Community Based Family Medical Education
Americans can be counted upon to do everything - except the right thing. This is not what Churchill said (maybe), but there are indications of what would be right as far as a design that fits the needs of most Americans most behind. Follow the breadcrumbs of what our nations and others are doing to focus on health professionals that are a better fit with regard to most of our population that has half delivery team members doing basic services. As our nation figures out that outcomes are shaped predominantly outside of practices, our communities need to have outreach. Local origin students along the pathway to health professional training represent a win win win situation.
Traditional Medical Education Fails for most of the American population most behind. Imagine Designs For Most Americans, Not Against
- Even modified pipeline medical education will not do what is needed.
- Primary care medical schools were nearly all reshaped and outcomes were diluted or destroyed. The deans lie - has become worse
Parts of the Whole Solution
Teaching Community Health Centers (CHCs) are only a small part of a solution as the origins of the medical students, their other training, and their support to practice where needed are wrong. Teaching CHCs are not specific to three key areas that have some relationship to physician practice location where most needed
- Training in Family Medicine
- Training in a state of greatest need
- Training in one of 2621 counties lowest in health care workforce.
CHCs where most needed also need better finances, including lower costs of recruitment and retention. They need more and better team members but the financial design relegates them to fewer and lesser, mixed with some very dedicated people.
ATSU SOMA is the osteopathic medical school that drew me to Arizona to become a faculty. It was innovative in the use of the scheme presentation model. It also modified the training location. Year 1 involved training in Mesa AZ. The training moved year 2 - 4 training to CHCs is good, and better with continuation into the local FM Teaching CHC site - but few have origins aligned with the medical school and FM training in CHCs and there is no obligation and support can lack after graduation.
- And who will repay training debt and help you to move health outcomes improvements beyond the walls of the CHC or practice into the community
The National Health Service Corps (NHSC) used to work up front to influence year 1 and 2 medical students but has destroyed the AMSA HPDP and terminated programs like ours that were on target. Influences toward community based may be greater just prior to the basic science indoctrination in year 1 of medical school.
In our NHSC Community Connections program we matched up NP PA and MD students to local mentors involving community driven health projects. The students were the support needed to reach out into the community and beyond the hospitals, practices, and local groups involved - NHSC gave us an award and 2 years later ended our funding. Now NHSC funds last minute interventions - costly with poor retention because the origins, training, debt, and other factors defeat it.
So How Do We Do It - Integrate Health Professional Training with Social Determinants and Admissions of Family Physicians that have Backgrounds that match the populations that they serve and also have a result of a decade or more of services where most needed for nearly every graduate.
There is not enough money to fund every segment of the pipeline with even more invested to patch the segments together for a decent yield of primary care where most Americans most need primary care.
To succeed, you can put the pieces of the puzzle together into a whole. Look at the process, the progress, and the impacts - and put it together. The breadcrumbs are all there.
This design can be local across all stages before and during and after training. It can have local community intervention project focus. The focus for training is about change agent focus that is community mentor-facilitated. The design should involve community connections in more dimensions than can be measured. It should address recruitment and retention. It should also fix the financial design by keeping health care dollars local as much as possible.
Historical Pieces to Bring Together
McMERF FM training was local and specific to Waco and McLennan County people in need of care and caring - and it was a privilege to train there before the state acted to destroy it and the hospitals went their own way. I doubt whether I would have taken the pathway that I have without this influence - which took me years and rural practice and rural medical education efforts to understand better.
- McMERF in Waco - the McLennan County Medical Education and Research Foundation - began as an effort to address the needs of the underserved and minority populations of the city and county. Needs assessments, public meetings, and discussions were held that led up to this City, County, Medical Association, public health, and 2 hospital effort. This was a grassroots inside out design - not distorted by the outside.
- They were not a CHC or FQHC until later - when the state tried to kill them with managed Medicaid cost cutting designs.
- They had sliding scale for services and drugs, ready access to social workers and pharmacists there at the clinic next to the hospital which was located near the populations in most need of services. As residents we served in the various sites across primary care, hospitals, ERs, public health, women's health, heart clinic, and more.
- We predominantly did not learn about social determinant and other factors from faculty. We learned from social workers and our patients. Awareness brings more awareness. When you go with a young African American male being abused by his employer and by workers comp - and also by his landlord and the utility companies because of his landlord failure to maintain - you add to awareness. Home visits, phone calls to help with barriers, and numerous contacts open up awareness.
