Primary Care Physician Shortage

By 2014, the Patient Protection and Affordable Care Act (ACA) will expand the Medicaid health insurance program to over 15 million people. Among many things, this expansion will allow millions of people access to regular primary care. But is the field of primary care prepared to deal with such an expansion?

Primary care physicians (PCP's) serve as the initial contact person for a patient’s health issue. PCP's work with the patient over a long duration of time, treating routine conditions and providing preventive services like vaccinations. PCP's also refer the patient to specialists (e.g. cardiologists, endocrinologists) when necessary. Depending on the scope of the physician’s practice, primary care providers are internists and pediatricians, but can also be geriatricians or obstetricians and gynecologists. Nurse practitioners and physician’s assistants are increasingly providing primary care to patients as well.

For many years there has been talk about a physician shortage in the field of primary care. At one time, primary care physicians constituted the bulk of American physicians. However, advances in technology, increased medical educational debt, lower reimbursements and higher patient loads for primary care physicians have caused most doctors in training to enter a specialty field. The Association of American Medical Colleges predicts that in the decade that began in 2010, nearly one-third of all practicing physicians will retire. As a result, Americans will need an estimated 45,000 primary care physicians by 2020.

This trend has far-reaching consequences. Many ethnic minorities, people with low socioeconomic status or no health insurance may use primary care physicians and/or community health centers as their only source of health care; however, access to these providers is already limited for some patients because of factors like geography and a lack of transportation, or more complex issues like language barriers. The actual shortage of physicians and lack of funding for community health centers only exacerbates this problem.

Also, one statistic from the Kaiser Family Foundation says that 56% of patient visits in America require primary care, but only 37% of physicians practice primary care medicine, and only 8% of the nation’s medical school graduates go into family medicine. Furthermore, a higher ratio of specialists to patients has been correlated with higher mortality rates overall. This suggests that a higher ratio of primary care physicians will contribute to better health. With better access to primary care, patients can prevent disease and receive early treatment in the event of an illness.

The ACA has proposed several pieces of legislation to help solve the primary care physician shortage (the following was summarized from a Kaiser Family Foundation brief):

• Add 15,000 new primary care providers to the workforce by 2015
• Allocate $300 million for the National Health Service Corps which recruits the primary care workforce in underserved areas 
• $230 million in award grants will go to “teaching health centers” to start primary care residency programs 
• 10% bonuses for primary care providers under the Medicare fee schedule (started in 2011)
• Increase PCP reimbursements at the state level from Medicaid rates to Medicare rates by 2014 
• Increase the number of Accountable Care Organizations (ACO's) which thrive on the quality and not the quantity of patient care. ACO's encourage collaboration among physicians and allied health professionals rather than overuse of medical services
• Increase the number of community health centers 

Lastly, medical education institutions are charged to shape medicine’s leaders of tomorrow. This means medical schools should continue to educate students about issues related to primary care and the state of the health care system. Shadowing and networking with primary care physicians may increase interest in the field. Curricula should include such activities. Also, the number of residency programs must increase in order to accommodate the growing number of medical school graduates.

Race and Disease

What is the difference between health inequality and health disparities? Dr. Olivia Carter-Pokras, Associate Professor at the University of Maryland School of Medicine and the School of Public Health, said that health inequality is just a difference in health; health disparities are marked not only by a discernible difference in health, but also an injustice that can be changed. Dr. Carter-Pokras has over 25 years of health disparities research experience within the Federal government and academia, and was previously the Director of the Division of Policy and Data, Office of Minority Health, Department of Health and Human Services. Here at the National Institute on Drug Abuse (NIDA), I attended a presentation Dr. Carter-Pokras gave about health disparities.

After the seminar, I began to think about race in general. When I first arrived at NIDA, research fellows were invited to the Smithsonian National Museum of Natural History in Washington, DC. The museum held an exhibit called “Race: Are we so different?” One idea the exhibit emphasized over and over is that race is a social rather than a biological construct. This means that we created the idea of race to distinguish one human from another. However, someone on the other side of the world is only 0.1% different from me at the genetic level. This may be hard to believe considering that humans come in many different shapes, sizes and colors. The exhibit had strong scientific and historical evidence to support the idea that race is purely a man-made idea.

If race cannot be defined by our genes, why do health care professionals use race to infer other characteristics about their patients? Why does the new Patient Protection and Affordable Care Act (ACA) require the Federal government to collect racial data?

