In my last blog entry, I reflected on why we teach health policy in our family medicine residency curriculum. It's not just because being wonky is sexy. Policies developed proximally to our distal clinical world have profound and lasting effects on our ability to deliver care for our patients and on our patients' abilities to optimize their health in the context of their neighborhoods. Yes, neighborhoods matter (http://bit.ly/cUoWPe) but I digress ...

Why does it feel that clinical medicine is so far removed from health policy to a degree that anything remotely wonky is rejected outright with an emphatic, "Dammit, Jim! I'm a doctor" not a wonk? Even the idea of non-partisan voter registration (http://bit.ly/cfIYEj) makes some of us docs want to run for the hills though it's about as Ameri-can as mother and apple pie.

It starts in medical school. In September 2006, the NEJM featured a review of the 100 years since the Flexner Report (http://bit.ly/97WQ4Q) which stated "our current predicament: medical students and residents are often taught clinical medicine either by faculty who spend very limited time seeing patients and honing their clinical skills (and who regard the practice of medicine as a secondary activity in their careers) or by teachers who have little familiarity with modern biomedical science (and who see few, if any, academic rewards in leaving their busy practices to teach). In either case, many clinical teachers no longer exemplify Flexner's model of the clinician-investigator." I would add that the modern day complexities of practicing medicine in the US health care system, the enormous debt burden facing graduating medical students, and the financial incentives in our fee-for-service model of reimbursement all conspire to shift medical students away from primary care (http://nyti.ms/ddJZXJ).

That said, what are some potential policy solutions to fix the issue of a declining primary care workforce in the US? Here are three:

1. Provide financial or other incentives for US medical schools to graduate a minimum percentage of each class (dare I say 51 percent!?) in a primary care specialty. For example, renewal of accreditation could be tied directly to a medical school's actual production of primary care physicians: produce too few and lose your accreditation. We need to hold public institutions, like UC, accountable for building our state's primary care workforce.
2. Eliminate medical school debt for graduates who choose a primary care residency, finish residency, and become board certified. I always advise medical students to keep a copy of their personal statement by their bedside to remind them of why they chose to become a doctor. Some listen but many more look at their debt burden and make a microeconomic decision for fear that they may never pay off their loans.
3. Maintain or increase funding for innovative programs, like PRIME-LC (http://bit.ly/bV8188), which stimulate bright and socially-minded medical students to become physicians that not only care for their panel of patients but also care for their communities. Without becoming more civically engaged, we are in danger of becoming RVU-producing docs-in-a-box that don't add value to our society-at-large.

If we are to build Patient Centered Medical Homes for America, we family physicians need to shift our view of ourselves from being victims of policy changes to actual policy movers-and-shakers. In fact, I would love to see every primary care residency program in the country develop health policy curricula to activate and engage our future leaders in this dialogue.

I challenge each of you to get involved in the dialogue and take on mentoring of a medical student or three. They need to know that we care about these issues and that the future of family medicine will involve working on fixing these vexing policy issues.

What say you?