New Medical Schools Aim to Double Primary Care Graduates

Marcia Frellick

April 05, 2013

Among the nation's newest medical schools are 2 that stand out for the career path they are emphasizing: primary care.

Quinnipiac University's Frank H. Netter MD School of Medicine in North Haven, Connecticut, and the University of California–Riverside School of Medicine both will admit their first students in August. They hope to at least double the percentage of graduating physicians who typically choose primary care.

A study published online December 4 in JAMA found that only 21% of third-year residents planned to enter internal medicine.

Primary Care Shortage Critical in California

In California, the need for the medical school mirrors the dire need for primary care physicians in the surrounding counties.

The area surrounding the Riverside medical school, known as the Inland Empire, has 40 primary care physicians per 100,000 people, according to the California Health Care Almanac, which is far short of the federally recommended 60 to 80 primary care physicians per 100,000 population.

Riverside's Vice Chancellor for Health Affairs and Senior Executive Dean Phyllis Guze, MD, FACP, said that means people asking to see a primary care physician have to wait several months. "And that's just the people who have insurance."

The medical school's primary care focus will be evident in changes regarding where and with whom students learn.

First, most of the teaching will come in an ambulatory setting.

"Maybe 80% to 90% of traditional medical education has occurred in the hospital, whereas 93% of all medical care occurs in the ambulatory setting," Dr. Guze said.

In flipping that clerkship model, students from their first year will pair up with a physician in an ambulatory setting and follow particular families throughout their medical school years.

Another piece of the model will be working on a community service project. A student on a pediatric rotation might collaborate with community members working to improve immunization rates, and someone in an internal medicine rotation might staff a teenager pregnancy hotline, Dr. Guze said.

Often-cited reasons for low numbers of physicians choosing primary care include perceived lack of prestige compared with specialists and schedules that can be high-volume and chaotic. However, often the choice comes down to finances. Students commonly graduate with 6-figure debt loads and then do not make nearly as much as specialists make.

Dr. Guze said one way Riverside is battling that disparity is by offering a scholarship-to-loan program. Scholarships will be awarded on the basis of merit and need. If students practice primary care in the region, they keep the money as a scholarship. If they decide against primary care, the scholarship becomes a loan.

Quinnipiac Board Makes Personal Commitment

Quinnipiac has developed a similar program called the Primary Care Fellowship.

Bruce Koeppen, MD, founding dean of the Netter school, told Medscape Medical News that at least one fellowship will be offered in the charter class of 60 students, which begins in August. The fellowship includes a full tuition and fee waiver for 4 years. If the graduate practices in primary care for 4 years, he or she keeps the money. If not, it becomes a loan.

"We hope eventually that we will have the capacity to name every single student in every class a primary care fellow if that's their desire," Dr. Koeppen said.

Original funding for the fellowship came from a board member who said, according to Dr. Koeppen, "I'm committing $50,000 today on the condition that by the end of today 3 more of you match my gift."

"This was 4 in the afternoon. By 6 pm, we had $200,000 in the endowment," Dr. Koeppen said.

That support — from the board to the administration, as well as the faculty hired according to their support of primary care — is essential to the success of the mission, Dr. Koeppen said. Buy-in also extends to the partner hospitals.

"As we have signed up our affiliated hospitals, we have made sure that they fully support our mission in primary care, which means that their specialists will not talk it down and will support it. We hope we're creating a program where primary care is celebrated, not denigrated," he said.

Finding the Right Applicants

Identifying those students who are most likely to choose primary care for the long haul is the first challenge, said Henry Sondheimer, MD, senior director for medical education projects at the American Association of Medical Colleges (AAMC).

Those candidates often live in the area and come from rural backgrounds and are more often women and older students, he said.

"All our data at the AAMC shows that the effect of your medical education on your career choice is relatively small. The secret sauce is admissions," he said, and choosing students with the appropriate background will be key to these primary care programs' success.

Another measure of success for these schools will be to produce a different type of primary care physician, Dr. Sondheimer said. Primary care physicians of the future will more often work in multidisciplinary team settings and need to develop management and collaborative skills in addition to receiving an MD or DO.

The Commonwealth Medical College (TCMC) in Scranton, Pennsylvania, is among a few medical schools that opened in the past few years with an emphasis on primary care. TCMC opened in 2009 and replaced the traditional model of episodic rotations with one in which students are assigned to a single cohort of patients that they follow through their 4 years.

"We think that's critical to addressing the hidden curriculum," said Steven Scheinman, MD, the college's president and dean. "It's well-documented that students in medical school will come to objectify their patients and talk about them in the third person, even when they're in the room with them.

"A longitudinal relationship with a patient really makes them real to the student and not just an episodic learning opportunity," Dr. Scheinman said.

TCMC will graduate its first MDs next month, so future years will yield more clues as to whether the school can help strengthen the primary care workforce in the area.

Still, Dr. Scheinman said he knows medical schools are only part of the solution. "Medical schools can do as much as we can to get students to choose primary care, but we're up against lifestyle choices and reimbursement forces that are larger than us."