By Kyle Bradford Jones, M.D.

Interviewing for residency spots in family medicine, Jones traveled the country to find a patient-centered medical home (PCMH). He was surprised to learn that most programs claimed they didn't yet "know what the PCMH looks like," so they hadn't begun to transform their clinics.

When I was traveling around the country interviewing for a residency spot in Family Medicine in the fall of 2008, I was eager to find a patient-centered medical home (PCMH). At every interview, I asked whether the program's clinic was a certified PCMH or whether it was moving in that direction. "Well, we don't yet know what that looks like" was the answer that I heard at nearly every destination. This baffled me; what do you mean we "don't know what it looks like?" The Joint Principles had been released the year before; demonstration projects were in motion. What more did one need to set it up? This was being touted as the future of primary care, and as such, I wanted to be trained in that model. The program I ended up matching with was the one program that provided a different answer.
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By Brian Klepper, Ph.D.

In order for primary care to be a policy leader, and not a follower, Klepper calls for a new unifying organization that "aggregates [primary care's] many groups and collective influence" rather than "scattering loyalties among six different medical societies." 

The dream of reason did not take power into account – modern medicine is one of those extraordinary works of reason – but medicine is also a world of power.
-Paul Starr, The Social Transformation of American Medicine, 1984

How can primary care’s position be reasserted as a policy leader rather than follower? Even though it is a linchpin discipline within America’s health system and its larger economy – a mass of evidence compellingly demonstrates that empowered primary care is associated with better health outcomes and lower costs – primary care has been overwhelmed and outmaneuvered by a health care industry intent on freeing access to lucrative downstream services and revenues. That compromise has produced a cascade of undesirable impacts that reach far beyond health care. Bringing American health care back into homeostasis will require an approach that appreciates and leverages power in ways that are different from the past.
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By Karly Pippitt, M.D.

Returning to a University of Utah very different from the one she herself attended for medical school, Pippitt now directs the Longitudinal Clinical Experience that gives first- and second-year students the hands-on primary care exposure that Pippitt never had in her first years of medical school.

I spent my first two years of medical school at the University of Utah frantically cramming for Step 1. My limited exposure to patients was restricted to shadowing only. My actual interactions with them were spotty at best.  Those first two years of medical school didn’t at all reflect what I would go on to love about primary care: building relationships with patients that would span many years.

I now teach at a very changed University of Utah where students are performing complete physical exams by the end of their first semester. Through this innovative curriculum, after students have learned the physical exam, they spend the next year and a half in a primary care clinic working with preceptors, interviewing and examining patients rather than waiting until traditional third-year rotations to have these kinds of experiences. I now lead this Longitudinal Clinical Experience that provides students opportunities I never had in my first years of medical school: the early exposure to primary care that is crucial to the future of health care. 
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By Joji Suzuki, M.D.

As a fellow in Harvard Medical School Center for Primary Care's Innovation Fellows Program, Suzuki is implementing a collaborative model of care through which a team of clinicians will work with primary care physicians to treat opioid addiction. 

Opioids, found in prescription pain medications like oxycodone or morphine, are extremely important in helping to alleviate pain and suffering. They are dangerous, however, if misused. Once addicted, users find it extremely difficult to stop due to the intense cravings and withdrawal. Also found in heroin, opioids are very expensive, costing as much as $100 to $200 a day for a moderate habit, and even more for heavier users. Many users resort to stealing, dealing, or prostitution to support their addiction. Particularly for users who transition to intravenous use, health problems also begin to accumulate, such as HIV, hepatitis C, abscesses, heart problems, overdoses and death. In Massachusetts, opioid-related overdose deaths were the leading cause of injury deaths in 2007 and the third leading cause of death overall behind heart disease and cancer.  As can be imagined, someone living this life will have difficulty maintaining employment, raising a family, and contributing to society.
 
As an addiction psychiatrist, I have seen how addiction can wreak havoc not only on patients’ lives, but also on the lives of members of their family and community. Adding insult to injury, though many chronic conditions – such as HIV, cancer, obesity, diabetes and hypertension – result in part from personal lifestyle choices, patients dealing with addiction, as well as their families, face particular stigma for their circumstances.
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By Katie Gesbeck

In pediatric neurology and surgery rotations, Gesbeck found herself frustrated with focusing on only a particular organ system or problem and not on the child as a whole. She knew she wanted to care for the whole person.

