On a typical day at Smiley’s Clinic in south Minneapolis, the parking lot just off Hiawatha Avenue is more than half full by the time doors open at 8 a.m. To kick off his day, one of the clinic’s family medicine residents, Richard Brown, D.O., sees two siblings with lice, then a college student with symptoms of depression. Next come a husband and wife — one needs an X-ray, the other a procedure on a cyst — followed by a fussy and feverish toddler, a woman with diabetes complications, and a patient needing a straightforward pre-op exam.
And it’s not yet lunchtime.
As a third-year resident, Brown typically sees 11 patients in the morning and another 11 in the afternoon. On top of that, he does curbside consults with colleagues, makes follow-up calls to patients, handles medication refills, updates medical records, delivers the occasional baby, and, through it all, keeps learning.
“There’s never a boring day in family medicine,” says Brown, “and since I’m not a fan of saying, ‘That’s not what I do,’ it’s a perfect fit for me.”
Fifty years ago, around the time Marcus Welby, M.D., reigned supreme on American TV, the family-doctor life was a good fit for about half of the country’s physicians. But today, fewer than one in three doctors works in primary care. Now, as the nation faces a worsening shortage of family physicians, medical schools across the country are scrambling to figure out how to encourage more students to choose family medicine.
They would do well to look to the north, to the University of Minnesota.
Web extra: Family medicine residents at work
According to the American Academy of Family Physicians, only about 9 percent of students graduating from MD programs in the United States choose to enter family medicine residency programs. But at the U of M Medical School, that number is about 19 percent — typically about 40 students per year — more than twice the national average and the highest in the country.
To understand how Minnesota wound up on top means going back more than four decades, when two significant plans were implemented. First, the Medical School launched the Rural Physician Associate Program (RPAP), giving third-year students a chance to spend nine months in a rural community learning about family medicine. Established in 1971, RPAP was the first program of its kind in the world; since then, more than 1,300 U of M medical students have participated in RPAP, and four out of five of them have gone on to practice primary medicine, many of them right here in Minnesota.
First-year resident John Tronnes, M.D., consults with third-year resident Steve Solum, M.D., at the CentraCare Family Health Center in St. Cloud. (Photo: Andra Johnson, CentraCare Health)
Then, in 1972, after the state Legislature charged the U with increasing the number of both primary care physicians and Native American doctors, the Medical School opened its Duluth campus, which was the starting point for many of the family practitioners coming out of Minnesota.
“It starts with recruiting the right students,” says Jim Boulger, Ph.D., a Duluth-based family medicine professor and director of the U’s Center for Rural Mental Health Studies. “We seek out students who have grown up in rural settings, who love that life, and have indicated a desire to practice family medicine.”
Even first-year Duluth campus medical students spend time in smaller Minnesota communities, living with practicing physicians and their families, to get a real sense of what it’s like to be a family doctor. The approach works: 47 percent of these students go on to practice family medicine, and 40 percent of them end up practicing in rural areas. Even better news? Seventy-five percent of Duluth’s students choose to practice in Minnesota and western Wisconsin — a big retention win.
These initiatives, of course, depend on a veritable army of practicing family medicine doctors working in small-town clinics and hospitals across the state who regularly welcome students into their homes and voluntarily teach them about family medicine. These preceptors play an essential role in Minnesota’s winning formula for training primary care physicians.
“The problem now? We can’t squeeze any more medical school graduates into our existing residency programs,” says Boulger. “They’re all full. But with Minnesota coming up short by a couple thousand family docs within the next 10 years? We desperately need more residency spots to train these doctors.”
Boulger’s concerns are well founded. According to studies from the Robert Graham Center, Minnesota will be short by a projected 1,187 primary care physicians by 2030.
Preceptor and alumnus Thomas Heinitz, M.D., discusses a patient’s care plan with first-year resident Jesse Susa, M.D., at the Duluth Family Medicine Clinic. (Photo: Derek Montgomery)
Steady hand at the helm
“It gets frustrating when we know so much about how to do it right and we still can’t make that happen,” says Macaran Baird, M.D., M.S., who has led the Medical School’s Department of Family Medicine and Community Health for 15 years and is now planning his retirement.
Given his genial nature, it’s not surprising that Baird seems to know everyone: state legislators, insurance executives, Medicaid administrators, and a legion of practicing physicians. And it’s a good thing. In the course of his day, he may well need to call on any or all of them to help keep his ship on course.
