This post is a little longer than usual. It’s one perspective on the Massachusetts insurance coverage expansion experiment. I’m sure this plan will receive greater scrutiny in the coming year if Mitt Romney continues to be a leading Republican candidate. The Massachusetts approach has had successes and failures. Growing primary care has not been one of its successes. The people named in this post are real and gave me permission to tell their stories.
Dr. Hannah Melnitsky grew up in Dedham, Massachusetts, and now she’s gone. For the people of Massachusetts, her exodus is especially unfortunate because she wants to become a family physician.
She just graduated from medical school at U Mass, which according to its website, “. . . was founded in 1962 to provide affordable, high-quality medical education to state residents and to increase the number of primary care physicians practicing in underserved areas of the state,” though according to published figures from the American Academy of Family Physicians (AAFP) its success at sending graduates on to residencies in family medicine is no better than national norms.
When Dr. Melnitsky told her parents she wanted to become a family physician, they didn’t know it even existed as a specialty, nor did many of her friends. From her experiences growing up adults go to internists, who sometimes act as not much more than medical traffic cops – acne is referred to a dermatologist, a painful knee is referred to a sports medicine physician, and stable thyroid disease is referred to an endocrinologist. A few female internists perform routine Pap smears and prescribe contraceptive pills, but any other women’s health concerns are expected to be handled by gynecologists.
Dr. Melnitsky concluded, “It’s difficult to find good family medicine training in Massachusetts. Family medicine is more respected in other parts of the country.” As of 1992 there was only one family medicine residency in the entire state. Now there are five, which is still small for its population. She was exposed to several of these residencies during her medical student years, and has a few friends who are pleased with their residency experience in Lawrence. She visited family medicine residencies across America and found more supportive environments in California, Arizona, North Carolina, and Texas. She is now a family physician intern at the John Peter Smith Hospital Family Medicine Residency Program in Fort Worth, Texas.
An anti-family medicine bigotry belt stretches along the urban Eastern seaboard from Washington, D.C. to Boston. Most of the Ivy League medical schools have no department of family medicine and their students have no exposure to family medicine. But this culture is not limited to the Ivy League. According to the AAFP among all Massachusetts medical students who chose family medicine residencies in 2008, only 21% stayed in Massachusetts for their residency training. This prejudice also exists in many other major metropolitan medical schools and their affiliated teaching hospitals. Anti-family medicine bigotry is also alive and well in Dallas and Houston.
When Dr. Melnitsky was asked in medical school what field she wanted to enter, an infectious disease professor railed against her educational plan saying it’s impossible to learn adult medicine, pediatrics, and obstetrics in three years. This scorn is commonly heard among medical students who are brave enough to voice their intention to become family physicians, and not just in Massachusetts.
Relying on new general internists won’t save the state from its primary care shortage. A recent survey of medical students about to enter internal medicine residencies found that less than 10% of the students expect to practice as primary care physicians. Internists’ scope of practice is narrower than family physicians. For example, most internists don’t diagnose and treat gynecological symptoms and family physicians do.
Harvard Medical School doesn’t have a family medicine department or even a family medicine division of another department, which helps explain why only about two percent of its graduates typically go into family medicine. Mass General Hospital has only a handful of family physicians on its medical staff of thousands of physicians who admit patients to the hospital, even though caring for hospitalized patients is within the scope of family physicians’ practices.
Research-focused medical schools such as Harvard collect about one-third of their revenue from federal research grants. Because there is no institute within the National Institutes of Health that funds primary care research, the institutionalized medical school prejudice against family medicine has deep financial roots. Why should Harvard hire family physicians for its faculty if there is no institute to fund their research questions?
Institutions such as Mass General and Brigham & Women’s Hospitals have enhanced their reputations on patients who travel 1,000 miles to Boston and finally have a rare disease diagnosed by one of their doctors. Armies of sub-sub-specialists at the medical schools make these journeys possible. However, a physician workforce necessary to staff a super-regional referral center is not the same workforce necessary to deliver affordable healthcare across a state.
Family physicians exist in this bigotry belt, but based on multiple conversations with physicians in that region, many have very limited scopes of practice, especially in the cities and affluent suburbs. It’s kind of like bad parenting. The prevailing tertiary hospital-driven medical culture convinces many urban family physicians they are incapable of caring for any patient with a disease other than mild high blood pressure, diabetes, or a cold. The family physicians, as well as many of the general internists, insist their patients also have appointments with many other doctors for diseases and procedures family physicians are fully qualified to manage. The family physicians have been told by every facet of the medical establishment they can’t do much, so many eventually believe it. Dr. Joe Gravel, a family medicine educator, heard a colleague exclaim, “How can we train family docs about diabetes if they don’t go to endocrinology clinic?”
There are a few pockets in Massachusetts where family physicians practice a more complete scope of generalist medicine – mostly the poor underserved pockets of the state. Dr. Gravel teaches family medicine at a residency in Lawrence, which has the second highest poverty rate in the state. Few obstetricians practice there, so family physicians deliver more babies than the OBs. In Lawrence and inner-city neighborhoods in Boston, a handful of family physicians are even allowed by the hospital privilege committees to perform Cesarean sections. Dr. Gravel also knows of a few family physicians with broad scopes of practice who work in more affluent areas.
Dr. Gravel is very optimistic about the future of family medicine in Massachusetts. He believes many of the states political and business leaders are beginning to see the value of family medicine and have recognized that most young internal medicine and pediatric residents ultimately narrow their scope of practice and don’t practice as primary care physicians. “We’re the only physicians providing primary care,” notes Dr. Gravel.
Dr. Melnitsky hasn’t decided if she will ever go back. She’d like to. Her heart is still in Massachusetts. But lower taxes and a student loan repayment program will probably keep her in Texas at least for several years after she completes her family medicine residency. She wants to practice in a rural area and occasionally go on medical mission trips to Central America, where she met her husband. A few areas of Massachusetts might allow her to fully practice all the skills she acquired in residency training. However, once a physician establishes a practice relocating isn’t impossible, but it’s not the norm.
Massachusetts’ journey to insure most of its citizens is a cautionary tale applicable to all other states with influential medical schools and their affiliated hospitals. Dr. Melnitsky’s dilemma means that for the state to ever grow the primary care physician workforce it so desperately needs, the financial incentives and prevailing attitudes of many of its physician and hospitals, and all of its medical schools, must significantly change. Because these special interests are so entrenched, changing its venerable institutions to train the family physicians Massachusetts needs will surely be a more difficult challenge than providing most of its citizens with health insurance.