While health reform will improve patient outcomes and care for the underserved, one significant wrinkle could make caring for many more Americans extremely difficult. By 2025 the United States may be running a deficit of as many as 159,000 physicians, with reform measures potentially increasing the shortfall by 25 percent, according to the Association of American Medical Colleges (AAMC).
“There are physician shortages in a variety of areas; general surgeons and pediatric subspecialists, for example; however, by far the largest shortage of providers we face is of primary care physicians and that’s without health care reform,” says Russell G. Robertson, MD, chair of the Department of Family and Community Medicine at Northwestern University Feinberg School of Medicine. Since 2006 Dr. Robertson has served as chair of the Council on Graduate Medical Education (COGME). One of 17 council members, he advises Congress and the Department of Health and Human Services on issues relating to U.S. physician supply and distribution. “One of the challenges is helping people understand how dire the shortage really is.”
On Capitol Hill
Involved in the development of the legislation pertaining to primary care training and access, Dr. Robertson traveled to Washington, D.C., more than a dozen times last and early this year. Fortunately, his background makes him uniquely suited to educating legislators and others concerned about a future drought of physicians and other health care professionals. Dr. Robertson taught elementary and junior high school in Utica, Mich., for four years before deciding to become a physician. After fulfilling his pre-med requirements, he started on his new career path by earning an MD degree at Wayne State University in 1982 and then completing a family medicine residency at Grand Rapids Medical Education and Research Center in Michigan, as well as a fellowship in faculty development at the University of Missouri in 1985. He later acquired a certificate of added qualification in geriatrics. Joining Feinberg in 2005 as department chair, Dr. Robertson continues to focus on education as a means to ensure an adequate pipeline of health care providers for the nation through innovative academic programs and experiences and mentoring junior faculty.
“Russ sees the big picture across many different stages, from national to local, and does a good job of finding the right people with the appropriate skill sets to make his vision come to life,” explains Deborah L. Edberg, MD, assistant professor of family and community medicine. “He’s an inspirational leader who sees people’s strengths—some they haven’t even identified themselves. He wants people to succeed and that’s refreshing.”
She speaks from experience. In 2007 Dr. Robertson recruited her to the former Evanston Northwestern Healthcare, where she became associate residency program director. In 2009 Dr. Robertson recruited Dr. Edberg to Northwestern to serve as program director for Feinberg’s new family medicine residency. But first, she had to help develop it. “He called me with a ‘crazy’ idea about starting a program from scratch,” laughs Dr. Edberg. “I was hesitant but also excited about all of the amazing things we could accomplish. If anybody could make this happen, Russ was the one to do it.”
One of only some 20 training programs in the country located in a Federally Qualified Health Center (FQHC) and affiliated with a university, it provides family medicine residents with community-based experience in underserved areas. Early on, Dr. Robertson recognized the impact physician shortages have on vulnerable populations. So he began exploring a new educational model for training family physicians while the Feinberg School’s family medicine residency was still based at Glenbrook Hospital. He quickly found a receptive audience in medical school leaders who were open to deepening and broadening the institution’s community engagement.
In 2007 Dr. Robertson started searching for a partner. He explains, “As we looked at hospitals to work with there were several necessary criteria: it had to be helping underserved patients, be reasonably accessible from our Chicago campus, and be eager to become a teaching institution.”
The decision to approach Norwegian American Hospital grew out of a conversation with Mark Loafman, MD, MPH, one of Dr. Robertson’s first faculty recruits and the chief clinical integration officer at Norwegian. It became apparent to them that a partnership would be a win-win for both organizations.
“Norwegian American’s patient population is medically underserved, and Erie Family Health Center’s [an FQHC] Humboldt Park office was only a few blocks away,” says Robertson. “In addition, Erie has a long history of collaboration with the medical school, and Northwestern Memorial Hospital Corporation has been providing Erie with financial support to maintain their clinical presence there.” Norwegian also shared the risk of starting a new training program and sealed its commitment to becoming part of Northwestern’s educational community: the hospital will be contributing $250,000 annually, in addition to providing graduate medical education funding.
Adds Dr. Loafman, “We all benefit from the collaborative relationships that have evolved. These partnerships will change the health care landscape, opening new doors for Northwestern to connect with and help transform the Humboldt Park community.”
The new three-year residency not only offers a rich environment for clinical training in diverse inpatient and outpatient settings but also affords a focus on research and leadership training. It will expose residents to programs that provide a full spectrum of community health issues, such as maternity care, HIV programs, and elder care. Three quarters of Erie’s patients speak Spanish, so the new trainees will begin learning the language through a month-long immersion program.
