Roy Ziegelstein, M.D., Vice Dean for Education in the School of Medicine, has been to plenty of meetings in his academic life, but he remembers one, two years ago, that he describes as “a shocker.” Paul Rothman, M.D., had just come on board as Dean and CEO of Johns Hopkins Medicine, and was meeting with a group to review medical education. Ziegelstein wasn’t Vice Dean yet, but he was there to talk about a course he directed in the medical school curriculum. During the presentation, “the Dean asked two educational leaders, “What about primary care?” Rothman was told by both, in effect, “‘Hopkins doesn’t do primary care.’ That took him aback, and it was a shocker to me.”
But in the greater context of Hopkins culture, Ziegelstein says, the answer was maybe not so shocking. Most residents at Johns Hopkins pursue subspecialties, and until now the few medical students each year who decided to pursue primary care would often admit their career choice with great trepidation, “as if they were confessing to something profoundly embarrassing,” he notes. Primary care has not been part of the culture at the School of Medicine. And that matters “because the culture of where medical students train is critical to what they’re going to do in practice.” Ziegelstein cites a 2013 article in Academic Medicine showing that students who practice “in an environment where primary care is badmouthed very rarely enter primary care.”
“I want to change the culture at Hopkins, so that primary care is viewed alongside subspecialties as a venerable career path for our students. I don’t want students to feel embarrassed about choosing primary care any more. They should be proud of it.”
But the culture is changing, for several reasons. One comes from the top, from Rothman, Ziegelstein, and others at Hopkins who recognize the importance of primary care. Hopkins, with its renowned Bloomberg School of Public Health; School of Nursing; the 30 master clinicians in the Miller-Coulson Academy of Clinical Excellence; strong programs in geriatric and pediatric primary care, and the Johns Hopkins Community Physicians (the largest primary care group in the state; whose President, Steve Kravet, M.D., is a Miller-Coulson Scholar), a respected group of expert primary care physicians; has ample opportunities for students to capitalize on the institution’s many strengths as they learn primary care.
“When I decided to come to Hopkins, I knew I would be trained to be an amazing doctor, which is what I want to be, but I knew I was entering a world where primary care was not front and center. I have been encouraged by the changes that I’ve seen happening.”
Two, the country needs more primary care doctors – internists, pediatricians, ob/gyns, family practitioners – generalists who represent the first line of care. An increase in primary care physicians was recommended recently by the U.S. Department of Health and Human Services’ Council on Graduate Medical Education (COGME), says Ziegelstein. “COGME recommended an increase in the number of primary care doctors from 32 percent of the current physician workforce to 40 percent over the next few years. It’s going to take a while to do this, but it’s important. And it’s not just about the numbers,” he states. “Our country needs primary care leaders, and Johns Hopkins has always been about training leaders in every field in medicine. If our institution can’t train the next generation of leaders in primary care, who can?” He adds that “some people believe that you cannot be a top-flight research institution like Hopkins and also be a top-flight primary care program. But that’s actually not true.”
“There’s increasing recognition that a good, high-quality health care system stands on primary care as its solid base. Without that base, health care systems tend to be very expensive and have more errors.”
And three – a dynamic push is coming from the students themselves. “Each year, the AAMC administers a questionnaire to all medical school graduates around the country,” says Ziegelstein, “and our graduates consistently report that primary care aspects of their training are not covered as well as other subjects in the medical school curriculum. Far fewer of our students answer that they’re going to pursue primary care specialties than the national average.”
One of the medical students advocating for change is Juliana Macri, who is head of the student advisory panel for this new primary care track. She is part of a Hopkins chapter of a national organization called Primary Care Progress. “We had a meeting last year where we made a list of things that we wanted to try to make happen at Hopkins,” she says. “One was a primary care track, or improved primary care in the medical school curriculum.” Macri led a working group that came up with a proposal and presented it to Ziegelstein and other faculty, who had already begun moving in the same direction. “They were very receptive to recognizing that there are deficits in our curriculum and that there need to be changes.”
Hopkins is ideally poised to develop leaders in primary care.