“It’s a complicated business, sure,” says Baird, who points out that the rest of the world already emphasizes primary care, because it costs less.
In a 2013 speech, Margaret Chan, O.B.E., J.P., the director-general of the World Health Organization, drove home the point when she said, “In some countries where chronic diseases are the principal health burden, family doctors manage 95 percent of the health problems while absorbing only 5 percent of the health budget.”
Baird’s second point: When primary doctors serve as the linchpin for all of the patient’s health care needs, morbidity and mortality are reduced.
“The best scenario is to place rich resources within a single facility, a place like Smiley’s,” says Baird, “because once patients leave that site to chase down problems on their own, it becomes ‘fragmented care.’ The enemy in the system is fragmented care, and it’s a huge problem in the U.S.”
Bottom line, he says, the state must support and grow family medicine residency programs to meet needs as Minnesota’s population ages and today’s primary care doctors retire.
“It’s too bad I can’t come up with a sexy slogan that boils it all down to a couple of words that fire people up,” Baird says, “but this is the best I can do: We need to integrate mental health and public health into primary care, and make fragmented care a never-event, because it costs lives and yields suffering. I’ll fight to the grave for that.”
(Photo: Scott Streble)
‘Raise our voices’
The U’s family medicine residency program got an unwelcome jolt last year when a public bidding process eliminated UCare as a provider of health insurance to low-income Minnesotans through the state’s Medical Assistance and MinnesotaCare programs.
UCare, which was started by the U’s Department of Family Medicine and Community Health before becoming an independent nonprofit organization, also supported the department’s residency programs financially, typically providing about 10 to 15 percent of the department’s funding. Without those dollars, the U is now scrambling to keep precious residency programs afloat.
“It’s not financially feasible to run a residency program — they don’t pay for themselves,” says Patricia Adam, M.D., M.S.P.H., the residency program director at Smiley’s Clinic. “Most residency programs across the country get funding from state or federal governments. But Minnesota doesn’t subsidize [most] U of M residencies.” (Of the U’s eight family medicine residency programs, only St. Cloud receives state funding.)
This year, the U has asked the state Legislature for $5.25 million in annual funding for family practice residency training beginning in 2018, with an additional $2 million tacked on in 2019, for what it calls “health training restoration,” following the loss of UCare funding. Those dollars would support clinical training, education, and research programs within the family medicine department and at its eight training sites in Minneapolis, St. Paul, Duluth, St. Cloud, and Mankato, and the UCare Mobile Dental Clinic.
“Without that state support,” says Baird, “several residency programs may be at risk.”
Adam feels the urgency keenly.
“As a family medicine doctor, I’ve also had to become political,” she says. “I’m scheduled to go to the state Legislature to talk about how important primary care is, about how critical we are to the well-being of the state of Minnesota. Do I like doing that? No. That’s not why I became a doctor. But now we all have to raise our voices.”
Adnan Kassim gets a cast from Smiley’s Clinic third-year resident Moaweya Zayed, M.D. (Photo: Scott Streble)
The good life as a family doctor
Will Nicholson, M.D., is one of those family doctors who is from Minnesota, trained in Minnesota, and now practices in Minnesota. And he loves it.
“I love the idea that family doctors are part of the community and become real advocates for their patients, looking for the root causes of recurrent problems,” he says.
Nicholson, who grew up in White Bear Lake and finished his residency in 2009, now heads up the family medicine hospitalist program at St. John’s Hospital in St. Paul.
“The more primary doctors you have in a community, the cheaper and more effective health care will be,” he says. “We’re lucky to be here in Minnesota, where we’ve figured that out to a greater degree than most other places in the U.S.”
Another U of M graduate, Ryan Fier, M.D., who now practices family medicine in Baxter, Minnesota, agrees. “I feel like the U’s residency programs are the hotbed of family medicine in the country. As I traveled to interview with other programs, I saw there just wasn’t a better place to train than here in Minnesota.”
As the physicians who work closest to patients, family medicine doctors represent the first and, arguably, best line of defense for improving outcomes for a society increasingly plagued by chronic health problems. In that, the University remains laser-focused.
“Research has shown us that we have better health care when it’s built on a primary care system,” says Boulger. “At the U, we understand that and, top to bottom, we’re all unified behind the mission to educate outstanding family medicine doctors.”