Retaining Primary Care Residents in Palm Beach County

1. Retaining Primary Care Residents in Palm Beach County Community Health NETwork Six Pillars Community Health Planning Meeting Joan St. Onge, M.D. Assistant Regional Dean for Clinical Curriculum May 22, 2012

2. Indebtedness • $157,944 – Average educational debt of indebted graduates of the class of 2010. • 78 percent of graduates have debt of at least $100,000. • 42 precent of graduates have debt of at least $150,000. • 85 percent of graduating medical students carry outstanding loans.

3. Cost of Medical Education • Local Tuitions: • Nova Southeastern School of Osteopathic Medicine • 4 year DO program: $32287 for Florida Residents and $38818 for out-of-state students. • FAU Charles E Schmidt College of Medicine • 4 year MD program: $25,725 for Florida residents and $57,225 for out-of-state • COST OF ATTENDENCE: $52,569/$85,282 • University of Miami Miller School of Medicine • 4 year MD/MPH program: $30,177/$39659 • 4 Year MD program: $30177/$39659+ fees= $40,492

4. Practice Environment Some aspects of the work environment dissuade medical school students from pursuing careers in primary care and lead practicing primary care providers to leave the field. These include sometimes long, erratic hours; administrative obligations, especially dealing with insurance companies; and malpractice liability. Medical students recognize and view negatively the increasing demands on primary care physicians “to accomplish large numbers of therapeutic interventions during short visits with chronically ill patients while managing increasing administrative expectations” (Hauer, et. al., “Factors Associated With Medical Students' Career Choices Regarding Internal Medicine,” JAMA, September 10, 2008, pp. 1154-1164).

5. Financial Incentives • Scholarships and loan repayments tied to service obligations are the most popular incentives. • 1-5 year commitment • Targeted to Physicians or other health providers • Scholarships attract low income students • Some begin at the undergraduate level • Loan repayment may be more effective in attracting graduates to underserved areas.

6. Minnesota is one of the few states to have evaluated its loan repayment program. • Begun in 1990 to recruit doctors to rural areas, by 2007 the program supported over 550 doctors, dentists, pharmacists, physician assistants, and nurses in those areas and in high-need facilities like nursing homes, intermediate care facilities for people with mental retardation, and dental practices serving a high proportion of low-income patients. The evaluation found: 1. the programs were effective in recruiting practitioners to high-need locations; 2. most practitioners who completed their service obligations remained in similar practice settings in the state; and 3. placement sites varied in their dependence on the program as a recruitment/retention tool, with smaller primary care and specialty clinics valuing the program the most.

7. Findings of the study 1. The programs were effective in recruiting practitioners to high-need locations; 2. Most practitioners who completed their service obligations remained in similar practice settings in the state; and 3. Placement sites varied in their dependence on the program as a recruitment/retention tool, with smaller primary care and specialty clinics valuing the program the most.

8. “The vogue for such specialties is part of a migration of a top tier of American medical students from branches of health care that manage major diseases toward specialties that improve the life of patients – and the lives of physicians” [3]. A growing number of medical students and residents are prioritizing lifestyle options above prestige from status or further specialization [4]. 3. Singer N. The price of beauty: for top medical students, an attractive field. www.nytimes.com. 19 Mar 2008: 1-2. 4. Dorsey ER, Jarjoura D, and Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA. 2003;290:1173-1178

9. White House announcement April 12, 2012,restating the following initiatives: -Tripling the number of healthcare providers in the National Health Service Corps. -Setting aside $230 million in the PPACA to increase the number of medical residents, nurse practitioners and physician assistants trained in primary care. -Establishing the Teaching Health Center Program, a part of the PPACA that aims to move primary care training into community-based settings. -Providing $10 million in 2012 to support mental health training. -Redistributing unused residency positions to open up spots for the training of primary care physicians. -Providing $50 million each year for the next four years, through the PPACA, to train advanced practice nurses

10. Tripling the number of healthcare providers in the National Health Service Corps. • FQHC’s and other sites within Palm Beach County serve as approved sites for the National Health Service Corps • Focus on Loan Repayment • Reinvestment in the community • Highlight these programs in the residency programs

11. Establishing the Teaching Health Center Program, a part of the PPACA that aims to move primary care training into community-based settings. • Family Medicine • Internal Medicine/Primary Care track • Offer “second clinic” to residents interested in Primary care, which would be within physician’s office( great recruiting strategy)

12. OB/GYN: New programs • Pediatrics: New programs • Providing $10 million in 2012 to support mental health training. • Psychiatry: new programs

13. Practice Support • Some states help doctors set up practices in underserved areas. • Under New York's Doctors Across New York initiative: physicians who commit to practicing for two years in an underserved rural or urban area can receive $100,000 for salary enhancements, signing bonuses, or other direct payments

14. Practice Support • Arkansas' Community Match Loan and Rural Physician Recruitment Program: doctor can receive up to $80,000 for four years of service in a medically underserved rural community. One half from the state, one half from the community. The community portion can be paid by a hospital, or other health care organization.

15. South Carolina SEARCH PROGRAMStudent Experiences And Rotations in Community Health (SEARCH) Program 10 Year Look – 1998 - 2008 297 students placed in rotations in medically underserved and/or rural communities 57% of those students now practice in primary care in rural/and or underserved areas of SC Remaining 43% are in non-rural areas or are still in training Seven participants have been NHSC scholars One out-of-state NHSC scholar was employed in SC after completing a SC SEARCH rotation

16. Coordination • Office of Primary Care Recruiting and Retention • Medical student programs • Residency “second clinic” coordination • NHSC scholarship and Loan Repayment assistance • Recruiting website with no fee for advertising

17. Other thoughts: The Millennial Generation • Palm Beach County: • Emphasize quality of life • NO state income tax!! Little known fact!! • Friendly environment for Primary Care? • Recruiting campaign for new residency graduates locally and in Florida • Mentoring through “second clinic” program: primary care lifestyle is not bad!!

18. Public/private partnerships to address indebtedness • Housing