At a time of soaring nationwide demand for primary care physicians, Massachusetts General Hospital is trying to train new ones and hold onto veterans like Will Schmitt, MD.
If a patient is too sick to get to the Charlestown HealthCare Center, Dr. Schmitt will hop on his bike and go to the patient’s home. Just about everyone he sees lives within a mile of Mass General’s Charlestown HealthCare Center. Twenty years ago, he started as the first resident at the health center. Today, he knows three or even four generations of families. Dr. Schmitt describes it as “small-town doctoring combined with a high-powered academic medical center.”
Dr. Schmitt is one of about 200 primary care physicians at Mass General. Ranging in size from five to 50 physicians, Mass General’s 18 adult primary care practices see more than 140,000 patients annually.
The Charlestown center is one of three community health centers that Mass General owns and operates. A fourth health center in the North End is also closely affiliated with the hospital. The Charlestown site and the other centers in Chelsea, the North End and Revere offer primary and specialty services to accommodate the special needs of the communities they serve.
Developing new Dr. Schmitts, who practice in the community, is part of the impetus for a generous gift from Robert and Myra Kraft. Mass General is one of the recipients of this $20 million gift to Partners HealthCare to develop physician leaders in community medicine by funding fellowship programs. The gift also supports loan repayment, mentorship and innovation grants to physicians, nurse practitioners, nurse midwives and psychiatric nurses already working in community settings.
As it stands, “primary care comes in many flavors here,” says Eric Weil, MD, associate chief for Clinical Affairs, Division of General Medicine. “Mass General has wonderful diversity with academic, community health and private practices, as well as practices that focus on special populations like women’s health or geriatrics.”
And yet the hospital’s primary care practices share a frustration with those elsewhere — how to provide quality, cost-effective care in a fragmented system that emphasizes specialist care. Currently, physicians are paid more for things that can be measured like scans, tests and procedures that, thanks to technology, can be done quickly.
In contrast, the job of a primary care physician involves diagnosing multiple illnesses, helping patients navigate a complex healthcare system and coordinating care among different providers and settings. Each hour of direct patient time may generate work requiring up to an equivalent amount of time after the visit. Compounding the issue is the fact that people, many with more than one chronic disease, are living longer.
Primary care helps patients stay healthy. Studies have linked a shortage of primary care physicians with higher infant mortality rates and more deaths from heart disease and cancer.
The healthcare system needs primary care to keep costs under control. Patients without primary care providers often use the emergency department for routine issues or don’t see a doctor until they are seriously ill. These same patients are more likely to be given costly, unnecessary tests and procedures. The clinicians they encounter don’t know them. As a result, such patients become vulnerable to getting more care instead of the right care.
There’s no definitive prescription for fixing primary care. Yet Mass General is making inroads with a number of initiatives that address different aspects of the problem. Says Sally Iles, associate vice president for Medicine and Primary Care Services: “Our goal is to support primary care in ways which make it a satisfying, doable job, improve the quality of patient care and slow the rate of growth in healthcare costs.”
Some of Mass General’s primary care initiatives involve teams to coordinate care. There are projects to control cost for some of the sickest and most complex patients. Technology is a critical component with web-based applications (developed at Mass General) that provide quick access to evidence-based information both for common diseases and conditions not typically seen.
Bolstering interest in primary care among young people is part of this effort. In addition to Crimson Care, a primary care summer scholars program and a new global health primary care residency program are designed to attract future primary care leaders in the United States and around the world.
The challenges of primary care are also what make it appealing to some Mass General practitioners. Leigh Simmons, MD, a primary care physician in her fourth year of practice, says that while the breadth of knowledge may be daunting for those considering the field, it’s never boring. As a generalist, she sees the variety of cases that emergency physicians do, but also enjoys the long-term relationships and the work of managing chronic conditions and preventing illness complications.
What’s clear is that there is still a real need for a strong primary care system and quality primary care providers. “There’s no better investment in your health than surrounding yourself with a team that knows you and the resources that you need,” says Dr. Simmons. “And at the helm of that team is your primary care physician.”