Taking stock: where does the time go?

Looking at the blog, it is hard to believe that it has been nearly one and one-half years since I updated or posted anything here. Frankly, even as I write this, I am not even sure what will follow this post: blogging does not come easily for me, and other time commitments do not easily allow me to focus on the blog.

It is also interesting to think about where we are since the blog started. When I first started blogging regularly, I was working as a full-time clinician at a safety net clinic here in Richmond, Virginia. I was pushing for healthcare reform, and advocating for the legislation that eventually became the ACA. I was also a board member of the Virginia Academy of Family Physicians and had learned about the National Physicians Alliance.

From 2009 to 2014, we saw the ACA become law and now survive two Supreme Court challenges while its reforms became increasingly ingrained in Americans' daily life. We have experienced a paradigm shift in that the presumption is now that all Americans will have access to health insurance, and through health insurance access to health care. Though it is clear that there is still work to be done--and perhaps more significant reforms to come--the truth is that most Americans will no longer be excluded from the system...at least in states that have chosen to expand Medicaid.

I have seen increasingly frequent discussions on the importance of primary care and family medicine, and have become a more-active member of the Society of Teachers of Family Medicine, including serving on STFM's Communications Committee as we work to train future generations of family physicians and family medicine educators. I have also seen that a flawed approach to paying for medical care and primary care is still in place, despite the evident need for change.

I have joined the leadership of NPA as the Vice-President of Communications, and have worked with the organization's leadership to continue to encourage the implementation of the ACA while increasingly focusing on other areas of importance: bringing attention to the issues around gun violence and promoting a focus on gun violence as a public health issue, addressing the influence of big PhRMA and the medical industry device on medical practice, and encouraging physicians and patients to work together together to make good decisions that benefit patients and that conserve valuable resources and prevent harm and over-treatment.

I have moved into a leadership role teaching medical students both in a specialized honors program for medical students focused on working with medically underserved communities after completing their training, and leading a curriculum focused on the humanistic, ethical and holistic care.

I finally authored an article that was published. The article focuses on the benefit of an interprofessional service learning activity focused on providing care to Richmond's Latino community.

Finally, I became medical director at the office I joined in 2007. I took on this role in December, and have spent the past 8 months working through the challenges that have presented themselves and looking to enhance care for our patients.

So: I am going to try and pick this up again, but I am not sure where it is headed. It will probably still be an advocacy blog--as there is still much work to be done related to the ACA, and I am still committed to the work NPA is doing--but I will admit that my focus is much closer these days. Being in a leadership role in a safety net clinic has provided the opportunity for me to help make our healthcare system more responsive and accessible for everyone, and to provide holistic care for patients who have serious needs. I hope that I will be able to use the blog to describe what we have been doing in the office, what impact it has, and how we are looking to continue enhance and improve our patients' health.

I will try to be less of a stranger heading forward, and appreciate those who might come along.

Continued decline in primary care

The results of this year's National Residency Match Program (NRMP), referred to everywhere as the Match, show a continued struggles to bring medical students into primary care.

The American Academy of Family Physicians reports that fewer medical students chose to enter family medicine this year. This continues the downward trend since 1997 in the number of students choosing family medicine. Last year showed a small increase in the number, but it appears to have been an exception. This is combined with fewer and fewer residency postions offered over the same period.

So--fewer family doctors are being trained every year. Family physicians provide health care to many, many underserved areas in the United States and if the numbers of family physicians being trained continues to drop, one expects that more and more communities will be designated as medically underserved.

To add to the problem, fewer students entered primary care internal medicine and internal medicine/pediatrics programs. Primary care pediatrics has also been struggling to fill offered positions.

So--primary care physicians, who are in short supply now and will continue to be in short supply for some time are not being trained at the levels needed to maintain the workforce. The largest culprit for this seems to be worries around medical school debt: students are less likely to consider primary care if they carry high levels of debt and instead move toward better-compensated specialties. In addition, the current structure of funding medical schools and the structure of medical school educational programs appears to discourage students from considering primary care (especially family medicine) careers.

As primary care continues to be undervalued in our health care system and as primary care physicians continue to be underpaid relative to the critical role they play in the health care system, it is easy to predict further declines in the family medicine/primary care workforce until either major health care reform makes the career option more palatable for medical students or a level is reached where this difficult situation becomes a greater crisis.