Study: Health Center, Family Medicine Residency Pairing Is 'Match Made in Heaven'

Resident Training, Patient Care Benefit From 'Hybrid Partnerships'

January 06, 2010 07:25 pm Barbara Bein

Training family medicine residents in community health centers, or CHCs, may provide a solution to the primary care workforce shortage, according to a study by two family physicians in Seattle. Such affiliations can be encouraged through changes in graduate medical education, or GME, funding and other proposals being discussed as part of health care reform, say the two FPs.

The study( by Carl Morris, M.D., M.P.H., associate director of the Group Health Family Medicine Residency, Seattle, and Frederick Chen, M.D., M.P.H, assistant professor in the University of Washington Department of Family Medicine, Seattle, appears in the November/December issue of Annals of Family Medicine.

In the study, the authors quote one health center administrator as describing this type of affiliation as a "match made in heaven." Located in rural and other underserved areas, the CHCs that employ such arrangements get dedicated physicians to staff their clinics, the residents get the rigorous and wide-ranging clinical training CHCs can provide, and the patients receive high-quality care, they say.

"We were impressed by the benefits to both sides of this partnership," Chen said in an interview with AAFP News Now. "The CHC benefits from having a regular stream of young physicians committed to and trained in their system of medicine for the underserved. We also found that both CHCs and residency programs felt that the quality of care and teaching was higher in these partnerships."

Moreover, residents who train in a residency-affiliated CHC are four times more likely than those from nonaffiliated programs to continue to work in CHCs, according to the study.

"Best of Both Worlds"

The study's recommendations are similar to those in the Academy's recently released workforce policy, which says CHCs should be better utilized as teaching and training sites for physicians and should be funded to do so. The centers also are a way to improve access to primary care at a time when health care reform proposals are expected to expand coverage, the policy says.

AAFP Board Chair Ted Epperly, M.D., of Boise, Idaho -- who also is program director and CEO of the Family Medicine Residency of Idaho, Boise -- agrees wholeheartedly with the study's findings and recommendations. He told AAFP News Now that his residency program was rejuvenated when it officially was designated as a federally qualified health center look-alike in 2007.

"These hybrid partnerships are a win-win whose time has come," Epperly said. "They bring together the best of both worlds by providing increased teaching to residents, service to many underserved people who need it and improved cost-based financing to residency programs to stabilize their bottom lines."

Two Sides of Same Coin

The study describes how family medicine residencies, or FMRs, and CHCs face different aspects of the primary care workforce crisis in the United States: The residencies suffer from declining student interest in primary care and threats to their financial solvency; the CHCs, also known as federally qualified health centers, face serious physician shortages.

A solution is the CHC-FMR affiliation, the study says. But even though both sides agree on the mutual benefits, the number of these partnerships has remained at 25-30 for the past two decades. According to the study, two barriers to expansion have been lack of a sense of shared mission and financial problems.

Granted, both CHCs and FMRs share a mission of service to the medically underserved and their communities. But for the residencies, that calling has to be reconciled with their programs' primary mission of educating tomorrow's doctors. The most successful affiliations created joint mission and vision statements, communicated those concepts clearly and adhered to them throughout all levels of both organizations, says the study.

In fact, according to lead study author Morris -- who trained at Sea Mar Community Health Center in Seattle in the mid-1990s and subsequently worked in a rural health clinic in Tonasket, Wash. -- the two partnering entities "have to have a shared mission."

"Like any organization, if (the CHC-FMR) is challenged by internal or external problems, it will split apart," he told AAFP News Now. So these (partnerships) have to have a shared mission of education and service when things get tough."

The Almighty Dollar

Money often is a key factor in establishing and maintaining such affiliations, the study said. Financial benefits to both partners include higher reimbursement, cost-savings realized through improved recruitment of physicians and residents, and liability coverage afforded to CHCs under the Federal Tort Claims Act(

On the other hand, some costs related to affiliation are not reimbursed, such as those associated with the increased administrative requirements of residency training, increased direct and indirect clinic costs, and decreased productivity, the study said.

"A lot of the money problems have to do with the way current funding flows," Morris said. "GME funding flows through the sponsoring hospital, and then the hospital distributes it to the residency. And the calculation of the amount of GME is based on the time residents spend in the hospital and the complexity of the patients -- which have no direct relation to outpatient family medicine residency training."

The solution is to reverse that flow, he said, so GME dollars go to the residency, and the residency passes it on to the hospital for its costs.

"It makes no sense that you would fund outpatient training based on the time spent in the hospital and how sick patients are. You get a system that trains residents in the hospital and doesn't pay for the costs in the outpatient setting," Morris said.

As a result, the authors are cheered by proposals in Congress to change GME funding, particularly funds for teaching health centers, which are described as residency-CHC hybrids.

"Not only would this support these partnerships, it would be an important recognition of how valuable it is to train family physicians in community outpatient settings and not just hospitals," Chen said.