New England Public Radio

Salaries of primary care doctors are lower than most specialists, and the workload is often higher. The field is losing more doctors than it’s gaining – and raising concerns over who will take care of the next generation. Last week, we aired a documentary following a group of primary care residents at Baystate Medical Center as they weighed this career decision. Today, we look at other efforts to not just recruit primary care doctors, but, ideally, make the profession more attractive.

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The shortage in primary care doctors is not theoretical for Andrew Morris-Singer. He says his mother almost died several years ago because of it.

“She had an atypical pneumonia,” he says.  “It didn’t present in an usual way and she didn’t have a primary care provider to take a comprehensive approach to her problems.  She ended up on a ventilator for 6 weeks.”

At about the same time, Morris-Singer was a resident at Harvard Medical School –  and learned from an email that the dean had defunded its division of primary care. He considered that yet another sign of a ‘hidden curriculum’ against primary care – where medical students are told, in subtle and overt ways, that the field is not as prestigious or lucrative as specialties, like cardiology or oncology.

Morris-Singer joined a petition drive to protest Harvard’s move away from primary care – which he claims ultimately led to a reversal of that decision.

“And we said this can’t only be possible in Boston,” he says. “This can’t just be a local phenomenon.”

Years earlier in college, Morris-Singer had been a LGBT activist, and it occurred to him the same sorts of tactics could work in healthcare. Today, his group — Primary Care Progress — tries to pressure medical schools into putting more resources in primary care training – and to create more leaders in the field.

Every year, Primary Care Progress invites medical students, doctors, and others to a forum in Cambridge – which, judging by a recent one, turns into something between a political rally and motivational lecture.

“If you look at how a lot of primary care leaders talk and act — ‘It’s not fair that we don’t get paid enough,'” Morris-Singer says to the crowd from the podium, mimicking a frustrated doctor. “‘It’s not fair that we don’t have the ability to hire social workers at the practice. It’s not fair, and you with power…. please care.’ So that strategy doesn’t work anymore, right?

Morris-Singer passes the stage off to his right-hand woman, Stephanie Aines, a professional activist.

“What do we have that they need?” she asks the group, her voice rising. “Our tuition dollars fund our schools. They need our money.”

The students brainstorm proposals to take back to their medical schools. And to add a bit of energy, they come up with chants – something to do with primary care. One group went for a pun using prime numbers:

“2,3,5,7 – C-A-R-E, 2, 3, 5, 7, C-A-R-E, We’re indivisible!”

Corny, perhaps. But there are signs that efforts like these are working.

In 2010, an anonymous donor gave Harvard Medical School 30 million dollars to launch a Center for Primary Care. Director Russell Phillips says giving students more hands-on primary care experience is a priority, but they also need to believe the field will be satisfying in the real world.

“We realized we couldn’t change the student experience if we put them into dysfunctional clinics, led by dispirited faculty who are not enjoying the work that they were doing,” Phillips says.

So the Harvard Center spends some of its money on promoting new ways to take care of patients. Like a team-based approach. That may not sound revolutionary, Phillips concedes, but for years primary care doctors worked in relative isolation – in charge of almost all administrative and medical tasks.

“Formerly, the patient would bring in a bag of medicines and I would spend half of my visit going through and checking which medicines they were on,” he says. “Now we have other team members who can assist with those kinds of activities.”

Among the team-based practices where Harvard students train is Faulkner Hospital in Jamaica Plain – an affiliate of Brigham and Women’s.

Second-year resident Kristin Castillo is preparing for her day’s patients with what’s called the daily huddle. It’s attended by a supervisor, a nurse, a patient coordinator, and a medical assistant. As Castillo reviews her charts, team members chime in to make sure she hasn’t overlooked anything.

“I’m not sure how current his depression is,” Castillo says at about one patient, to which her nurse replies that he’d recently taken a survey.  “Ok, so maybe we can hold off.”

Castillo’s first patient is a 39-year-old woman with poorly controlled diabetes, which causes pain and numbness in her feet. Castillo uses a soft filament to test her nerve endings. She notices that the patient can’t feel the tool when Castillo rubs it against her left toe, “which makes me concerned there may be more nerve damage to this side because of longstanding diabetes.”

Afterwards, Castillo says she feels good about the visit. On top of the diabetes, she addressed the woman’s fainting spells, weight gain, and depression. She gives credit to her team for keeping her efficient. But she’s not ready to commit to primary care after her residency. She’s strongly considering cardiology.

“I’m not certain that folks choose their specialty based on whether a team- based approach is there or not,” she says. “I think people tend to be attracted to specialties based on their interest in the subject, whether it’s an organ system or a disease that excites them.”

And it can be a relief to only have to know about one organ system or disease – and to know it incredibly well. That’s pretty much the opposite of primary care, where doctors are being asked to take on more and more, from mental healthcare to social work.

“Everyone loves it, if you can spend an hour with a patient and sit down and talk to them and really get to know them,” says Eric Churchill, a primary care doctor at Baystate Medical Center in Springfield. “It’s much less rewarding when you have 15 minutes per patient, and you have to try to cram in everything you need to get done.”

That said, he does his best to persuade residents they can be happy as primary care doctors. But Churchill and others say training and advocacy can only go so far. For more doctors to choose primary care, the healthcare system has to change — including how it’s paid for — so that conversations and preventive care are rewarded as highly as specialized procedures.

THIS PROJECT WAS SUPPORTED BY A FELLOWSHIP FROM THE ASSOCIATION OF HEALTH CARE JOURNALISTS AND THE COMMONWEALTH FUND.