Strive to Reform Health Care, AAMC President Tells Students, Residents

Darrell Kirch, M.D., president and CEO of the Association of American Medical Colleges, took the stage July 29 during the 37th AAFP National Conference of Family Medicine Residents and Students in Kansas City, Mo., to urge family medicine residents and students to take up the challenge of reforming the U.S. health care system.

"When I was a student and resident, I thought my colleagues would fix all the problems in American health care," Kirch told an overflowing crowd in the main stage lecture hall. "We didn't get it done.

"Why didn't I become cynical? Because of the convergence of things that have happened this year."

Kirch said the contemporary medical culture has been influenced by two legacies: that of Abraham Flexner, whose 1910 seminal work, "Medical Education in the United States and Canada," provided the first blueprint of medical education, and that of President Lyndon Johnson, who signed the 1965 Medicare bill that provided federal health insurance coverage to the elderly and disabled.

Flexner brought medical education back to the culture of the university, Kirch said, but Medicare solidified an economic model of medicine that is built around fee-for-service and that rewards performance of procedures and tests rather than evaluation and management skills. Physicians continue to live with that system today, he added.

Now, the Patient Protection and Affordable Care Act promises to whittle down the proportion of Americans who have no insurance, but it will create problems in access to care, Kirch said. He pointed to the lessons being learned in Massachusetts, which, in 2006, became the first state in the country to enact a law requiring its residents to carry health insurance.

"You give more people insurance, but you lay bare your access problem, and you need more physicians in primary care," said Kirch.

In the face of these political and economic realities, have we really reformed health care? Kirch asked his audience. His answer: No, it is health insurance coverage -- not the health care system -- that has been reformed.

"The lack of health insurance coverage has ripple effects throughout the entire system," Kirch said. "But we also need a rational payment system. I can't tell you how severe the cognitive dissonance is in the health care system."

The health care reform law doesn't address certain key issues that health care professionals deal with every day, Kirch said.

"The government can't create a health care team in the front lines of the clinic. You need to do that. Are we ready to create hundreds of medical homes that people need?

"In meetings, I ask, 'How many of you have health insurance?' Many hands go up. Then I ask, 'How many of you have medical homes?' Ten hands go up."

According to Kirch, medical culture is becoming collaborative, team-based, service-based, mutually accountable and patient-centered. As a result, medical education has to change, too, and become more individualized to accommodate different kinds of students, including nontraditional students who don't have a premedical degree, aspiring medical students who start their education in a community college, and physicians who leave practice temporarily and need retraining when they return.

Kirch said new and future physicians have important issues to work on, including building the physician workforce and decreasing the gaps between physician supply and demand.

"This will take our creativity and put more pressure on us to create team-based care models where everyone is working appropriately (in accordance with) their license. This is a huge challenge," he said.