The next generation of primary care
Primary care today involves much more than one-on-one outpatient visits. The Measey Primary Care Pathway Program prepares the next generation of physicians to experience what makes these specialties special.
Promptly at noon on March 19, Mariam Olujide opened her email and screamed. The Perelman School of Medicine fourth-year saw she had matched into a pediatrics residency in Washington, D.C.—which meant she was going home.
Olujide’s parents and three younger brothers cheered with excitement for the soon-to-be first doctor in their family, shaking pom poms and popping confetti cannons—items from a gift bag assembled by classmates to help make Match Day special during the celebration attended mainly virtually from students’ homes.
Olujide is among the 41 percent of Perelman School of Medicine Class of 2021 students who matched into a primary care residency that day, and among the smaller subset of those who plan to spend their whole careers in primary care—she matched to a specific track at Children’s National Hospital in primary and community health. Her interest in general pediatrics began before medical school but deepened during her participation in the Measey Primary Care Pathway Program, launched in 2019 to prepare students for careers in family medicine, general internal medicine, general pediatrics, and geriatrics. As a widely publicized primary care physician shortage persists—the Association of American Medical Colleges now predicts the U.S. will face a dearth of up to 55,200 by 2033—the Pathway offers students enhanced clinical experiences, research and mentorship opportunities, courses and workshops, and community engagement activities designed to draw them to primary care specialties.
Tending to emphasize highly specialized medicine and hospital-based clinical training, academic health institutions often leave primary care to “simply get lost,” said Jennifer Kogan, MD, a professor in Internal Medicine who spearheaded the Pathway’s development and serves as its director. “What we’re doing is validating the importance of primary care and showing students how we’re innovating just as much as other specialties to transform the way we deliver care.”
Early and often
When they hear the words “primary care,” Kogan says, most people envision a doctor sitting alone in an office with a patient, addressing concerns only in the context of that visit. She and Pathway co-directors Renée Betancourt, MD, an assistant professor of Clinical Family Medicine and Community Health, and Jane Nathanson, MD, a clinical assistant professor of Pediatrics who sees patients at Children’s Hospital of Philadelphia’s South Philadelphia outpatient office, stress that primary care is much more than that.
“Today, I am just as responsible for the health of the person who does not come to my office as the person who does,” Kogan explained. “Of all my patients who have diabetes, for example, I want to identify who I have or have not seen, who needs to go to an eye doctor, whose diabetes is not well controlled. We can leverage patient outreach and technology, having patients check their own blood pressure and sugars at home and uploading them to their own electronic health record, and use that data to determine who needs intervention or support to achieve better health across the population.”
The Pathway, which during the 2020-2021 academic year comprised 31 students spanning all four class years, exposes participants to interprofessional team care and the use of tools and metrics to ensure that entire patient populations are up to date on both preventive and chronic disease care.
Pathway participants have opportunities to work in outpatient primary care settings earlier and more often than is typical in medical school. Before their core clerkships, students shadow an attending during an extended bimonthly ambulatory care experience.
“Primary care attendings are not very visible to medical students—and if they don’t see positive examples of people they could envision themselves being like and working with in the future, why would they think primary care is a viable career option?” Nathanson said.
Participants can also do an outpatient primary care externship that lasts six months or more.
“Some of the wonderful aspects of primary care are difficult to fully demonstrate in episodic educational experiences,” Betancourt said, emphasizing the importance of building relationships with patients over time.
Olujide felt firsthand the value of these connections. One of her favorite Pathway memories involves caring for an infant whose mother requested a follow-up appointment with Olujide, even though she was a student.
“Conversations with patients are easier the second time. You understand their chart and their history and have a stronger rapport, organically,” she said. “That is often missing in medical school, which is unfortunate, because if more students had that experience, they might consider primary care a little bit more.”
Sticking together
Beyond clinical experiences, Pathway students also engage in primary care-focused research, service activities, class-specific mentoring groups, and individual mentoring sessions.
The sum of all these parts? A tightly knit community of likeminded aspiring and seasoned physicians. It’s a community Olujide was thrilled to join, as she previously struggled to find peers who shared her passion for primary care.
“The Pathway brought me back to why I chose medicine to begin with: to be an advocate and focus on population health,” she said. “Being surrounded by physicians who are doing this work and by students who want to do this work, despite the fact it might pay less or get you less glory than other fields, really solidified my desire to be a pediatrician.”
Unfolding during the Pathway’s second year, the coronavirus pandemic presented valuable learning opportunities for students. Olujide recalls watching as clinicians swiftly adapted, transitioning to telehealth appointments while also employing more creative strategies to keep their patients safe.
“Well child visits weren’t happening, which meant we had to figure out ways to keep children on their vaccine schedules,” she noted. “Some groups did mobile vaccine clinics or had families come to get their vaccines outside on playgrounds. It opened my eyes to the fact that no matter what is going on in the world, primary care is a matter of making sure you switch things up to provide whatever care your population needs at that time.”
In 2017, two years before the Pathway kicked off, Penn Medicine formalized its Primary Care Service Line, unifying a network of 90 primary care practices across the University of Pennsylvania Health System in a movement to improve quality, access, and experiences for patients. Matthew Press, MD, MSc, medical director of the service line, championed the idea of a primary care educational pathway then and continues to do so today. Kogan co-chaired the service line’s education committee that proposed the pathway to the medical school with Christine Stabler, MD, vice president of Academic Affairs at Penn Medicine Lancaster General Health. Generous funding from the Measey Foundation supported the program’s first three years.
“The fact that the Perelman School of Medicine has a primary care pathway is both a public and an internal statement that the institution recognizes the value of primary care and encourages our best and brightest students to choose careers in primary care. It indicates that Penn Medicine is on the forefront not only in basic science research and hyper-subspecialized care, but also in the evolving approach to primary care,” Press said.
“We want students to appreciate that being a primary care doctor looks a lot different now than it used to, and the Pathway is helping us do that.”