Kansas Primary Care Education Enhancement A report commissioned by the Executive Dean of the KU School of Medicine and the Dean of the KU School of Medicine-Wichita to make recommendations for primary care education enhancement in Kansas.
Kansas Primary Care Education Enhancement Background The University of Kansas School of Medicine (KU SOM) has a proud history of being committed to training doctors for Kansas. Recent statistics show that KU SOM has produced a higher percentage of graduates choosing family medicine residencies over the past three years than any other allopathic medical school in the United States. In 2005, the KU SOM was approached by the Kansas Department of Health and Environment (KDHE) and the Kansas Academy of Family Physicians (KAFP) about the future of the Kansas physician workforce. With funding from KDHE, a collaborative effort began, and what emerged was the Kansas Physician Workforce Report (KPWR), published on March 12, 2007. Other organizations that participated were: the Kansas Medical Society, Kansas Hospital Association, Kansas Rural Development Council, Kansas Association of Counties, Kansas League of Municipalities, Onaga Community Hospital, Medicine Lodge Memorial Hospital, Kansas Health Policy Authority, and Kansas Farm Bureau. As one result of the KPWR, Dr. Barbara Atkinson, Executive Vice Chancellor of the University of Kansas Medical Center (KUMC) and Executive Dean of KU SOM, and Dr. S. Edwards Dismuke, Dean of the KU SOM-Wichita, appointed the Primary Care Education Enhancement (PCEE) Task Force in April 2007 to make recommendations to maintain and enhance the school s tradition of education for primary care careers. Members of the Task Force are listed in the Appendix. Purpose and Scope of Work The PCEE Task Force defined primary care as family medicine, general internal medicine, and general pediatrics. Given that definition, the Task Force then considered: How new and existing resources might best be directed to improve primary care physician workforce outcomes Strategies to meet primary care workforce requirements Potential medical student class size adjustments Optimal programs and services for recruitment and retention of primary care physicians in Kansas Expansion of graduate medical education programs in primary care Enhancements in the primary care curriculum and training programs for all KU SOM residents and students All of these considerations were seen through the historical lens of the Primary Care Physician Education (PCPE) initiative. This extensive project addressed many of the issues identified above nearly 10 years ago. Excellent programs resulted from PCPE, and perhaps KU SOM s current reputation as a leader in medical students selection of family medicine residencies is a result. Although many good ideas were implemented during PCPE, adequate long-term funding was not available, and some of the new educational improvements were not able to be sustained. The PCEE Task Force was charged with looking again at PCPE initiatives and advancing new ideas in today s environment to address workforce shortages and other issues. The Task Force acknowledges that without sustained vigilance and funding for primary care education programs, there will likely be an even further deficit in primary care physicians in Kansas. Market forces do not attract students to these fields of medical practice. Recommendations The Task Force identified six overarching areas to address the primary care physician workforce for Kansas. Each area has specific recommendations. Increase compensation for primary care faculty and residents. 1
Foster a culture within undergraduate and graduate medical education which embraces primary care. Invest further in pre-matriculation programs and admissions practices to encourage careers in primary care. Invest in initiatives to support the development of a primary care workforce. Enhance recruitment and retention initiatives for primary care. Influence state and federal policy to enhance primary care education. Increase compensation for primary care faculty and residents 1. Increase retention of quality primary care faculty in all teaching settings. Increase existing faculty compensation to competitive levels and provide significant amounts of protected time for faculty to teach and conduct primary care research. 2. Increase recruitment of top-tier primary care faculty in all teaching settings. A greater emphasis should be placed on recruiting and retaining top-tier primary care faculty for all teaching settings. Recruitment and start-up packages for incoming faculty should provide salary and benefit compensation well above the 50th percentile of peer Midwestern institutions. 3. Increase resident salaries to above average for the region and provide professional development allowances and improved reimbursement for residency education. Increase the salaries of all residents in all programs to above average for the region as determined by the Association of American Medical Colleges Survey of GME programs. Stipends and incentives associated with primary care and rural programs such as Scholars in Rural Health, the Kansas Medical Student Loan Program, the Kansas Bridging Plan, and rural tracks in Salina and Junction City should be increased and marketed more widely. Current salary differentials between Kansas City, Wichita, Salina, and Junction City residency programs should be maintained. Provide professional development allowances to residents. Improve reimbursement for residency education that is offsite from teaching hospitals and occurs in other primary teaching environments. 