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Archives - A Prime Priority

Winter 2014

A Prime Priority

By: Paul B. Rothman
Date: February 1, 2014

By Dean/CEO Paul B. Rothman
Dean/CEO Paul B. Rothman

Here’s an ego-boosting exercise. Skim the editorial mastheads of major medical journals and the executive bios for medical specialty associations and see how many of those thought leaders are currently or formerly affiliated with Johns Hopkins. We produce an astounding number of the nation’s who’s who in health care.

Yet there’s one vital area where we still have room to improve. When people think of Hopkins, primary care isn’t the first field that comes to mind. It has to do, partly, with the types of patients we attract. We are, to a large degree, a subspecialty referral center, and a lot of our training still takes place in the hospital.

In the past, we might have been satisfied with our status as an incubator for the nation’s preeminent subspecialists and biomedical researchers. After all, you can’t be the best at everything, right? Actually, that’s not true. For example, one of our peers, the University of California, San Francisco, is ranked in the top five in the nation in both research and primary care.

Not only can we do both things well, but changes in society dictate that we must do both things well.

Medical interest groups have spent a lot of time sounding the alarm about the shortage of family physicians in this country, particularly in rural areas. Moving forward, health reform, demographic shifts, and trends in medical education are expected to amplify the problem.

One variable is the graying of our population. By 2030, one in five Americans will be considered elderly. About 80 percent of older adults have at least one chronic disease, and without an involved doctor managing their care, these patients become emergency-room regulars. And although the numbers are still speculative, the Affordable Care Act certainly will lead millions more Americans to obtain insurance—plans that will be required to cover checkups and other preventive services. This will spell increased demand for front-line caregivers, who already are straining to see up to five patients per hour.

As one of the country’s leading academic medical centers, we are compelled to act. The first question we need to address: Why aren’t more young doctors choosing the primary care path? We need a surge of energetic new physicians to keep up with society’s needs, but instead we’re seeing tepid interest. At Johns Hopkins, more medical graduates say they will pursue dermatology or ophthalmology than internal medicine, gynecology, or family medicine.

So how do we make primary care a more attractive option?

For starters, we need to elevate the status of primary care physicians. On the one hand, that means changing reimbursement so they are not earning a fraction of what their peers in subspecialties make. Unfortunately, we at Hopkins don’t have much control over how much doctors get paid. What we can do is change the culture of our institution so that primary care is perceived as being highly valued by academic leaders.

Our residents need more exposure to primary care practice and health-policy leadership. We’re looking at how to accomplish this as part of our five-year Strategic Plan. In addition, we are exploring how to give more weight to clinical excellence in our professorial promotion process.

We also must pioneer ways to make primary care practitioners more efficient, whether through electronic medical records, better diagnostic tools, an expanded role for nurse practitioners, or other means. And because all this will only get us so far, we are thinking beyond the small family-doctor practice, finding innovative ways to deliver more services to more people. Our new partnership with Walgreens is one such approach. By setting up nurse practitioners at clinics inside retail stores and training pharmacists to administer vaccines, local pharmacies can be partners in caring for members of our community.

Philip Tumulty served on our faculty for decades and helped found the Division of Internal Medicine. In his book The Effective Clinician, he notes that an internist should be judged by “the genuineness of his interest; the thoroughness of his approach to the problem; his personal warmth, understanding, and compassion; and the degree of clarity to which he gives the patient insight.” Primary care doctors are, in many ways, the unsung heroes of medicine. They must be able to integrate ever-advancing knowledge from many different fields, while balancing technical expertise with compassion, curiosity, and keen intuition. So many of our trainees are equipped with these qualities. We have to supply the nudge.