Guest Editorial

Trial by Firings: Lessons in Organizing at NewYork-Presbyterian

October 19, 2015 02:00 pm Residents of Columbia University/NewYork-Presbyterian's Family Medicine Residency Program

The room, filled with physicians wearing crisp white coats and solemn faces, was pin-drop silent. Silent, that is, except for the new family medicine intern who could no longer hold back her tears.

Residents at the Columbia University/NewYork-Presbyterian Family Medicine Residency Program do most of their inpatient rotations at The Allen Hospital, a 200-bed, community-based facility.

She was crying because after four years of premedical studies and four years of medical school training, she was being told that her decision to pursue a career in primary care in New York City was foolish.

She was crying because after an anxiety-ridden interview and match process, she had finally matched to her dream residency. Now she realized, just a few months into her training, that her hospital administration looked down on her entire profession.

But mostly, she was crying because after her third straight 80-hour work week, she was being told that she and the more than 30 other primary care physicians in the room were being fired.

On Oct. 12, we were informed that the CEO of NewYork-Presbyterian Hospital (NYP) and the dean of the Columbia University College of Physicians and Surgeons (P&S) had decided to divest from primary care and shut down our family medicine residency program. It was not due to financial constraints. After all, NYP ended the 2014 fiscal year with more than $4.6 billion in revenue,(www.modernhealthcare.com) and net revenue exceeded $365 million. Instead, the shell-shocked primary care physicians in the room were simply told that delivering high-quality primary care in the Manhattan/Washington Heights community was no longer a strategic priority for NYP(www.capitalnewyork.com) and that the hospital planned to expand its ambulatory clinics in wealthier areas of the state, such as Westchester,(careers.nyp.org) and focus its resources on high-margin subspecialty care.

Residents (left to right) Zane Martindale, M.D.; Olivia Perlmutt, M.D.; Anoop Raman, M.D., M.B.A.; Emily Holt, D.O., M.P.H.; Michael Spertus, M.D.; and Christine Chang, M.D., entered the Columbia University/NewYork-Presbyterian Family Medicine Residency Program in 2013.

Unfortunately, given the news of late, this may sound all too familiar. Driven by the bottom line, CEOs all over the world make decisions that adversely affect people.(www.nytimes.com) The difference, of course, is that Columbia University and NYP are not-for-profit organizations. They are venerated institutions established with the intention of serving the public good, as enshrined in NYP's motto, "We Put Patients First." The profits they make are not taxed because they are meant to be reinvested in the communities they serve.

It's clear that what New York City and America need from our medical academic institutions is more primary care, not less. With an aging population and millions of people gaining access to health insurance(www.cbo.gov) through the Patient Protection and Affordable Care Act, the need for more centers of excellence for comprehensive primary care has never been more acute.

The family medicine residency program at Columbia University/NYP(www.columbiacfcm.org) is a linchpin in this pipeline, especially given its history and reputation. During the two decades that the program has been in existence, we have trained more than 100 family physicians. At our Farrell Community Health Center, new family physicians are trained to be primary care specialists. We learn to deliver prenatal care; to insert intrauterine devices; to manage diabetes, hypertension and heart failure; to perform school physicals; to counsel people on smoking cessation; to see the elderly on home visits in their walk-up apartments. In short, we learn to deliver great primary care to those who need it most. The graduates of the program practice primary care all over the world, from Australia to rural American Indian reservations. But many of our graduates also stay close to where they were trained, working in clinics in both wealthy and underserved areas throughout New York City.

And yet, in this moment when the nation and the city need academic medical centers to invest more resources into primary care and innovation in care delivery, Columbia P&S and NYP planned to divest. They planned to tell the more than 5,000 uninsured and underinsured patients we serve at our family health center to go find new physicians. They chose to increase the wait times for underserved patients in Washington Heights to find a primary care doctor and, thus, to increase the already prolonged wait times in the ERs(blogs.wsj.com) where these patients would inevitably end up -- sicker and untreated. And they chose to tell Columbia P&S medical students who were interested in family medicine and primary care that their mentors were being fired.