4. Develop a primary care educational loan forgiveness program. Develop a primary care educational loan forgiveness program that would consolidate educational debt and provide forgiveness for service in primary care specialties and a premium for service within Federal Health Professions Shortage Areas (HPSAs). Other areas that could be examined are: loans for practice start-up, loans for implementation of electronic health information systems, and loans for other equipment costs. All loans would be provided by state funding and repaid with a service obligation. Foster a culture within under graduate and graduate medical education which embraces primary care 5. Communicate clearly to all faculty and staff that all specialties and sub-specialties are expected to be involved in and support primary care resident education and training. Task Force members strongly recommend that the Executive Vice Chancellor of KUMC and Executive Dean of KU SOM mandate that all faculty and staff, across specialties and sub-specialties, be involved in the education and training of primary care residents. 6. Increase and improve primary care clinical experiences for all medical students. Increase primary care clinical experiences in the first and second years of medical school to encourage students to consider careers in primary care. This would 2
require extended placements in highly desirable clinical practice teaching environments with students averaging one full day per month over the first two years. An effective way to accomplish this would be to establish student continuity clinics using the JayDoc Clinic model that serve the indigent communities in Wyandotte and Sedgwick County. Students would have two rotations a month in these clinics for four hours per session. Each student would be assigned to a panel of patients managed by a group of students representing each class year. Primary care faculty would provide supervision in these clinics as well as clinical skills education during each clinic session. During the third and fourth years, students would be placed in model primary care clinics for their ambulatory rotations. This would include clerkships in Family Medicine and Pediatrics as well as in Ambulatory Medicine/ Geriatrics. These clinics would need to be state of the art model primary care clinics, housed in modern facilities, utilizing extensive health care informatics resources, and designed to deliver top quality medical care. Students would be taught the principles of a medical home (identified as a priority by all primary care specialties) and would learn how to apply these principles. Rigorous curricular activities, which aim to increase student autonomy, prepare students well for practices in primary care. Activities such as night call and ambulatory care of complex patients in model practice settings are recommended. In addition, longitudinal models of primary care outpatient experiences should begin in the first and second years of medical school and continue through the third and fourth years. These will require ongoing, frequent experiences in the same primary care settings and treating the same panel of patients. This will also entail supervision but gradually enhance patient care responsibilities for students as members of a primary care health care team. 7. Establish a faculty and student development program focusing on the benefits of primary care education and service. The program could include periodic seminars or continuing education classes that would promote a collaborative and patient-centered culture, identifying the unique and valuable ways that each specialty contributes to improving the health of the population. When a student expresses interest in a primary care specialty, everyone involved with that student should support such interest. 8. Establish a Rural Medical Education Program. This program would have 20 to 30 students and would begin by expanding the Scholars in Rural Health program. Rural tracks, each consisting of 3 to 10 students at each of three to five non-urban sites, would provide the bulk of these students curriculum in their third and fourth years. Technology, such as interactive television, would allow rural track students to connect virtually with their urban classmates and faculty at any educational site. In the fourth year, rural electives could be designed to provide the unique skill set required of rural primary care doctors. In addition, the rural weekend program should be expanded as well as rural electives for students in all four years of medical school. Fourth-year students could also participate in collaborative activities, for which they could earn credits toward residency completion. 9. Establish a volunteer faculty advisory board of practicing primary care volunteer faculty and involve them in institutional decision-making. Establish a volunteer faculty advisory board of practicing primary care volunteer faculty, from both underserved urban and rural areas, that would review curricula and offer insights and suggestions as to relevance for primary care. This board would convene three to four times a year, possibly in concert with Network Site Director Meetings. These community-based faculty should be included in all school-wide faculty meetings, forums, and other activities. Community-based faculty should be invited annually to teach at selected SOM sites, with provision of locum tenens service to cover their practices in their absence. Community-based physicians should participate in residency 3