There are a few instances in which race (heritage, to be more accurate) may help physicians and allied health care professionals better treat their patients. However, this is a line that must be walked carefully. For example, some ethnic groups do have a higher prevalence of certain diseases (e.g. Ashkenazi Jews have a higher prevalence of Tay-Sachs disease and African-Americans have a higher prevalence of Sickle Cell Anemia). If a physician understands these links, a diagnosis may be made sooner. However, sometimes making assumptions about race and disease can hurt a patient. The Race exhibit at the Smithsonian featured a video of a father whose infant daughter was not quickly diagnosed with Sickle Cell Anemia. The parents were both white and Sickle Cell Anemia seemed like an unlikely cause of the baby's illness. However, the father was of Sicilian ancestry. A simple blood test confirmed the baby had Sickle Cell Anemia. This was an example in which generalizations about ethnicity and disease can be harmful. Though it may not be commonly known, Sickle Cell Anemia spread to places in southern Europe as well as throughout Africa.

The ACA is working to eliminate health disparities. In a 2011 report, the American Medical Association says the first step to eliminating disparities is to detect them. If this is true then the collection of racial is data is justified. However, a closer look at what we define as race may actually be an indicator of the greater disparities that exist among social determinants of health. For example, while it is true that many minorities endure numerous health disparities, this is often due to the environment in which minorities live and inequities in education, socioeconomic status, and other factors—not race. Poor whites have similar health outcomes to those of ethnic minorities. Similarly, ethnic minorities with higher socioeconomic status have better health outcomes than their poorer counterparts. Race should not define who we are nor how healthy we can be. We should focus on improving the conditions in which many disadvantaged people live which will result in an improvement in health.

Three CCNY Students Named 2012 Salk Scholars

This press release was taken from the City College of New York's website. The following was released on May 16, 2012.

 

Lisa Brandt and Julian Flores, members of The City College of New York Class of 2012, and Alexa Mieses, a 2011 graduate, have been selected to receive the 2012 Jonas E. Salk Scholarship awarded by The City University of New York.

The awards recognize the high ability and scholarship of students who plan careers in medicine and the biological sciences and who are judged likely to make significant contributions to medicine and research. They are selected on the basis of original research papers undertaken with prominent scientist/mentors.

“Congratulations to Lisa, Julian, Alexa and the winners from the other CUNY Colleges,” said CCNY President Lisa S. Coico. “Their achievements are a testament to their hard work, dedication, and perseverance as well as to the support of the faculty.”

The Salk Scholarship provides a stipend of $8,000 per scholar, to be appropriated over three or four years of medical studies. Salk Scholars also receive achievement citations and diagnostic kits that include an otoscope and ophthalmoscope. The scholarships will be presented at a ceremony Wednesday, May 16, in the William and Anita Newman Conference Center at Baruch College.

Dr. Jonas Salk, a 1934 graduate of City College, developed the polio vaccine in 1955. He turned down a ticker-tape parade in honor of his discovery, asking that the money be used for scholarships instead. New York City provided initial funding for the Salk Scholarships in 1955.

Ms. Brandt, Mr. Flores, and Ms. Mieses were all inspired to become doctors to aid their communities. After graduation, Ms. Brandt will attend either Columbia University Medical School or Mount Sinai School of Medicine, while Mr. Flores plans to attend Harvard Medical School. Both want to become pediatricians. Ms. Mieses will attend Mount Sinai School of Medicine. Brief profiles of the students follow:

Lisa Brandt
Ms. Brandt, born in the Dominican Republic to a Dominican mother and an American father, wants to become a pediatrician to provide free and affordable care to her community. “I wanted a career that had a purpose for me, a versatile career where you’re a student, teacher, and guide, and can be a pillar to your community.”

Ms. Brandt was so impressed by City College’s affordability and high quality of education, that it was her only choice when she applied to college. “I knew I wanted to go to medical school for a long time, and I knew I didn’t want to come out with debt. I wanted to go to a school that would give me a high quality education,” said the biology major.
Currently, she is working in the lab with Professor Jonathan Levitt, using a ferret as an animal model to examine the postnatal development of the brain. She is also volunteering at Morgan Stanley Children’s Hospital of New York-Presbyterian and has volunteered at numerous health fairs.

At CCNY, Ms. Brandt received a myriad of honors such as the 2010 Annual Biomedical Research Conference for Minority Students Presentation Award, and the 2011 Collegiate Science and Technology Entry Program Honorable Mention Award in the Natural Sciences.

She also received the Zeldin-Sviridov Scholarship, Edmund Baermann Scholarship in Natural Sciences, Associated Medical Schools of New York Stipend and Student Support Services Program Outstanding Academic Award. Additionally, she shadowed a pediatric endocrinologist, and gastroenterologist in private practice. Outside of school, she enjoys drawing.

Julian Flores
Mr. Flores, the son of Costa Rican immigrants, believes he has an obligation to help the Hispanic community, since he has an opportunity to make an impact. “Being Hispanic, makes me want to want to give back to the Hispanic community to bring about longstanding change.”

