FAMILY MEDICINE UPDATES Max has been a member of the Governing Board of the Student Outreach Resource Center (SOURCE) From the Association at Johns Hopkins for 3 years. He is a co-leader of his of Departments of medical school’s Urban Health Interest Group and Family Medicine Family Medicine Interest Group, he sat on the board of the Maryland Academy of Family Physicians Foun- dation, and he served as a Student Delegate to the National Congress of Student Members of the Ameri- From the Association can Academy of Family Physicians (AAFP). Recently, of Family Medicine Residency Directors Max was appointed to a 1-year term on the AAFP’s Commission on Health of the Public and Science and was named a Sommer Scholar at the Johns Hopkins Bloomberg School of Public Health. From the Society of Teachers of Family Medicine As a future family physician, Max looks forward to practicing community-based primary care and preven- tive medicine. He wants to bring innovative models of From the North American primary care delivery to underserved communities and provide coordinated, comprehensive, and compassion- Primary Care Research Group ate care to his patients. Ann Fam Med 2014;83-87. doi: 10.1370/afm.1608. Chas Salmen, a 2013 Pisacano Scholar, is a 4th-year medical stu- dent at the University of Califor- THE FOUR PILLARS FOR PRIMARY CARE nia, San Francisco School of Medi- PHYSICIAN WORKFORCE REFORM: cine (UCSF). He graduated with A BLUEPRINT FOR FUTURE ACTIVITY honors from Duke University with The passage of the Affordable Care Act and the intro- a Bachelor of Arts in English Liter- duction of health insurance exchanges are increasing ature. He was awarded a Rhodes demand for a primary care physician workforce able Scholarship where he was awarded to manage populations, deliver care within inter-pro- highest distinction upon receiving his Master in Medi- fessional teams, and address quality outcomes of prac- cal Anthropology. tice. Nevertheless, national statistics demonstrate that At Duke, Chas was captain of the varsity cross an insufficient number of students and residents are country and track and field teams. Chas was also the choosing primary care careers.1-5 Family medicine orga- founder and chairman of Peace or Pieces, an Arab-Jewish nizations and researchers have identified factors that Student Coalition that raised over $20,000 for twin influence specialty choice including individual learner communities in Southern Lebanon and Northern Israel. characteristics, training and practice environments, and Chas is the founding director of The Organic Health payment systems,6-11 and national debates continue the Response (OHR) in Kenya. Today, OHR has an annual conversation about physician workforce.12 This paper budget of over $250,000 per year and is a US-based presents a framework with consistent language to 501c3 nonprofit and a registered Community-Based guide our efforts to increase production of well-trained Organization in Kenya. Chas directs a team of 12 US- primary care physicians for our populations. based staff and volunteers and 42 full-time Kenyan staff. The Council of Academic Family Medicine As a medical student, Chas was awarded the UCSF (CAFM), representing the family medicine academic School of Medicine Dean’s Yearlong Research Fellow- organizations, has adopted the “Four Pillars for Pri- ship. He is the senior vice-president of MicroClinic mary Care Physician Workforce” as a succinct model International (MCI), a global nonprofit with programs to identify necessary conditions to ensure the needed in Jordan, India and Appalachia-USA. Chas secured a growth in the number of primary care physicians. We $100,000 catalyst grant to launch the world’s first Micro- are very pleased that other family medicine organiza- Clinic program for HIV/AIDS on Mfangano Island. tions, including the American Academy of Family Chas looks forward to continuing his clinical train- Physicians (AAFP), the American Board of Family ing as a rural family physician. Eventually, he hopes to Medicine (ABFM), and the AAFP Foundation have build a community-based practice in the rural Midwest joined CAFM in embracing this model and language while continuing to grow clinical services on Mfan- as a blueprint for growing the number of primary care gano Island, Kenya. physicians. We expect that this conceptualization ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 12, NO. 1 ✦ JANUARY/FEBRUARY 2014 ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 12, NO. 1 ✦ JANUARY/FEBRUARY 2014 82 83 FAMILY MEDICINE UPDATES Figure 1. Four Pillars for Primary Care Physician Workforce Development An expanded primary care physician workforce is necessary to meet our country’s