conferences on a regular basis. 10. Establish a forum in which primary care residency programs can share best practices. A forum should be established in which best practices are shared among all primary care residency program leaders as well as primary care department leaders. 11. Assist in supporting and developing primary care clinical research. KU SOM should assist in supporting primary care practice environments that are attractive to students and practicing physicians. Participatory involvement in clinical research enhances student interest in primary care and long-term retention. Expansion of all primary care clinical research from all campuses and offices would require a dedicated budget to develop the appropriate research infrastructure for the first 3-5 years. Strong consideration should be given to building an infrastructure which supports life sciences research in primary care. The new resources would foster new research, support existing efforts and also recruit new faculty with primary care research interests. Invest more in pre-matriculation programs and admissions practices to encourage careers in primary care 12. Continue current admissions practices which support applicants with backgrounds positively correlated with eventual practice in primary care settings. The SOM should continue to give priority to applicants most likely to select a primary care career. Applicant characteristics such as community of origin, parental occupation, applicant age, and employment history should be regarded as central to the admissions decision-making process. Candidates should be evaluated on these factors first, as well as on service commitment, experience, and interview scores. Academic performance criteria would be used as final arbiters. These academic criteria should be presented to the admissions committee as categorical variables in a format such as high, medium, or low, instead of exact scores and percentiles. 13. Enhance and increase the Scholars in Rural Health program. The Scholars in Rural Health program is a guaranteed medical school admissions program for Kansas high school graduates who have achieved junior status at a state college or university. This program has an initial track record of success. It began in 1997 with six students. Currently, the program is authorized to increase from 10 to 16 students. The PCEE recommends doubling the overall size of the program to admit 30 students. In addition, the program should be enhanced by adding stipends along with service repayment obligations similar to those in the Kansas Medical Student Loan Program. 14. Establish the Primary Care Medical Scholars Academy for future Kansas physicians. Develop a large scale coaching and mentorship program to facilitate interest among young adults and children most likely to enter primary care specialties. This program would be coordinated by Area Health Education Centers (AHECs) and Network sites in collaboration with the Kansas Academy of Family Physicians, Kansas Medical Society, Kansas Chapter of the American Academy of Pediatrics, and other groups. Students who apply would be paired with local physicians and current medical students and residents in both Kansas City and Wichita. Scholars in the program should be linked to in-state pre-med advisors on Regents and other undergraduate private campuses. Invest in initiatives to support the development of a primary care workforce 15. Expand the medical school class size by five students each year for five years. Discussion of increasing the medical school class size has been ongoing for a number of years. It is recognized that it is extremely difficult to increase class size without also enhancing or increasing resources such as facilities and faculty. If such resources are available, then an incremental approach to expanding the medical school class size should occur. These new students would be directed to the Wichita campus for their third and fourth years of study. 16. Increase the number of primary care residency positions affiliated with KU SOM. Success of the Wichita and Salina residency programs 4
in placing graduates in Kansas provides the rationale for increasing residency slots which foster future primary care physicians. With this knowledge in mind, it is recommended that two new non-metropolitan programs be established with preferential salary granted to residents in those settings. Consistent with recommendation two, salary and compensation should be provided above average of the region as determined by the Association of American Medical Colleges Survey of GME programs. In addition, studied consideration should be given to expanding primary care residency positions in Wichita to further address primary care shortage needs. Consideration should include available faculty, facilities, patient base and qualified resident applicants. 