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Thursday Mar 07, 2019

Spread the Word: Teaching Health Centers Deserve Support

After two weeks of working the night shift on our maternal child health service at the hospital, I was grateful to return to the Erie Family Health Centers clinic on the west side of Chicago in Humboldt Park. I looked forward to my morning schedule, which included a newborn my co-resident had just delivered, a middle-aged woman who has been making great strides with diabetes control, and an older man I see monthly for chronic pain. My session also included sibling well-child visits, a returning prenatal patient and some acute care issues. I was glad to be "home."

[headshot of Michelle Byrne, M.D., M.P.H.]

Here I am at my representative's office in Washington, D.C. Members of the AAFP Board of Directors were on Capitol Hill this week to discuss issues important to family medicine, including funding for teaching health centers.

Two years ago, as I made my rank list, training at a teaching health center (THC) was a priority for me. I had learned about THCs at the AAFP's National Conference of Family Medicine Residents and Medical Students, which offers medical students a chance to meet with representatives from hundreds of family medicine residency programs, including those based in THCs. So, as I started my fourth year of medical school, I was intrigued by the idea of training in a program that made a clinic my residency sponsor rather than a hospital.

As I progress through residency, I can see even more clearly what a profound difference this makes. Most training programs, including traditional family medicine residencies, are based at hospitals that pay residents' salaries and depend on them as a workforce. When residents spend time in community settings away from the hospital, the funding the hospital receives can be reduced.

It is no secret that our country needs a revitalization of primary care far more than a boost in the number of subspecialists. The medical education system needs to train residents to be skilled primary care physicians who consider the whole patient -- including social determinants -- use resources judiciously, and provide culturally competent health care for diverse and vulnerable populations.

The Teaching Health Center Graduate Medical Education (THCGME) program is training me and my colleagues to do exactly this.

THCs are making it possible to provide excellent primary care for some of the most socially and medically complex patients in our country while simultaneously educating the next generation of physicians -- a combination of tasks that has been described as "impossible." The objective difference between THC programs and other family medicine residencies is simply financial -- they are funded through different streams. But as a resident, the difference feels equal parts logistical and philosophical.

Logistically, our curriculum is structured in a way that prioritizes clinic time and patient continuity, and centers around team-based care. Fresh interns inherit a patient panel that they are expected to manage full-time, regardless of rotation or year. We are organized into care teams that share patient responsibility as needed to minimize delays in access and maximize continuity despite rigorous resident schedules. My clinic schedule is regularly filled with patients I know and follow, making my clinic visits more effective and enjoyable for both me and the patients.

As residents, we answer to the community health center, not the hospital. It's somewhat of a running joke that while our program is generally flexible about time off, if you have clinic on your wedding day, you better move your wedding. When push comes to shove, we are responsible for the mission of our Erie clinic, and thereby the needs of the community we serve -- not a hospital's bottom line. Residents are part of the pool for phone triage as well as weekend and evening clinic because these are services that our patients depend on, and Erie needs our help to provide them.

Freedom from a hospital budget also enables our faculty to design a curriculum that prepares us for what we plan to do. We have more flexibility in electives, enabling us to gain special skill sets in areas like medication-assisted treatment for opioid use. We have a robust curriculum in leadership, advocacy and community health so we can care for patients beyond the clinic encounter. Although we are privileged to work with excellent subspecialists in the hospital setting, the training we need is largely found with community health experts in the trenches of underserved care. THC funding gives us the flexibility to be there.

This model is working. THCs have demonstrated success at graduating residents who practice primary care and remain in underserved communities. A survey done by George Washington University(www.rchnfoundation.org) in 2015 showed that 91 percent of THC grads work in primary care, compared to 23 percent of traditional GME graduates. Furthermore, 80 percent of THC graduates work in underserved areas (compared to 26 percent of overall grads), with 19 percent of THC grads in rural areas (compared to 5 percent overall) and 45 percent in community health centers (compared to 2 percent overall).

The numbers show that this program is really extraordinary at training residents in a way that enables them to have a successful career doing what our country needs most: providing excellent primary care in rural and urban underserved settings.

Although these logistical and financial impacts of THC funding are clear, there is another piece of training at a THC that cannot be documented. Making a community health center my home for residency, instead of a hospital, provides an important philosophical shift. As corny as it may sound, I enjoy that we are expected to be a part of Erie's monthly staff meetings and included in all of its communications and events. It feels like I am a real part of the staff community, not just a resident who pops in for a few hours a week.

Having our core faculty's offices, our didactic lectures and even our lockers in clinic contributes to this cultural shift. Though my co-residents and I may be rotating in various locations during any given month, clinic is the place we continue to share.

It is clear that our country is at a pivotal point when a recommitment to primary care is needed, along with a shift in who our health care system prioritizes. If residents continue to show up to clinics where they see a handful of patients they've never met and do not feel capable of helping due to the immense social complexity they face, those residents will continue choosing careers in a hospital or private setting. Teaching health centers are visionary in their ability to facilitate the training residents need to do primary care in underserved areas.

Members of the AAFP Board of Directors were on Capitol Hill this week to discuss issues important to family medicine, including rural health, graduate medical education and teaching health centers. The AAFP is supporting legislation introduced in the Senate that would authorize adequate and sustainable funding for existing THC residency programs as well as expansion of the model. You can voice your support for the bills by contacting your legislators through the Academy's Speak Out tool.(www.votervoice.net)  

Michelle Byrne, M.D., M.P.H., is the resident member of the AAFP Board of Directors.

Posted at 02:54PM Mar 07, 2019 by Michelle Byrne, M.D., M.P.H.

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