A Remedy for the Primary Care Gap
I’m now of an age where I can look back over roughly a half-century of practicing medicine and consider some of the different approaches I’ve witnessed, and have been part of, in my time. With that perspective comes the realization that the problems we face in medicine, whether here at home or elsewhere in the world, remain only partially solved. Delivering accessible care to people remains a challenge for our profession.
Consider those living on islands in the Pacific under British control in the 1960s. When I visited Fiji then, the British authorities were in the process of shutting down the medical practitioner (MP) schools they had established to care for the islanders. The MPs were not full doctors, but rather local people trained to provide effective health care to a mostly rural, widely distributed population. The system worked well. By closing the schools, the British were following the same shift toward specialization that Americans were experiencing.
In the early 1970s, the new model of the multispecialty practice arrived in the United States. I saw this firsthand as one of the founders of the Matthew Thornton Health Plan in New Hampshire. The founding physicians were all members of a close-knit team. If I had a question, I could simply walk across the hall and ask a colleague, “Say, would you take a look at this?” That intimate approach made medicine fun; it also allowed me to provide comprehensive primary care even though I had trained as a specialist.
Before long, the big insurance companies modified their products to look more like HMO coverage, eventually displacing many of the original community-based, nonprofit HMOs. The feeling of a medical team was lost as companies established contracts with doctors who were often miles apart.
Doctors in the early HMOs were zealots for the cause of creating effective and affordable health care for their patients, but this changed as physicians began to prefer the lifestyle and economic advantages of the fee-for-service system. The trend away from primary-care practice has continued, largely unabated. This is the crisis in U.S. medicine that persists: We have too few primary-care doctors to go around.
Here at Tufts, we have taken steps to remedy the situation. We give our students early exposure to primary care. Toward the end of first year, they visit doctors’ offices weekly and get the chance to observe patients interacting with their physicians the old-fashioned way. They can see with their own eyes how enjoyable a primary-care practice can be.
Meanwhile, we have built a highly resilient family medicine program that prompts more than 20 students a year to pursue residencies in that field. In these times, those numbers represent a remarkable measure of success.
The success of our Maine Track program has inspired another new initiative on our part. The new program will improve the delivery of medical care to neglected urban areas in our country through the recruitment, training and placement of young people dedicated to serving the needs of the inner city upon graduation (see “Universal Care,” page 38). The new program will be comparable to the Maine Track, but with service to a different patient population.
I find it interesting that the challenges and the solutions haven’t changed much over the past half-century. In an irony that doesn’t escape me, Tufts now sends an average of 30 or 40 students a year to India to acquire the essentials of community medicine, at which our partners at Christian Medical College in Vellore, South India, are masters, with their frequent home visits and intimate knowledge of local residents. Fifty years ago American doctors—myself, a young Peace Corps physician, among them—went to India to help provide medical care. Now we send Tufts students there to learn.
Harris A. Berman, M.D., is the dean of Tufts University School of Medicine.