NORTH HAVEN–As if creating a medical school from scratch in just four years isn’t ambitious enough, Quinnipiac University has compounded the challenge: It wants to get a sizable portion of the graduates to pursue primary care, an area that badly needs more doctors.
If it works, Quinnipiac could become a pipeline for addressing a key health care workforce shortage, just as health reform increases the need for general internists, family doctors and pediatricians.
It could be a tough task.
“Absolutely, there’s a shot, but it’s treacherous waters,” said Dr. Bruce Gould, associate dean for primary care at the UConn School of Medicine. “You can start off with the best intentions. Getting there is not easy because everything is working against you, including the marketplace.”
Primary care pays substantially less than other fields, which can skew decisions for students graduating with six-figure debt loads. The work can be challenging and chaotic, with little support, leading to burnout for those who choose it. And in a state like Connecticut, where small practices are the norm, it can be hard to reconcile the demands of primary care with the defined hours many students seek.
Quinnipiac President John Lahey recognizes the challenge, which he said the school will address through admissions, curriculum and partnerships with clinical sites where students will gain experience.
There are many American students who attend medical schools overseas because they can’t get a spot in a U.S. school. That convinces Lahey there is a market for the new medical school, which will be housed alongside the other health sciences programs on Quinnipiac’s North Haven campus.
But how many applicants will want to pursue primary care?
“That’s the unknown,” Lahey said.
A Primary Care Magnet
As millions more Americans get health insurance in the coming years, the demand for doctors, particularly in primary care, is expected to grow. And the supply is expected to fall short.
The Association of American Medical Colleges projects shortages of both primary care doctors and specialists over the next decade, including a shortage of close to 45,000 primary care physicians.
The majority of medical students are picking fields other than primary care. In a survey of 2010 medical school graduates, just over 30 percent indicated that they were going into family medicine, internal medicine or pediatrics – and nearly three-quarters of those planned to go into a subspecialty.
So how will Quinnipiac attract the right students for what one official called a “magnet school” for primary care?
University officials expect the process to begin with admissions – or even before that. Founding Dean Dr. Bruce Koeppen said it would be useful to have “pipeline programs” that get students interested in primary care even before college.
The admissions process, Koeppen said, should target students who have demonstrated service to others, particularly to disadvantaged people.
“Those are the types of students who eventually end up in primary care,” he said.
Admitting students with the highest grades or MCAT scores won’t necessarily increase the odds of producing primary care doctors, Gould said. Instead, admissions officers could look for students with a history of service, who might be older and have a background in humanities.
“Your admissions committee has to own that,” Gould said.
The admissions process might also favor students with experience in health care, such as work as nurses or EMTs, Lahey said.
There are limits to what the admissions process can do. Often, students arriving at medical school don’t yet know what field they will pursue.
But Lahey believes Quinnipiac will be able to sidestep some of the things that push medical students into subspecialties. Those include the focus on specialized research at many universities and the clinical experiences students get at acute-care hospitals, which give them more exposure to specialty care.
As one place for students to get clinical experience, Lahey said officials are considering partnering with community health centers, which focus on primary care.
And while Quinnipiac’s medical school will include research, it will not be as extensive as what research-oriented universities like Yale and Johns Hopkins do. Much of the federally-funded research is highly specialized, which can lead medical schools toward a focus on specialties, Lahey said.
Federally funded research is a major factor in medical school rankings, reinforcing the push for schools to focus on specialized areas. And according to a recent study published in the Annals of Internal Medicine, the amount of research funding schools receive is inversely related to their production of primary care doctors and graduates who practice in underserved communities.
The study ranked medical schools by “social mission,” and found that those in the Northeast, many of which are research-intensive, had the lowest scores in producing primary care doctors or those practicing in underserved areas.
Gregory Makoul, chief academic officer at St. Francis Hospital and Medical Center, pointed to another critical piece in getting students into primary care: The school culture. In some medical schools, he said, the field gets little respect.
“You will hear, if a student wants to go into primary care, their peers and sometimes their faculty will say, ‘Why? Why would you do that?'” said Makoul, who is developing an institute focused on primary care, a partnership between St. Francis and UConn. “We need to change that conversation.”
That could be easier to achieve by building a new medical school with a clear mission than to try to refocus an existing one, experts said.
“If you’re starting from scratch, you can hire leadership that has bought into the value of primary care,” Gould said. “Not even the value, just the absolute imperative for primary care … if you’re going to build a functional health care system that gets the quality of outcomes that our Americans deserve at a cost they can afford.”
Barriers Beyond Campus
Many barriers can be addressed in a medical school’s design. But some roadblocks keeping students out of primary care are beyond what a medical school can control.
This year’s medical school graduates had an average of nearly $125,000 in student debt, and more than a quarter owed more than $200,000, according to a survey conducted by the American Association of Medical Colleges.
Public Health Commissioner Dr. J. Robert Galvin, a family physician, said he expects Quinnipiac to succeed in its goals. But he said it will be difficult to push medical students toward primary care without reforming the system that pays specialists significantly more and rewards performing procedures more than counseling patients.
“That all has to be corrected,” he said.
Massachusetts offers loan repayment options for doctors and other health professionals who work in primary care as a way to address shortages in underserved areas.
Quinnipiac is exploring ways to reduce the financial barriers. Officials are considering offering a 3-year medical school program, although Lahey said it’s not clear if that would be realistic.
Medical schools typically rely on research funding and their faculty’s medical practice to supplement tuition, but Quinnipiac won’t benefit much from those funding streams. Medical school faculty might have practices in the community, but they won’t be attached to the university, Lahey said. And the school won’t likely do the sort of specialized research that garners major federal grants.
Lahey hopes to create an endowment, generate enough income from students who pay full tuition and use the school’s resources and financial aid to help students pursuing primary care. The board has recognized the possibility that the university will need to subsidize the medical school, Lahey said.
“We could run the medical school on a break-even basis if we didn’t have a plan on doing something in the primary care area,” he said. “But when you add to our mission the primary care emphasis that we want, that’s where it becomes complicated and challenging for us.”
So what will happen down the road if Quinnipiac operates a respected medical school but turns out no more primary care doctors than its peers?
“I’ll be unhappy,” Lahey said. “I don’t think it’s an either-or thing, but I do think we are attempting to do something that traditional medical schools have not done, that is to have a significant commitment to primary care, but at the same time, have a first-rate medical school that this university can be proud of. I want to achieve both and I don’t think they’re incompatible, but I’m not underestimating the challenges and the resources that will be needed to do it.”