Primary care is foundational to the U.S. health system, but not enough students are entering the field. Whether students are interested in medicine, nursing, social work or pharmacy — it is critical that we share the exciting aspects of primary care and then adequately prepare them to work in the field. High loan burden and low pay relative to other potential jobs and specialties and training within a culture that devalues primary care discourage students from entering the field.
A formative experience
When it comes to deciding which field to enter, one of the most influential factors may be primary care rotations. Students must be exposed to the best that primary care has to offer. Schools need to carefully curate the practice experiences that are offered.
As articulated by Barbara Starfield, the core attributes of primary care include “first contact” access, comprehensiveness, continuity, and coordination ( the 4 Cs), and these need to be experienced by students in continuity settings.
Students should train in patient-centered medical homes that offer team-based care focusing on the 4 Cs with teams that include primary care physicians, nurses, nurse practitioners, physician assistants, pharmacists and social workers, along with support from medical assistants, receptionists and other team members that may include community health workers and health coaches.
Working together, the team offers comprehensive, equitable care that enables patients to have their medical, social, and emotional needs met. Given the frequency of behavioral health conditions, harmful health behaviors, and barriers to care caused by social determinants of health, integrated behavioral and social resources are key to creating a practice designed to meet patients’ needs. Further, teaching practices should address the seven shared principles for primary care identified by the Primary Care Collaborative.
These include that primary care is: 1) person and family-centered, 2) continuous, 3) comprehensive and equitable, 4) team-based and collaborative, 5) coordinated and integrated, 6) accessible, and 7) high value. And practices offer exceptionally positive experiences to patients, staff, and clinicians.
For inclusion as teaching practices, I also suggest that we insist that practices offer students exceptionally positive experiences. Students should be surrounded by teachers, which include clinicians, staff and patients who believe that primary care is the essential foundation of health care and that there is no other health care work that has the capacity to have a profound effect on patients’ lives. Students should learn that primary care is a social good.
Research shows primary care is the only health care specialty with the capacity to extend lives at the community level and that high-value primary care addresses equity and social needs, improves care quality for patients, and offers the opportunity to reduce the growth in health care costs.
Qualities of the teaching practice
To qualify as teaching practices, we should insist that practices leverage telemedicine and virtual care to meet patients where they are while also having ways to connect with patients who lack access to smartphones and computers.
Practices must be supported by population health teams that assure preventive services are offered to patients. This includes the use of pharmacists to assist with titration of medications for diabetes and hypertension. Practices need a culture of innovation and improvement with designated staff and clinicians to work on those activities.
Finally, and most critically, practices should be paid in a value-based way that frees clinicians and staff from the inequities and limits imposed by fee-for-service medicine. If not in place yet, practices should advocate for increased payments to make these services sustainable. At a minimum, there should be documentation showing that at least 10% of patients’ total medical expense is devoted to primary care services, or practices should be engaged in advocacy to make this happen.
Practices that meet these criteria should be entrusted with the education of our students. If we can provide these kinds of value-based experiences, we will not face as many challenges recruiting students to the critical field of primary care. Not only will we address the shortage of students entering the field, but we will also address the burnout crisis.
Burnout is an expected response to working in dysfunctional systems that make it challenging to care for patients’ needs. We need students to encounter clinicians who are happy in their work, possess the tools to make an impact on their patients’ lives and are able to go home when their workday is over with their work completed.
There are examples of these practices, but we need more. One example that I have visited is SouthCentral Foundation in Alaska. Many community health centers already offer many of these services, as do many innovative entrepreneurial efforts to redesign primary care. In some places, veterans administration primary care practices and academic practices may meet these criteria, but I fear that the current amount is insufficient for the number of students we need to train.
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. Katie Cavender is a communications specialist.
Image credit: Shutterstock.com