population health needs and to address the priorities of better access, better health, a better care experience, and reduced costs. These Four Pillars provide consistent language to improve communication and advocacy about the need for increased numbers of well-trained primary care physicians. Pipeline Process of Practice Payment Reform Medical Education Transformation Efforts need to be National advocacy must focused on identify- All levels of medical, The Patient-Centered continue to address ing, recruiting and residency and fellow- Medical Home (PCMH) the need for approxi- retaining students and ship education should model of care provides mate reimbursement residents into primary model excellence in the framework for of primary care prac- care throughout the training physicians primary care practices tice as well as primary continuum of training. who practice evidence- in the future. Learners care medical educa- Activities should: based, compassionate must be exposed to tion. Activities should • Expose elementary, and comprehensive practices that deliver target ways to: high school and primary care. This this desirable and • Address student college students to includes the traditional sustainable model of debt, which dif- high-quality primary concerns of curricu- patient-centered care ferentially impacts care practices and lum and educational • Practice teams must specialties research, as well as: physician role models include generalist • Close the gap in pri- • Develop more holis- • Appropriate expo- physician leaders mary care/specialty tic medical school sure to excellent who serve as role care payment admissions pro- and inspiring role models and who models throughout deliver comprehen- • Transition from cesses, and enhance volume-based pay- participation of the continuum of sive, broadscope medical school and primary care ment to value-based primary care physi- payment cians on admission residency • Learners are part committees, to iden- • Systemic efforts to of interprofessional • Reform graduate tify students who respond to the “hid- practice teams medical education are more inclined den curriculum,” to allow payments • Continuity of care is to non-hospital toward primary care including bias and maintained through- (e.g., those with “trash talk” about educational entities, out multiple delivery support appropriate, more service-ori- specialty choice settings (ambulatory, entation and those additional primary • Integration with inpatient, extended care ambulatory from rural and low- Interdisciplinary Pro- care, etc.) income families) training, and cover fessional Education • Population-based actual costs of train- • Enhance outreach • A diversity of sites care is enhanced ing in the community and mentoring with community cli- and supported by programs designed nicians outside of the system changes to to sustain interest AHC, including rural reinforce the “medi- in primary care of ces and CHCs cal neighborhood” throughout medical of colleagues and school and residency consultants Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of per- sonal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. (OM de nition) Developed by the Family Medicine Organizations (9/3/13) and terminology can help our organizations provide • Pipeline consistent messaging for advocacy for appropriate pri- • Process of medical education mary care workforce development programs. We also • Practice transformation anticipate that this framework might be useful for the • Payment reform broader primary care community as we seek ways to Each of these pillars will be described, and a conclud- work together in pursuit of our shared goal of access to ing section will address how this conceptual model quality health care for the American public. may help focus training and advocacy activities needed Efforts to develop an appropriate primary care to develop the primary care physician workforce workforce include attention to each of the four pillars: required to meet the needs of our nation’s populations. ANNALS OF FAMILY MEDICINE ✦ WWW.ANNFAMMED.ORG ✦ VOL. 12, NO. 1 ✦ JANUARY/FEBRUARY 2014 84 FAMILY MEDICINE UPDATES Pipeline especially the Society of Teachers of Family Medicine This first pillar relates to the continuum of identifying, (STFM) and the Association of Family Medicine Resi- recruiting, and sustaining those students who are most dency Directors (AFMRD), are recognized leaders likely to seek careers as primary care physicians. The throughout the medical education community for their pipeline process actually begins in the early school focus on innovative curriculum, assessment and evalua- years as students are exposed to role model primary tion,