- Tim Henderson in an OTA report indicated that Waco had 30 - 50% less health care costs compared to similar places
SERPA/Blue River Valley/ RCCN is an example of an organized health care entity involving local practices that has branched out to stabilize practices and hospitals and services where needed - and could take over more of a social determinant and training role. Grassroots insiders can make a difference as compared to meddling outsiders. If the training is not specific and appropriate, change the training design. The obvious question after reading this will be – why are we not doing this? Why are misguided efforts thrust upon us by national, state, or corporation experts? Why not focus local and from the inside out?
Hospitals have facilitated the work of early influence of local health professional careers - Alliance Nebraska had a hospital that sponsored local teens and college students to work with them in the summers - part work and part shadowing. The administrator started as early as 4th grade to influence local students.
Southcentral Foundation took back local organization from IHS to more comprehensively serve its populations in the Anchorage Alaska area. It has also done work on quality measures, outreach, integration, coodination, and organization specific to population needs. https://www.southcentralfoundation.com/
- All of the above could do more if Medicaid payments were up by 20 - 30% instead of payments 20 - 30% below costs of delivery.
Community Based Medical Education can be seen in other countries - notably Canada, Norway, and Japan. Mindanao has local origins, training, and practice. Jichi in Japan has demonstrated success with a long term obligation of 6 years https://www.rrh.org.au/journal/article/930
Community Based Family Medical Schools - Why?
The main reason is because traditional designs have failed - miserably.
1. Our communities with deficits of generalists, general specialists, social workers, teachers, child developers, and social resources need a small army of teens and young adults working on basic health, child development, early education, COPC projects, outreach and more.
2. Our designs retard health professional education, particularly medical school education. Medical education retardation isolates physicians from what they most need to understand to hope to help change populations. Serving careers need a local specific training location, local mentors, and local job activities
3. Most Americans need a stable, dependable source of health professional training specific to their needs
4. Most Americans need a family physician who shares their origins and understand their needs and local resources - with local coordination
5. Current medical and family medical education is the opposite - wrong student origins, wrong preparation, wrong selection, wrong training curricula, and wrong training location acts against what is needed. And the financial design completely prevents the resolution of basic health access barriers even if the training design had a chance to work.
Community Based Family Medical Schools
1. Local origin teens and young adults are encouraged locally to prepare to be local health care, teaching, social work, or child development professionals
2. They work locally on community, home, family, group, elderly, parenting, school, public health, and similar projects
3. Those demonstrating their ability in projects as change agents that can work in teams and communicate well - are selected for training
4. The family medicine pathway integrates college, medical school, and FM residency into an 8 or 9 year training working locally across the years
5 The graduates owe 8 years for an obligation
Traditional obligations have created controversy. This is because the origins, training, and ultimate career plans are different. This community based obligation is quite different. - where else would they go?
- Their last decade or more of life experiences and contacts is local (marriage, family, kids, groups, home). They did not ship out for college and for medical school and they did not train in concentrations such as Seattle or New York City or other places with 94% of residency positions).
- Why not work where their work is appreciated?
- Why not work in a place where your work is facilitated with a small army of local team members working in homes and in groups?
- Why not train colleagues and replacements for local work?
Contrast with Pipelines, Special Training, or Primary Care Schools
The problem with primary care pipelines or rural pipelines is the failure of the financial design for the graduates, for primary care, and for the communities
- Post medical education debts of $250,000 to $400,000 are impossible. These benefit those who train and those who finance the training more and others less.
- Communities must spend $100,000 per fte of primary care physician per year on turnover costs - about 10 - 20% of revenue generated. They have to have an obligated workforce to save these dollars and more as graduates reach 8 years and beyond in continuity with community and practice.
- Regions of counties and communities working together with fully trained and fully aware community leaders - can demand a better financial design. They can work to improve their 10% of health spending for the 40% most left behind toward 20%
The local practices where needed must be organized together in a way that bypasses traditional health insurance. This would likely involve a direct primary care approach working directly with employers.
Local dollars must stay local and be invested locally in health care delivery - not shipped to insurance or to micromanagement consultants
Local children and teens and young adults established locally and with local backgrounds need to serve their local communities.