That opportunity is a scholarship to Harvard Medical School, where he will pursue his dream of becoming a pediatrician. “It is a great honor to come from City College and to represent both CCNY and CUNY at Harvard,” the Flushing, Queens resident said.

Mr. Flores, who is receiving a BS in biology, came to City College on full scholarship as a Macaulay Honors College student. He used the resources of Macaulay to go beyond the textbook and the classroom.

He counseled parents in a family health intervention program run by Columbia University and also participated in a summer undergraduate mentorship program between his junior and senior years at Albert Einstein College of Medicine. Currently, he is using Drosophila Melanogaster, the common fruit fly, as an animal model to study autism spectrum disorders as a research assistant to Professor Tadmiri Venkatesh.

At City College, Mr. Flores received countless awards including: best poster in neuroscience at both the Annual Biomedical Research Conference for Minority Students and the 2012 Collegiate Science and Technology Entry Program Conference. He also received a Weston Scholarship, in addition to the scholarship from Harvard. Outside of school, he enjoys playing soccer and baseball as well as dancing and listening to music.

Alexa Mieses
Ms. Mieses already had dreams of becoming a doctor as a junior in high school. While she attended Bronx High School of Science, three students died of drug-related causes.  A sophomore she mentored was one of them, a victim of a heroin overdose. “The experience definitely inspired me to learn more aggressively about the effects of drug abuse on the brain and the body. It increased my awareness of it,” said Ms. Mieses.

She volunteered at Montefiore Medical Center in the Bronx and tutored low-income children at the Champion Learning Center in Lower Manhattan.  As the coordinator for the CCNY Minority Association of Pre-Health Students’  “Harlem Take Care of Yourself” health fair, she helped increase attendance twenty-fold. She also interned at the Bronx Zoo, the Gay Men’s Health Crisis Center and worked with autistic children in Chile, as a Watson Fellow.

A Queens resident of Dominican and Italian heritage, Ms. Mieses graduated magna cum laude with a BS in biology in 2011. She deferred medical school for a fellowship with the National Institute on Drug Abuse in Baltimore, where she examined behavioral and genetic correlates of drug addiction. The fellowship provided professional growth and gave her access to new lab techniques.

After the fellowship, she will attend Mount Sinai School of Medicine in August and hopes to become a primary care physician in an underserved community. “In addition to practicing medicine as a clinician in New York City, I am also committed to mentoring aspiring medical students and students from underrepresented minority groups.”

At CCNY, Ms. Mieses was awarded a J.K. Watson Fellowship and Outstanding SEEK Graduate of the Year Award; she was a SEEK Scholar and tutor, and belongs to three honor societies. In addition, she shadowed a surgeon in private practice as well as conducted neuroscience research on eye movements and studied Spanish and art history in Spain. Outside of school, Ms. Mieses writes poetry and loves singing. She hopes to incorporate her love of writing into her career.

Media Contact
Ellis Simon     P | 212-650-6460     E | esimon@ccny.cuny.edu

My First Acceptance

On October 15, 2011, I received a phone call from an unfamiliar phone number. I was in Baltimore, in the lab, analyzing data. I am admittedly a die-hard New Yorker (the juice of the Big Apple is in my blood) but I moved to Maryland to complete a research fellowship at the National Institute on Drug Abuse. Though I could not take the phone call, I quickly typed the number into Google’s search engine. Normally I am not paranoid. However, the medical school application season had begun several months prior. I needed to make sure I didn’t miss a medical school’s call.

Before I could hit “enter” on the keyboard, a voice mail notification appeared on my phone. Unable to endure the suspense, I excused myself from the room. I quickly dialed my voice mail. That was the day I received my first acceptance to medical school! The school’s dean had called to inform me of the good news. My hard work had finally paid off! 

Applying to medical school is a year-long process. There is a lot of “hurry up and wait.” You work hard to meet the primary application deadline, and wait for schools to send you their secondary applications. You devote time to crafting eloquent secondary applications and wait to be invited to interview. After weeks of interview preparation, the day finally comes and afterwards you are left to wait for the verdict. 

Applying to medical school definitely has its share of drama and suspense but the process is also fun and rewarding. This may sound odd but allow me to explain. First, my desire to become a physician trumps any amount of paperwork. It should also be said that my writing improved as the result of all the essays I submitted. Interviewing was the fun part. I traveled to different cities around the country and had the opportunity to meet wonderful faculty, medical students and other applicants. Best of all, I had an opportunity to elaborate on my past experiences and allow the admissions committees to gain a better sense of who I am. 

The truth is -- that for me, the medical school application process began many years ago. And the truth is that the process never ends. To be a physician is to be committed to a lifetime of inquiry and learning. There will always be more hands to hold. There will always be more information to learn and questions to ask. I will always strive to grow both personally and professionally in the interest of providing better care to my patients.