Approved late last year by the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee, the program filled all of its eight spots during this year’s Match. Northwestern’s first class of family medicine residents will begin their training in July.
A New Pipeline
The AAMC and its members have embarked on their own strategy to avoid a physician shortage. Among its solutions, the organization supports the increased use of non-physician health care professionals such as physician assistants—and so has Northwestern in a big way. In early June, the Feinberg School of Medicine will welcome 30 students to its new 24-month PA program. Serving as the program’s academic home, the Department of Family and Community Medicine also houses classroom and training space in its Abbott Hall offices for these new students.
Dr. Robertson credits former medical school Dean Lewis Landsberg with initiating the PA program at Northwestern. An alumnus and former faculty member at Yale University’s School of Medicine, Dr. Landsberg had watched physician assistants and PA students interacting with faculty members and students at his alma mater. He wondered why Northwestern didn’t have a similar program.
“I got wind of his idea to create a program at Feinberg and helped lay the initial groundwork,” Robertson recalls. “Our new PA program adds to the portfolio of individuals that we will be training to become health care providers. At the same time, we will introduce medical students to more contemporary models of care that rely on mid-level providers and their contributions to interdisciplinary health care teams.”
The plan calls for budding physician assistants and physicians to learn together and from each other in classroom and small group discussions that already exist in the medical school curriculum. Topics such as bioethics, economics, and organization of medicine could provide common ground to explore their future working relationships and understand how each group may have differing yet complementary approaches to patient care.
“One of Feinberg School’s main competencies focuses on system awareness and team-based care,” says James A. Van Rhee, PA program director and associate professor of family medicine and community medicine. “It’s difficult for students to achieve this competency if they are only exposed to working with similar students. If we can add a different group of learners, with different life experiences and future responsibilities to the mix, it may help to enrich, enliven, and bring new ideas to discussions.”
By law, physician assistants must work as part of a team with supervising physicians. While medical students will benefit from the perspective of their health care paraprofessional colleagues, Northwestern’s first crop of PA students will gain an early appreciation of the challenges physicians face. Remarks Van Rhee, “Our PA students will not need to wait until the clinical rotations of their second year to come in contact with physicians. We will start integrating the two groups now.”
Medicine on the Run
Dr. Robertson recounts how he had just stepped out of his car, after a two-hour drive down a bumpy road to a Mayan village near the Guatemala-Belize border in Central America. A frantic man approached: his pregnant wife was in labor in a nearby thatched-roof hut with dirt floors. Dr. Robertson entered the simple home to find a woman lying on an elevated wood frame bed cushioned with cardboard. The baby had a compound presentation with its hand next to its head, putting the mother at risk for vaginal tearing.
Using his satellite phone, Robertson reached out to Sherman Elias, MD, chairman of the medical school’s obstetrics and gynecology department. His advice? An emergency C-section and preferably performed in a hospital. Dr. Robertson promptly loaded the woman in a car and off they went to the nearest medical facility. The woman and baby survived, and Dr. Robertson once again learned that practicing global medicine means to expect the unexpected.
If the United States potentially faces a severe physician shortage, especially critical in rural and underserved urban locations, then imagine what underdeveloped and impoverished areas of the world face every day. As board president of Hillside Healthcare International, a health clinic in Punta Gorda, Belize, Robertson has been committed to providing global health services—both immediate and sustainable—since his first volunteer stint at the clinic in 2001. He says, “It was a transformative experience. We take for granted so much of what we have in our country.”
Dr. Robertson has used his expertise to foster Hillside’s mission to provide inexpensive medical services and
valuable clinical experiences for medical students and other allied health care students from the U.S. and abroad. Traveling to Belize at least once a year, he serves as faculty supervisor for the organization’s clinical education program.
This former faculty member at the Medical College of Wisconsin brought his personal interest and acquired skills in international medicine to his position at Northwestern, where the Department of Family and Community Medicine soon began developing clinical global medicine opportunities for medical students and residents. Dr. Robertson is now the associate director for global education within the Feinberg School of Medicine’s Center for Global Health. Among many educational initiatives, he plans to create a series of courses that better prepare students for some of
the surprises they will encounter in international and under-resourced settings.
