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University of Maryland program encourages medical students to consider primary care

Univ. of Maryland School of Medicine tries to get students to consider primary care early in their training.

Dr. Eugene Newmier moved to the small Eastern Shore city of Cambridge in 1997 because the state promised some help repaying his medical school loans. He soon was charmed by the lifestyle — and the patients.

He now cares for 3,000 to 3,500 people, about the most recommended under federal guidelines and more than a quarter of the city's population. But he is loath to turn anyone away.

"We need to be there," said Newmier, who has not had a physician partner for years. "A good percentage of other doctors in town don't take new patients."

With such a keen understanding from the front lines of the national primary care doctor shortage, he agreed to serve as a mentor in a University of Maryland School of Medicine program designed to excite students about such medicine by immersing them in apprenticeships early in their medical school training.

Program organizers hope it will help ease the shortfall. The Association of American Medical Colleges recently forecast the nation would need 35,600 more primary care physicians by 2025.

"When students get exposure early, many have liked it," said Dr. Richard Colgan, a professor of family and community medicine at the University of Maryland School of Medicine and its vice chairman for medical student education and clinical operations.

The Maryland program matches students who just completed their first year of medical school with primary care doctors in underserved areas on the Eastern Shore, in Western Maryland and inner-city Baltimore for two weeks.

The matches are done through three Maryland Area Health Education Centers formed in the state and around the country to help facilitate community programs.

"The problem is definitely more acute in small towns," said Newmier, who was taking a break from seeing patients one recent day with Siobhan Kibbey, a Maryland student shadowing him on the job.

Medical students typically do not see much action in a doctor's office or hospital room until their third or fourth years, but by then most students already have chosen a track that is focused on research or a specialty and not on primary care.

The Maryland program, launched four years ago, offers students a taste of the challenge and satisfaction of primary care practice, Colgan said.

"They are allowed to work alongside a family care doctor in their first year," he said. "So come their third years, they know more what it's about and are already excited about it."

The program, which Colgan helped create with an $880,000 federal grant, is showing signs of success. About one-third of the University of Maryland's 600 or so medical students have joined the primary care track and more than 75 percent of the ones graduating this year plan to become primary care doctors, he said.

The program offers other training opportunities, but it is the 80 hours with one of 150 volunteer doctors across the state that serves as the linchpin, said Colgan, who will be seeking funding to sustain and expand the program.

He still needs to evaluate what happens to the graduates, who must complete three-year residencies to practice medicine. Some might choose later to pursue a specialty or another path.

The nation's medical schools generally are producing more researchers and specialists than primary care doctors, though most doctor visits are for relatively routine health problems, according to Dr. Fitzhugh Mullan, professor of health policy at George Washington University. He studied the issue and found that public medical schools have a better track record of producing primary care doctors than private schools but all need to do better.

The nation's health care system is being strained by the millions of people who gained health insurance since passage of the Affordable Care Act of 2010, as well as aging baby boomers who now need more care for chronic conditions such as heart disease and diabetes, Mullan said.

Many medical schools are launching programs to steer students toward primary care, particularly in underserved areas. One such urban-focused program at the Johns Hopkins School of Medicine trains students to work in inner cities. But Mullan believes programs that emphasize the "social mission" will reach the most students.

"The problem is a profound one," he said. "We need generalists, people who work intimately and regularly with the population. This is where medicine is practiced most often, the heart."

Mullan said specialists and researchers are crucial, but there is a risk that the "pyramid becomes inverted," with too many specialists and not enough primary care doctors, who include family physicians, pediatricians and internists.

A major factor is the pay. Specialists generally make more money than primary care doctors. That is a big incentive for students who take out loans to pay for medical school that can top $50,000 a year.

Other programs aim to alleviate the shortage, such as the state loan reimbursement program that helps pay off medical school debt in exchange for working in an underserved area. That program lured Newmier from Cleveland and helped others work as primary care doctors without being overburdened by student loans.

A similar federal program was created by the Affordable Care Act. The federal law also encourages wider use of physician assistants and nurses under the direction of doctors.

Another problem is that hospitals are hiring many primary care physicians to become so-called hospitalists, who coordinate care for patients admitted to hospitals. While these are needed positions that improve efficiency, Mullan said, they come at the expense of the family practice.

Maryland's medical society, MedChi, reported in 2010 that there were 4,596 primary care physicians in the state, but half were hospitalists. When hospitalists were excluded, there were only 52 doctors for every 100,000 Maryland residents.

Even so, Maryland fares better than most. A 2014 national ranking by the Association of American Medical Colleges found that the state had the fifth-highest ratio of primary care doctors to patients, with 114 per 100,000 people. The national average was 91, which is below the benchmark 100 that the association deems necessary. Generally, states in the Northeast ranked the highest and in the South the lowest.

That does not mean that such doctors are distributed evenly within the state. Rural and inner-city residents have the most trouble accessing routine care, said Gene M. Ransom III, MedChi's CEO.

The shortage looms even larger as federal and state authorities push for so-called value-based care, which emphasizes wellness and preventive care. Compensation for doctors increasingly will be based on patients' overall health rather than fees for each service.

"Primary care is becoming an even more important and bigger piece of the puzzle, as they coordinate all the care," he said. "We need to make sure everyone has access to physicians."

Ransom said the University of Maryland program is a good one because it shows students what it is like to work in a family practice located somewhere they might not have considered.

"These are some great places to live," he said.

Some students do not need a whole lot of cajoling, such as Kibbey, who was working in Newmier's practice, Rose Hill Family Physicians. She learned to take patient histories, present cases to a doctor and write up notes. She got a feel for what it is like to be slammed with patients and got an understanding of how to work with nurse practitioners, insurance companies and electronic medical records.

A Montgomery County native who earned an undergraduate degree in public health, Kibbey knew when she applied to medical school that she wanted to be a primary care doctor.

"I won't be here for the six-month follow-ups," she said of patients she met in Cambridge. "But I still feel like I'm developing relationships with them. I may not see the same patient again, but maybe I see his wife. It's been really gratifying."

meredith.cohn@baltsun.com

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