Dave Pedersen, UI Health Care Marketing and Communications, 319-356-1498
The University of Iowa Roy J. and Lucille A. Carver College of Medicine is known for many things—its research enterprise, its curriculum and learning opportunities, and its faculty—but one of the hallmarks of the college is its success and commitment in the area of primary care.
For each of the graduating medical school classes over the past five years (2008 through 2013), at least four out of 10 students have chosen primary care specialties such as family medicine, general internal medicine, general pediatrics, and obstetrics and gynecology for their medical residency training after graduation.
That bodes well for communities across Iowa, where today more than half of the state’s practicing doctors have a connection to the university—as a graduate of the UI Carver College of Medicine or a UI-affiliated residency or fellowship program.
In fact, developing and monitoring Iowa’s physician (and nonphysician provider) workforce and fostering relationships with medical practices, hospitals, and health systems across Iowa is the mission of the college’s Office of Statewide Clinical Education Programs (OSCEP).
UI-affiliated Regional Medical Education Centers—in Cedar Rapids, Davenport, Des Moines, Mason City, Sioux City, and Waterloo—and eight residency programs that comprise the Iowa Family Medicine Residency Network are just two of the many OSCEP initiatives that serve medical students, residents, and practitioners. More than 700 Iowa doctors serve as volunteer clinical teachers who contribute to UI medical education in their communities.
Iowa Now spoke with Roger Tracy, assistant dean in the UI Carver College of Medicine, who has seen and influenced changes across the state’s health care landscape. This week, he’s retiring after 44 years of service to the university, including 40 years as OSCEP director.
Let’s talk about the origins of OSCEP.
It arose out of conditions in 1973 where the state legislature was concerned about a looming primary care physician shortage, which was true in Iowa and across the nation. They passed enabling legislation that led to the creation of a statewide medical education system. This established training centers in six of Iowa’s major cites where physicians would train in primary care, particularly family medicine. The legislature expected community hospitals in these cities to host residency programs in family medicine. It also stated that once established, these training hubs would host medical students from the UI who would rotate out to these sites for clinical education. In addition, each of the sites would provide continuing medical education for the local practitioners, many of whom would teach in the programs, Later, as this evolved, physician assistant students would go to the centers, as would pharmacy students and pharmacy residents, as well as medical residents from UI Hospitals and Clinics from many specialties, such as urology, surgery, and otolaryngology.
Our role in the college was to develop this statewide system—providing direction, technical assistance, and educational support once the training programs were in place.
So, the goal…
The idea was that students would have a good experience in the community, hopefully select a primary care specialty as a career choice and follow up with residency training at an Iowa location—with the hope that they’d stay in Iowa to practice.
Has this been successful?
Yes. Today, we have 868 of the graduates of the residency programs practicing in Iowa. Of everyone who entered, 62 percent have stayed in Iowa, and roughly half of them are practicing in rural communities with fewer than 10,000 people.
The first effort back in the early ’70s was to develop the system. Next, we needed to get out and support these training hubs and do a good job of keeping graduates in Iowa. So we developed models—one in Muscatine and one in Red Oak—to test medical practice concepts to better determine what it’d take for graduates to stay in the state. One requirement of success was small-group practices; another was contemporary-styled practices. So, we established a second OSCEP division to go into smaller, rural-based communities and help them reorganize their medical practice so they were more attractive to new graduates.
Your office also established a database that’s been widely lauded as a unique workforce information resource.
That’s right. It’s called the Iowa Health Professions Inventory, which now tracks all of Iowa’s physicians, dentists, pharmacists, physician assistants, and advanced nurse practitioners. It’s a continuous-tracking, longitudinal database, and we’re still the only state in the nation that has the capacity to do this. Other states use medical licensure data and typically do an annual “snapshot” of their health care workforce. Ours is interactive and changes every day.
Why create such a resource?
Once OSCEP was firmly established, it was clear that we needed to be able to assess our progress. We couldn’t yet answer certain questions—if there were more doctors in the state than in past years, for example, or whether the physician workforce was getting younger, or which specialties in which communities were seeing increases or decreases. These were questions coming directly from the state legislature, the governor’s office, the Iowa Medical Society, and the Board of Regents.
It took three years to build and wouldn’t have been possible without deep cooperation from doctors, hospitals, board of medical examiners, and others. Our first benchmark was reached on Dec. 31, 1977. We were able to call out the first data and pull a physician’s gender or age, whether the physician population was getting younger or older, and where the gains/losses were in terms of workforce numbers. We collected the name, place, specialty, and established a profile on every one of Iowa’s physicians, and it continues today.
What is the current state of Iowa’s physician workforce?
Let’s put it in a time perspective. In the early 1970s, when the legislation was passed, the deficit was clearly in primary care. By the mid-to late ’90s, primary care had made a great recovery, and the physician shortages were mostly in the subspecialties of internal medicine and pediatrics, as well as some surgical specialties.
More recently, with a decline in interest among medical students, the number going into primary care—family medicine and general internal medicine, specifically—has sharply declined. At the same time, the Affordable Care Act will allow more than 30 million individuals nationwide who don’t have health coverage to get insurance. This creates a sharp increase in demand for primary care services, with fewer students—at this point in time—choosing primary care for specialty training. The UI still does well, relatively speaking, in terms of students choosing primary care specialties, but not at the levels we were seeing 10 or 15 years ago.
The other specialty that is in short supply in Iowa and across the country is psychiatry, both adult and child-adolescent psychiatry. It’s traditionally been low in terms of student interest, and this continues to be the case.
What’s the primary care situation in Iowa?
We take a “snapshot” annually of the demand at that moment. We do this every year with no variation in our method, and we have 100 percent response rate from all entities in Iowa that employ at least one physician. There are currently 165 jobs open for family medicine physicians, and 87 jobs open for general internists. Those are big numbers.
Where do you see health care and medical education heading?
We’re going to see a much greater effort to practice in teams of health professionals, so that means we’ll need a greater effort to train as teams across the health professions. Clearly, there is an effort going in that direction.
Also, for the future we’re going to see changes in reimbursement for both hospitals and physicians that will help make the health care system safer, more efficient, and more effective.
What sorts of changes in reimbursement?
Physician reimbursement will be based more on value and less on production. This will reduce the growth in health care expenditures as part of our economy. Reimbursement is already part of reform, but that will accelerate.
Preventive medicine is addressed in the Affordable Care Act, and prevention has long been a buzzword in health care reform…
That’s one element of a patient-centered medical home, which is very important to the changes the system is undergoing. Ten years ago, I would have said that we may never see reimbursement for prevention services, because unless it’s covered, those services simply are not going to be provided, or at least not in a great effort. So by emphasizing the patient-centered medical home in the reform bill, there’s already more attention.
You’ve met and worked with a lot of influential people over your career—physicians, hospital CEOs, legislators, policymakers, medical education leaders. You were fostering relationships before “network” was also used as a verb.
The success of OSCEP has been due to the relationships we’ve developed across the state. We have always emphasized to local leaders that we do what’s in the best interest of Iowa communities. It’s led to our being credible and trustworthy. That’s been our currency. It’s served us well, as well as the state’s medical practices and health care systems and, ultimately, Iowa’s patients.