One evening during my first year of medical school, I was waiting by the entrance to The Salvation Army to let another student back into the free clinic.  The weekly clinic was organized by MEDiC, an organization of student-run free clinics in the Madison area.  A family with four small children was returning to spend the night at the shelter, and one of the kids saw the stethoscope around my neck.

“What’s that?” A boy who was about five years old asked.

“It’s so I can listen to hearts,” I explained. 

Then they all wanted to know if I would listen to their hearts and if they could listen to mine.  Spending that time with them, showing them how to listen to my heart, and making sure they all had a turn was the highlight of my day. I knew that I wanted to have interactions like that every day. 
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By Joseph Pelli

Embarking on his final year of medical school, Pelli calls on his classmates (and himself) to take a step back and remember the idealism that brought them to medical school in the first place.

Six years ago, as pre-med undergraduates, my roommate and I founded an idealistic non-profit called The Mission Health Inc.  As a worldwide Christian community service organization, we have since taken groups of college students and physicians on medical missions to Haiti – both pre- and post-earthquake – six times as well as Kenya, Honduras and Peru.
 
The idealism that drove us to found Mission Health was the same idealism that eventually drove me to medical school. I’m going to take a leap here and say that most physicians were originally driven to medicine by a similar idealism: the desire to “help people.”
 
This noble goal motivates students through O-chem, MCAT and STEP I. But now between my third and fourth years of medical school, I have become quite dismayed by how easily and often I seem to forget the grand goals of serving others that were outlined in my personal statement and focus instead on my own responsibilities and lifestyle. The burdens of clerkships, clinic and call have begun to weigh down mine and my colleagues’ once lofty ambitions. 
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By David Nash, M.D., M.B.A.

Medical school dean says upholding of The Affordable Care Act lets us get to the real task at hand: transforming the U.S. health care system.

My initial reaction to the Supreme Court’s ruling to uphold The Affordable Care Act was to breathe a sigh of relief.  The law, particularly the individual mandate – the cornerstone provision – is constitutional and now we can get on with the real task at hand of transforming the U.S. health care system into one in which high-quality and safe care is delivered in an effective, timely, and patient-centered manner. To me, that’s the bottom line. And I don’t think the real task at hand would have changed had the Supreme Court struck the law down.

That’s what I kept reminding myself as I awaited the decision in a crowded conference room with many of my colleagues from the Jefferson School of Population Health. Upheld or struck down, the mission would continue.
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By Trista Stankowski-Drengler

Student in the Wisconsin Academy for Rural Medicine blows the whistle on myths that research and innovation are not happening in rural areas or in primary care.  

Many advocates of primary care have speculated as to why so few medical students choose primary care.  Some argue it’s the reimbursement discrepancy; others say it’s the care delivery model. Still others say students don’t know that exciting research and innovation are taking place in primary care just as in other specialties.  These argue that to address this issue, medical schools must expose students to these innovations, to modern (and more attractive) models of care.
 
The same can be said of rural medicine. Many students don’t consider practicing in rural areas because they don’t know what these areas have to offer. They don’t know, for example, that one can practice in a rural area and still be involved in clinical research or practice in modern, state-of-the-art facilities.  Likewise, to address this knowledge gap, medical schools must expose students to the reality of rural practice.
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By John Corker

The misconception that primary care is dull is just as damaging as the salary discrepancy, says John Corker. By his third year in medical school, Corker saw that primary care is anything but boring and that the misconceptions of many are far from reality.  

The AAMC projects that by 2015 - the year after the Affordable Care Act is scheduled to add approximately 32 million patients to the ranks of the insured - we will have 63,000 fewer physicians than we need in the United States.  If nothing is done, that number is then projected to surpass 130,000 by 2025.  Unfortunately, as of this time one year ago, these "projections" had already become reality for 22 U.S. states and 17 medical societies across the country.
 
While these shortages span all medical specialties in most of the country, the day-to-day strain is felt most in primary care and in the under-served areas of our urban and rural communities.  Already, foundational efforts are underway to address this growing shortage.  Medical schools are increasing class sizes.  And, since 2007, 18 new medical schools have opened and 10 more are in the works – many created with the express purpose of training more primary care physicians.
 
Despite these new schools' best intentions, however, they cannot force students to choose primary care after graduation.  This challenge in recruiting students to primary care will arguably be the biggest obstacle (adequate Graduate Medical Education funding for residency slots being the other) that we face in our ongoing attempts to train enough doctors to meet our growing population's needs.  Before we can adequately tackle this daunting challenge, however, we must first understand why medical students are avoiding primary care to begin with.
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