medical schools affiliate themselves with established universities and hospitals. In Flexner’s view, Baltimore’s Johns Hopkins School of Medicine, tied to Johns Hopkins University, was the quintessential example of how to do medical education right. The Flexner Report remains the most influential document in medical education today.

Still, for all the improvements that Flexner helped bring about, his report is often blamed for glorifying hospital research and medical specialization at the expense of primary care. That’s why many of the new medical schools have been experimenting with significant variations on the Flexner model.

In a typical medical school, for example, a student like Klein would be cramming for a pathology exam, confining his work to the classroom rather than working in a real medical practice. At Commonwealth, though, studies are interspersed from year one with hands-on patient contact, and professors make a strong effort to integrate classroom and clinical learning. Students say that this makes it easier to learn the myriad facts about health and disease that they must quickly master. “When you see that first person with swollen legs from being a diabetic, you never forget that,” says Kevin Baker, a second-year student.

Commonwealth assigns every student to work with a multigenerational family. For all four years of his or her education, the student follows the family through its encounters with the health-care system. The idea is to mimic the broad perspective that primary-care physicians get in their practice.

Commonwealth also takes an unusual approach to clerkships — the rotations, starting in the third year, that medical students make through different specialties. The usual system emphasizes the technology and specific knowledge of a given field over a more holistic picture of a disease and its impact on a patient. A student might see a patient, Fred, undergo bypass surgery but not observe Fred’s recovery or learn much about the causes of Fred’s heart disease. The student simply moves on to the next specialty clerkship. At Commonwealth, though, clerkships are “longitudinal and integrated.” That means students follow individual patients from the beginning of their medical treatment to the end, as they come in contact with different specialties and levels of care. This, too, helps mimic life as a primary-care physician.

Data from schools in Canada and Australia show that students who are placed in the type of clerkships Commonwealth offers are more empathetic than their peers. In fact, numerous studies show that most students become less empathetic over the course of their medical education. A 2008 study by the University of Rochester found that surgeons and oncologists responded only 10 percent of the time to cues that lung cancer patients were sad, frightened, or anxious. A recent study by Jefferson Medical College in Philadelphia showed that patients managed their diabetes better when their doctors scored higher on an empathy scale.

Harvard has been offering integrated clerkships as an option since 2004, though most students still take the more traditional route. David Hirsh, who directs the integrated clerkship program, says he has trouble believing that innovation in medical education ended with the publication of Flexner’s report. “April of 1910!” he says in amazement. In designing the program, Hirsh and his colleagues looked at everything from the work of the educational reformer John Dewey to the reflections of the physicist Robert Oppenheimer on the chasm between science and humanity. “There is no model that everyone likes,” says Hirsh. “The question is: What values does your model perpetuate?”

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On the other side of the country, the University of California, Riverside, is launching a new medical school. The school plans to enroll its first class in 2013; when it does, it will provide the vast majority of training in outpatient settings, rather than in large hospitals, as most schools do. Since outpatient settings are where 80 percent of health care is delivered, they are a good place for students to gain experience. Educators hope that a student who is trained outside of a hospital will be more inclined to practice outside of a hospital — ideally, as a primary-care physician. Currently, only one in six medical students in the United States chooses to practice primary care. G. Richard Olds, the dean of the Riverside medical school, hopes to improve upon that rate considerably.

Part of Olds’s approach will involve recruiting as many locals to his medical school as possible. “We have a particular physician manpower problem in our part of the state,” he says. Inland Southern California is looking at a physician shortage of about 5,000 in the next decade, and Californians who pursue a medical degree rarely choose to set up shop in places like Riverside. The area has a higher poverty rate than the state as a whole and is struggling to provide services to a growing immigrant population. Olds believes that if UC Riverside can attract more students from inland Southern California, particularly less affluent ones who might normally consider medical school out of reach, community ties will encourage them to stay in the area. Since most medical students practice close to where they complete their residencies — the period of training immediately following medical school — Olds is also scrambling to establish residency slots in inland Southern California.