Residents (left to right) Quang Huynh, M.D.; Lalita Abhyankar, M.D.; Elyceia Dortch, M.D.; Sharon Chacko, M.D.; Lara Harisay, M.D.; and David Jang, M.D., joined the residency program in 2014.

What is incredible is that these two decision-makers have such awesome power. With one decision, they could rob a community health center of its family physicians and gut a training program that has produced excellent primary care physicians. Perhaps worst of all, their decision sent a ringing message to a generation of medical students that family medicine is not a field they should choose if they go to an elite medical school.

And yet, what also is incredible is that less than 36 hours after they handed down their brazen edict, they took it all back.

In those hours, the hospital and medical school administration learned how much primary care means to students, the city and the country. In those hours, we learned how much power we have as a community when we come together to make our voices heard. And in those hours, we all learned how much harder we will have to fight to make family medicine a respected profession at this academic institution.

What happened during those hours was truly amazing. Moments after the decision was handed down to us in that packed and somber room, the residents and faculty began mobilizing. Residents taught faculty how to send their first tweets. Medical students who heard about the decision via texts and social media began organizing a massive town hall meeting(columbiaspectator.com) and demanded the dean attend to explain the decision. Sympathetic journalists quickly found out about the decision and began reporting.(www.ibtimes.com) Government officials from New York City Hall to the White House were quickly briefed on the situation and began advocating on family medicine's behalf.

And as remarkably as the bad news was handed down to us in a quiet room, the announcement reversing the decision was disseminated to us … on Twitter.(twitter.com)

Residents (left to right) Laura Belland, M.D.; Rebecca Roach, M.D.; Hyowoun Jyung, M.D.; Daniela Fanto, M.D.; Jenny Bohrman, D.O.; and Mary Claire Abbot, M.D., entered the program this past June.

Although we cheered the decision -- and we have been awestruck by the power of our community of family doctors, government allies and student leaders -- we remain clear-eyed about the obstacles that lie ahead.

At the town hall meeting, the dean was asked about the need for more primary care doctors. Tellingly, he said that although family medicine is "an important part of the American medical scene, and we don't discourage our students going into FM, our primary goal is not to train family physicians, which is the goal that some state schools have."

Now, we do not expect Columbia University to single-handedly fill the primary care chasm. But we do expect large, well-endowed academic institutions like Columbia to play a leading role, to use their enormous resources to pilot and pioneer new ways of delivering primary care, to fund family medicine departments adequately and, most of all, to inspire some of their brilliant medical students to become brilliant leaders in primary care. It's not enough to simply "not discourage" them from the field.

For now, NYP and P&S have heard our voices. For now, the decision they made on Oct. 12 has been reversed. But this battle for primary care to be respected, for family medicine to be funded, and for institutional change to be enacted(www.npr.org) has just begun. This no doubt will be a marathon, not a sprint. Yet, our success has shown us that people coming together and mobilizing toward a common goal can make all the difference in this fight.

We have now seen that even in big-city academic medicine, family medicine can prevail. Indeed, for the sake of cost, quality and access(www.hindawi.com) in our nation's health care system, we must prevail.

If you would like to be a part of this effort to #growfamilymedicine, please follow us on Twitter @NYP_FamMed,(twitter.com) or contact us at familymedicineunited@gmail.com or 212-544-1881.

Anoop Raman, M.D., M.B.A.; Christine Chang, M.D.; Daniela Fanto, M.D.; David Jang, M.D.; Elyceia Dortch, M.D.; Emily Holt, D.O., M.P.H.; Hyowoun Jyung , M.D.; Jenny Bohrman, D.O.; Lalita Abhyankar, M.D., M.H.S.; Lara Harisay, M.D.; Laura Belland, M.D.; Mary Claire Abbot, M.D.; Michael Spertus, M.D.; Olivia Perlmutt, M.D.; Quang Huynh, M.D.; Rebecca Roach, M.D.; Sharon Chacko, M.D.; and Zane Martindale, M.D., are residents of Columbia University/NewYork-Presbyterian's Family Medicine Residency Program.


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