Colleen Christmas, M.D., Director of the Internal Medicine Residency Program at Johns Hokins Bayview, is the director of the new track (see side story). “Colleen has a done a wonderful job reaching out to medical students,” says Macri, “and seeing that the needs they identify are prioritized. She’s making sure the medical students are front and center in this. We have a lot of ideas, and we have the best sense of what we’re missing.”
One thing Macri hopes will happen when the program, which will be voluntary, begins in 2015 is that students who choose the primary care track will get to spend a lot more time in an outpatient setting. “Right now, we have very minimal outpatient exposure,” she says. In January of the first year of medical school, students begin a yearlong clerkship in an outpatient clinic. However, Macri notes,“the students placed in pediatric or specialty clinics won’t ever see adult primary care visits or the complete picture of primary care. Also, it’s early on in our medical training; we don’t take endocrinology or cardiology until halfway through our second year, so we don’t yet understand the basic pathophysiology or pharmacology of diabetes or heart disease… it’s much more of a clinical skills experience, where you learn how to interview and examine patients, but you’re not really at the knowledge level to truly understand or participate in the care decisions that are being made.”
In the third year of medical school, students do their “core clerkships,” in traditional primary care specialties like pediatrics, women’s health, and internal medicine, but only pediatrics includes a mandatory outpatient portion. “You get very little outpatient time,” says Macri. “So it’s actually possible to go through four years of Johns Hopkins and never see a diabetic follow-up visit or a regular hypertension outpatient visit, which is pretty alarming, considering that those are the biggest health problems facing future physicians today.”
The opportunity for students to see patients and develop relationships with them over time is very limited in many medical schools, says Ziegelstein. “It certainly was for me. I actually saw a patient zero times in clinic. I don’t think I ever set foot in a clinic in medical school; my training was in the inpatient setting. That’s not primary care; primary care is all about longitudinal relationships. We’re not teaching our students properly if we don’t give them those experiences.”
“Many of the master clinicians in the Miller-Coulson Academy are primary care physicians, and they’re ready and eager to support students who want to be in this track.”
It must be noted, Ziegelstein points out, that the stage for learning in medical school has always been the hospital. More than a century ago, when Johns Hopkins Hospital was founded, that’s where the sick people were, and Osler revolutionized medical teaching by bringing students to the bedside where they could “learn by doing,” instead of sitting in the classroom. Even now, “it’s not surprising that the fastest-growing field in medicine is hospitalist medicine,” says Ziegelstein. “It’s just taken off like wildfire. But to some extent, the hospital-based care is the antithesis of primary care.” Years ago, the TV doctor was Marcus Welby, the respected family physician. “Now it’s ‘Gray’s Anatomy.’ Primary care doesn’t have the same caché. At Hopkins, it most definitely does not have the same caché, but that’s the whole point. It should.”
Years ago, the TV doctor was Marcus Welby, the respected family physician. “Now it’s ‘Gray’s Anatomy.’ Primary care doesn’t have the same caché. At Hopkins, it most definitely does not have the same caché, but that’s the whole point. It should.”
Macri hopes the primary care track will create more of a “culture of acceptance” for primary care among those who decide to become specialists. “It’s not just important that we are training good primary care doctors, but also helping subspecialists to understand how to work with their primary care colleagues to make care for the patients better – more coordinated, more thoughtful and careful, and less expensive. When I decided to come to Hopkins,” she adds, “I knew I would be trained to be an amazing doctor, which is what I want to be, but I knew I was entering a world where primary care was not front and center. I have been encouraged by the changes that I’ve seen happening.”
Scott Wright, M.D., Director of the Miller-Coulson Academy of Clinical Excellence and a primary care physician, says that “there are many outstanding clinicians, teachers and researchers who will provide wonderful mentorships to students who elect to participate in this track. Many of the master clinicians in the Miller-Coulson Academy are primary care physicians, and they’re ready and eager to support students who want to be in this track and who then may go on to become leaders in primary care.”
Adds Ziegelstein: “I want to change the culture at Hopkins, so that primary care is viewed alongside subspecialties as a venerable career path for our students. I don’t want students to feel embarrassed about choosing primary care any more. They should be proud of it. And when Paul Rothman asks next time, ‘What is Hopkins doing in primary care?’ there will be a very clear answer for him.”
