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Dome - Back to the Future

Dome March 2013

Back to the Future

Date: March 1, 2013

Drawing on the legacy of William Osler, Johns Hopkins Hospital’s first head of medicine, John Flynn, Maura McGuire and Steve Kravet are among the leaders of an effort to bring primary care to the fore.
Drawing on the legacy of William Osler, Johns Hopkins Hospital’s first head of medicine, John Flynn, Maura McGuire and Steve Kravet are among the leaders of an effort to bring primary care to the fore.

Systemwide efforts aim to reinvigorate primary care.

If William Osler could return to Johns Hopkins today, he’d likely be astonished to find so many specialists. Indeed, Johns Hopkins Hospital’s revered first physician-in-chief preached a “generalist” approach that combined empathy for patients with the best that medical science had to offer. His 1892 textbook The Principles and Practice of Medicine urged doctors to “care more particularly for the individual patient than for the special features of the disease.”

Osler’s insights laid the groundwork for the field of medicine that would become known as primary care, the health care given by a physician who acts as the central point of contact for patients and guides them through myriad options and referrals. Granted, most doctors during Osler’s time were considered generalists. But as specialties have come into their own, primary care across the nation has grappled with challenges. These include lower pay and longer hours compared with other disciplines, low Medicare reimbursements and more elderly, complex patients.

Although the Affordable Care Act will ensure universal care for all Americans by next January, predictions abound of a deficit of about 29,000 primary care doctors by 2015. Yet most U.S. medical students—even those who match in internal medicine and pediatrics—still opt for specialty training.

It’s the perfect storm, and not a day goes by that John Flynn doesn’t think about these thorny issues. Fortunately, says The Johns Hopkins Hospital director of clinical practice improvement within the Clinical Practice Association and former clinical director of general internal medicine, much has already been done to raise the profile of primary care at the institution. The establishment of the Osler Center for Clinical Excellence in 2002, which uses philanthropy to support research and education in internal medicine, is but one example.

Even so, during a past dean’s retreat, Flynn noted that primary care issues dominated the agenda: urban health, chronic disease management and reaching out to community physicians. With the dean’s blessing, a series of meetings was launched with several clinical leaders throughout Johns Hopkins Medicine, including colleagues at the schools of nursing and public health. All agreed that a more concerted effort was needed to bring people together to bolster the role of primary care both at Johns Hopkins and on the national stage, much as the Armstrong Institute for Patient Safety and Quality is doing within and well beyond Johns Hopkins’ walls.

The result of their conversations is the newly formed Johns Hopkins Consortium for the Advancement of Primary Care, which held its first open-to-all event on Feb. 21 at The Johns Hopkins Hospital. Aiming to nurture the development, value and growth of primary care research, education, national policy and clinical medicine for pediatric and adult patients within all entities of Johns Hopkins Medicine, the consortium is building on an already strong base. Johns Hopkins Community Physicians, for example, is the largest primary care group in Maryland. The network of community-based practices serves more than 280,000 patients annually at more than 35 locations throughout the state.

“Our primary care is incredibly robust,” says JHCP President Steve Kravet. “Collectively, we’ve made great strides in delivering care that averts crises and keeps patients home longer.”

Nurse practitioners and physician assistants help, he says, along with patient education and wellness programs that teach patients ways to prevent chronic illnesses from spiraling out of control. Still, Kravet worries about the impact of the looming shortage of primary care physicians.

Addressing that challenge, consortium leaders agree, must begin with exposing students early on to primary care. One example that’s been in place at the school of medicine since 2007 is the Longitudinal Ambulatory Clerkship. Directed by Maura McGuire as part of the Genes to Society curriculum, the clerkship gives medical students firsthand experience in community doctors’
offices. “You can talk about patients’ struggles with insurance, landing an appointment, transportation and family dynamics, but you won’t get it till you go out in the world,” says McGuire, who is also director of education for JHCP and assistant dean for part-time faculty.

Feedback has been overwhelmingly positive. “I learned something that I could never learn in the hospital,” wrote one student. “We are privileged to have the opportunity to become a part of the lives of our patients; to watch children grow, to be there for our patients at some of the scariest and happiest moments, and even to help them cope with the end of life.”

In that spirit, says McGuire, the new Consortium for the Advancement of Primary Care will continue to collect “wonderful ideas to expand the visibility of primary care across the institution.” That includes enhancing research in the field and inspiring more students to join its ranks.

If William Osler were alive today, he would no doubt champion these efforts.

—Judy F. Minkove

To view the agenda and outcomes of the recent conference, visit