17. Enhance the Kansas Medical Student Loan Program and expand availability to all students anticipating a career in primary care. The Kansas Medical Student Loan Program (KMSLP) should have a 10 percent increase in the current stipend, and availability should be expanded in order to accommodate all students interesting in pursuing a career in primary care. In the 2007 state legislative session, the KMSLP stipend was increased from $1,500 to $2,000 per month. However, according to the U.S. Department of Labor, the stipend should be at least $2,200 in order to have kept up with inflation since the program s 1992 revision. Enhance recruitment and retention initiatives for primary care 18. Increase funding for the Kansas Bridging Plan The Kansas Bridging Plan (KBP) is a highly successful program, designed to encourage primary care physicians to practice in Kansas upon completion of residency training. Currently, primary care residents fill the 10 available KBP slots each year. They then receive $5,000 in their second year and $5,000 in their third year of residency training. In exchange for this financial support, they commit to working in rural Kansas for at least 36 months. The program needs to be enhanced in three ways. The number of slots needs to be increased from 10 to 15 per year. The program needs to expand to include first year primary care residents. The amount of the loan should be increased from $20,000 to $30,000 per resident. These enhancements would increase the effectiveness of the program and would be competitive with contiguous states. 19. Expand the resources and capabilities of the Kansas Recruitment Center. The Kansas Recruitment Center (KRC), a statewide health care recruitment program, addresses the need for physicians and other health care providers in rural Kansas. KRC works directly with the communities and candidates. The number of health care organizations that are utilizing KRC services has increased from 22 organizations in 2004 to 48 organizations currently. Likewise, the number of search requests from these health care organizations has doubled from 63 positions in 2004 to 165 positions to date. The Center has made 42 placements since it started in July 2003. It is recommended that the recruitment center receive funding to accommodate the increased demand for KRC services. This additional funding would specifically go to increase the KRC staff by adding two new positions (salaries and benefits), candidate sourcing materials, and office expenses. Influence state and federal policy to enhance primary care education 20. Educate legislators and key leaders about primary care education as an investment. Efforts must be made to educate legislators and other key leaders about the importance of investing in primary care education. The training of primary care physicians is an investment because the clinical revenues generated from primary care services cannot compare to most other specialty and sub-specialty clinical revenues. Primary care is absolutely critical to improving the health of Kansans. 21. Support tax abatements for primary care physicians in underserved areas for the first five years in practice. Georgia, Montana, Louisiana, Oregon, and other states have initiated tax abatement programs, providing tax relief in the range of $5,000 per year of primary care practice in rural areas. The state of Kansas should adopt $5,000 tax abatements per year for the initial five years of practice in a federally designated Heath Professions Shortage Area (HPSA). Recipients of this 5
benefit would be required to accept Kansas Medicaid patients. 22. Mandate electronic re-licensure survey completion by all physicians in Kansas. Mandate electronic re-licensure survey completion by all physicians, using the Kansas Board of Healing Arts system. Information from these surveys should then be included in ongoing collection, monitoring, and analysis of physician workforce data. This analysis should run on a two-year cycle and be run by the Kansas Health Policy Authority. 24. Improve reimbursement structure for primary care providers. Increase Medicaid reimbursements by 10 percent for primary care providers. Financial practice incentives will enhance recruitment and retention of physicians into rural and underserved regions, and it should stimulate physician service to Medicaid enrollees in these regions as well. 23. Continue the J-1 Visa Waiver Program and provide supportive mechanisms. The J1 Visa Waiver Program serves a valuable purpose by providing a physician in communities where physicians may not have been previously. Restructuring the program to reward long-term retention would provide increased value to this program. The current J-1 program should be continued with annual renewal extensions to primary care physicians that remain in their practice to provide a reward to participants agreeing to continue service following completion of their initial service obligation. A Special Thanks to our Task Force Members Don Brada, MD, KU SOM-Wichita; Co-Chair Allen Greiner, MD, KU SOM-Kansas City; Co-Chair Glendon Cox, MD, KU SOM-Kansas City Mark Meyer, MD, KU SOM-KC Scott Moser, MD, KU SOM-W Michael Kennedy, MD, KU SOM-KC Garold Minns, MD, KU SOM-W Doren Fredericksen, MD, KU SOM-W Tim Bennett, MD, KU SOM-KC Barbara Gibson, KDHE Brian Holmes, MD, Kansas Academy of Family Physicians Dave Cook, Ph.D., KUMC External Affairs; Staff Lorene Valentine, KUMC Rural Health Education and Service; Staff Dorothy Hughes, KUMC External Affairs; Staff 6