Olds’s plan to recruit locally will mean focusing particularly on the undergraduates of UC Riverside; the school won’t necessarily be recruiting students with the most impressive academic records or highest scores on the MCAT. “Just good performance in the sciences and doing well on standardized tests is a poor indication of what kind of doctor you’re going to be,” Olds says. “I can take any reasonably qualified person and turn them into a doctor.” He will place a premium on things like community service and interpersonal skills when evaluating a potential student, he adds. And there seems to be no shortage of solid candidates. A strong consensus among educators holds that the number of qualified students dwarfs the number of spots available in medical schools.

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While making up for a shortage of physicians is unquestionably a major part of what these new schools are trying to do, it’s not their only aim. Another goal is simply to produce better — and kinder — doctors all around.

In Hamden, Connecticut, Bruce Koeppen, the dean of a fledgling medical school at Quinnipiac University, plans to create a school where students who are training in the various health professions will interact as equals. Quinnipiac already trains nurses, physician assistants, and other health professionals; now that doctors will be entering the mix, Koeppen wants to forestall what he calls the “pyramid” that places doctors on top. Common areas will be shared by students from all the programs, and they will be evaluated on how well they work together. Health care is “a team sport and will become even more of a team sport,” Koeppen says.

Many of these new schools encourage a strong focus on underserved communities. At Florida International University’s Herbert Wertheim College of Medicine, launched in 2004, teams of medical, nursing, public-health, and social-work students serve individual families in low-income neighborhoods. They spend four years collecting data on the families’ health problems and developing plans of care to address them. All medical schools do some type of outreach. But according to the dean of the school, John Rock, community involvement at Florida International is central to the school’s mission and character. “We’re not leaving,” he says. “This is part of our program, and we will be here. This is not a grant.”

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The drive to produce more primary-care doctors certainly faces obstacles. One of the biggest is outside any school’s control: a growing income gap between primary and specialty physicians. A 2010 study by the University of California, Davis, found the wages of procedure-oriented specialists to be 36 to 48 percent higher than those of primary-care physicians. And primary-care doctors put in more nights and weekends to earn their lower salary.

In theory, schools could offer loan forgiveness to students who go into primary care, and administrators at the new schools say they have been considering such incentives — but so far the money to finance them isn’t there. “I have to deal with reality,” says Olds of UC Riverside. “What are the things I can control?”

Then there is U.S. News & World Report. The magazine ranks medical schools by weighing factors like research dollars and incoming student grade point averages — areas in which these new schools, often by design, rate lower than their peers. A 2010 study published in Archives of Internal Medicine, however, found no association between the ranking of a physician’s alma mater and the quality of care that a patient receives.

“I wish those things were blown up and thrown away because they don’t reflect everything that is important,” says Dr. George Thibault, the normally reserved president of the Josiah Macy Jr. Foundation, which funds improvements in medical education. The foundation sponsored the development of a ranking system that evaluates the community impact of a medical school. Deans of the new schools tend to support these alternative ratings. Several deans interviewed for this article discussed their fear that the prestige associated with the U.S. News rankings could exert pressure on the new schools to drift toward traditional models.

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At Dr. Sokach’s office, Adam Klein is getting a history and checking some preliminary vitals on a middle-aged patient in for an annual physical. Klein asks a lot of questions about diet and exercise. The patient, who is on medications for high cholesterol and high blood pressure, goes to the gym every day. Klein praises him and makes small talk about the man’s history as a high school athlete.

“You’re a healthy guy,” Klein declares.

The man laughs. “Let me know when you finish up” medical school, he says. “I’ll come see you, because you’re going to be a lot less critical than she is.” The patient is Steve Sokach, the doctor’s brother—lines blur between the private and the professional when you work in a small town.

Klein continues chatting with Steve about the surrounding towns. He leans toward his patient, sometimes smiling, mostly just listening.

Mary Elizabeth Sokach hopes that Klein will remain in the community as a primary-care physician and take care of her someday. Klein is considering this, but he hasn’t ruled out becoming a specialist, either.

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Colleen Shaddox
Colleen Shaddox worked in daily journalism until an editor told her, "No more stories about people with AIDS. That stuff hurts us in the suburbs." She quit to run a soup kitchen and has kept one foot in journalism and one in nonprofits ever since. She's written for NPR, The Washington Post, The New York Times and many other media outlets.

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