Interestingly, Dr. Robertson’s efforts in boosting this nation’s supply of primary care providers have a global and a local connection. Several years ago, he shared data showing a weak but real connection about medical students with international experiences being more likely to become primary care physicians with Robert J. Havey, MD ’80, GME ’84. Dr. Havey, who practices with Chicago Lake Shore Medical Associates, had noticed a disturbing recruiting trend that was affecting his clinical practice: a shortage of generalist physicians. As a result of their conversation, Dr. Havey and his associates raised more than $230,000 for the Center for Global Health in 2009 to make it financially viable for Northwestern medical students to travel to underserved areas around the world to expand their education.
Although Dr. Robertson transitioned from being a teacher to becoming a physician some 35 years ago, he has never stopped being the consummate educator. He uses the power of education to address health care challenges that affect us close to home and across the globe, while doing what he loves best: being a primary health care provider.
Robert J. Havey, MD ’80, GME ’84, a practitioner with Chicago Lake Shore Medical Associates, Inc. (CLSMA), noticed a disturbing trend in the lack of primary care doctors in the recruitment pool. After talking to Russ Robertson, MD, chair of the Department of Community Medicine at Northwestern University Feinberg School of Medicine, who shared data showing that medical students with international experiences were more likely to become primary care physicians, Dr. Havey and CLSMA decided to take action.
The Chicago practice, which has more than 40 physicians, organizes two fundraisers a year to promote global health education, provide medical aid to resource-limited countries, and encourage interest in primary care medicine. They hold a golf outing for doctors who are affiliated with Northwestern in the spring and a dinner for interested patients in the fall. In 2009 under their Global Health Initiative (GHI), they raised more than $250,000 for the Feinberg Center for Global Health. These efforts made it financially viable for Northwestern medical students to travel to underserved areas around the world to expand their medical education.
Since December 2008, CLSMA’s support has enabled more than 140 Feinberg medical students to travel internationally. The students have been to 17 low-resource countries, including clinical sites in Bolivia, Nicaragua, Jamaica, Ecuador, Guatemala, Mexico, India, Nepal, China, South Africa, Kenya, Uganda, Botswana, Tanzania, and Liberia. They report that the experience is life-changing, that it increases their commitment to and enthusiasm for the practice of medicine, and, for many students, fuels an interest in primary care.
It also makes them good-will ambassadors — students report receiving expressions of gratitude and hope from the people they encounter. The patients are deeply impressed that American medical students have taken the time to make the journey to a foreign land to learn from doctors in their country, and provide compassionate help, often in very difficult circumstances. This is high-impact philanthropy.
First-year and fourth-year medical students comprise the biggest groups of travelers. M3 students plan their fourth-year elective rotations, which now include global health, around these experiences. The Global Health Initiative at Chicago Lake Shore Medical Associates, which recently obtained 501(c)3 charitable status, funds both individual students and student groups. Depending on the time of year, students are away for either a week (over break) or six to eight weeks (over the summer or fourth-year rotation period).
Students apply through the Feinberg Department of Family Medicine, have their applications reviewed by a panel of CLSMA doctors, and receive notification of approval through the medical school. Students are required to sign a funding agreement and provide the Chicago medical practice with pre- and post-survey information on their experience, as well as a reflection paper.
“The doctors at CLSMA are committed to the idea of aiding in the professional development of Feinberg students,” says Cynthia Horvath Garbutt, JD, executive director of The Global Health Initiative at Chicago Lake Shore Medical Associates. “Our physicians are actively involved in raising the awareness of the GHI, both to their patient populations and Northwestern colleagues, and are inspired by the growing response to this initiative. This is an uncommon, innovative program that benefits many here and in underserved regions worldwide.”
Read what some students have to say about their global health experience:
“This gave me an appreciation for preventative medicine. In areas where patients do not have good access to medical care, it is important to prevent people from acquiring diseases…This requires spending time educating patients.”
—Female M4 who went to South Africa
“In so many ways you realize how primary care can make the widest impact on the most people in underserved populations.”
—Male M1 who went to Nicaragua
“My commitment to primary care medicine has only increased through this experience. To see how knowledgeable and dedicated these physicians are in doing literally everything — I know that I can also provide effective and excellent care that is comprehensive.”
—Male M4 who went to South Africa
“Now, more than before the experience, I realize the need for medical service in underserved populations, especially at international sites. I also appreciate the human aspect of medicine more rather than just focusing on the science aspect.”
—Female M1 who went to Nicaragua
“This experience has increased and solidified my interest in serving underprivileged populations of patients. It has also encouraged me to seek out future international health experiences.”
—Female M4 who went to Tanzania