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A Primary Need
Why medical school students must be included in efforts to solve our primary care shortage.
In 2010, as the Affordable Care Act was being introduced, a controversial article was published in the Annals of Internal Medicine. It focused on how well U.S. medical schools were doing in increasing the nation’s primary care physician workforce, the number of physicians in medically underserved locations and the pool of minority physicians. Many leading academic medical centers — including Johns Hopkins — were relegated to the bottom ranks in progress toward these goals.
At the time, I was a first-year medical student at Vanderbilt, which also ranked at the bottom. I had come to medical school intent on becoming a leader in primary care, especially to underserved populations. Now I worried: Would my school’s mission to produce leaders in medical discovery through scholarly investigation eventually drown out my desires?
Fortunately, I was able to feed my interest in primary care by volunteering in a student-run clinic serving low-income patients in Nashville. There, I not only learned the intricacies of managing common medical conditions, such as diabetes mellitus, but also came to understand the challenges these patients face, such as barriers to getting the medications they need due to cost. I also saw firsthand how hard it is for patients without health insurance to obtain specialty care.
Though I sometimes got discouraged, I was heartened as I worked alongside my colleagues to find solutions and to provide excellent medical care and access to other resources. Nearly every medical student at Vanderbilt volunteered at least once at this clinic. My work there impacted my career decision to become a general internist serving low-resource populations.
When it came time to apply for residency, I was drawn to the Urban Health Primary Care Track at Johns Hopkins. The program — which includes about 30 internal medicine and combined internal medicine/pediatrics residents — focuses on the medical needs of inner-city, often poor patients. Our inpatient training on the medical wards comes as members of the Osler house staff, and we receive additional outpatient experience as clinicians in various city locations. It’s at these locations that we learn the fundamentals of caring for the disadvantaged — including the formerly incarcerated, those struggling with substance use disorders and the homeless population. My fellow urban health residents and I also receive specialized outpatient training in treating patients with HIV/AIDS, hepatitis C and psychiatric disorders.
I’ve found that Baltimore provides the perfect setting for training primary care providers for the underserved. Recently, for instance, I evaluated an uninsured patient who had recently emigrated from Nepal. I saw the stresses he faced in becoming naturalized while providing for a large family in a new country — and how it was taking a toll on his health by limiting his ability to afford necessary medications, for example. In his case, as with other such cases, I work closely with case managers and social workers to connect patients with important resources they need, such as access to cheaper medications and overdue vaccinations.
My experiences in the urban health track have further confirmed for me that underserved populations, such as those in Baltimore and other large cities, need dedicated primary care physicians. But these exposures should not be limited to the residency curriculum. We must start earlier in the pipeline.
Bringing medical students into the conversation would not only expand their views in terms of the psychosocial needs of patients, but also could encourage them to strongly consider careers in primary care, a field in which severe shortages are predicted. That is why I feel that it is absolutely crucial for medical schools, especially premier medical institutions such as Johns Hopkins, to include required rotations — for all students — that emphasize care to underprivileged patients.
The stage is set for an educational revolution, and Johns Hopkins is poised to lead this revolution in primary care education. Where Johns Hopkins leads, others will follow.
Ryan Lang is a second-year internal medicine resident at Johns Hopkins in the Urban Health Primary Care Track.
The Association of American Medical Colleges predicts that by 2020, the United States will be short more than 45,000 primary care doctors. What do you believe is the single most effective strategy for increasing the nation’s pool of primary care physicians?