Pulse of Longwood takes you inside one of the nation’s largest hubs of hospitals and biomedical research.
The world’s most famous medical school is teeming with experts on cutting-edge procedures such as face transplants and fetal heart repair. But students say it’s missing something fundamental: a department that trains doctors to care for the whole family, whether delivering babies, giving kids shots, or performing surgeries.
Harvard Medical School is one of only 10 medical schools in the nation that don’t have a department of family medicine, according to the American Academy of Family Physicians. Yale, Johns Hopkins, Columbia, and other elite schools are also among those 10.
“We call those schools the ‘orphan schools,’ because they are deficient,” said Dr. John Meigs, Jr., the group’s president-elect. “They’re shortchanging their students and also shortchanging the needs of this country,” which faces a major shortage of primary care providers.
Now a group of Harvard students — including the medical school dean’s daughter — has launched a campaign to address that omission, with the support of some faculty.
Lydia Flier said Harvard students have little exposure to family medicine, in part because there’s no required clinical rotation in the specialty.
“I think it’s a disservice to everyone who is interested in primary care or outpatient medicine,” said Flier, whose father runs the school.
Flier, who’s about to graduate, said she spent most of her third year studying inpatient medicine, which doesn’t reflect the way most people get health care. In an average month, 217 out of 1,000 people visit some kind of doctor’s office, but less than 1 in 1,000 visit an academic medical center, one study found.
Dr. Russell Phillips, who directs the school’s Center for Primary Care, said the center “is eager to see family medicine flourish at HMS” — including getting its own department — because the specialty is important nationally and accounts for about 40 percent of primary care visits in the country. Schools without family medicine departments send fewer graduates into the specialty, the AAFP has found.
But the dean, Dr. Jeffrey Flier, said the school can’t create a new department without help from its affiliated hospitals, which the school does not control. None of Harvard’s affiliated hospitals has a family medicine department or residency, except Cambridge Health Alliance. The Cambridge hospital’s residency, the postgraduate training doctors need to practice medicine, is affiliated with Tufts’s medical school.
“I personally would be delighted if such a residency or department were created at HMS,” Dean Flier said in a statement. But unless at least three hospitals create family medicine departments, he said, Harvard Med won’t have the clinical foundation to support a department.
Harvard Med tried to nudge hospitals in that direction in 2013, when it offered $2 million in matching funds for an affiliated hospital to create a residency in family medicine. None of the hospitals took the offer.
Beth Israel Deaconess Medical Center was “very excited” by the idea but found it cost too much, said Dr. Richard Schwartzstein, director of the hospital’s center for education. He said a new department would require investment in infrastructure, faculty, research, and residents’ salaries, which add up to millions of dollars. The hospital, which has the equivalent of 530 full-time residents, has already hit its maximum number of federally funded residency spots, he said.
“We’d have to cut residents that we already have,” or find the money elsewhere, to pay for the new spots, he said.
Harvard’s two other major full-service teaching hospitals, Brigham and Women’s and Massachusetts General, said they are not planning to create family medicine residencies. They both pointed to their combined internal medicine and pediatrics residencies, which they said offer a similar approach to family medicine, except without obstetrics.
The Brigham “is committed to training the next generation of primary care physicians,” said spokeswoman Lori Schroth.
Doctors who train in internal medicine or pediatrics often leave primary care to pursue more lucrative subspecialties, however, while the vast majority of those who choose family medicine stick with primary care, said Dr. Kristen Goodell, a family physician on staff at Harvard Med’s Center for Primary Care.
The reasons for this may be both financial and cultural. Students face a prevailing sentiment at Harvard Med that “you’re less competitive, or you’re less rigorous, if you’re interested in primary care,” said student Ashley Shaw.
Goodell and the primary care center’s Student Leadership Committee are working to expand family medicine’s presence on campus. Students have been interviewing other students, doctors, alumni, and residents from Harvard and beyond, and are working on a proposal to create, in the absence of a department, a collaborative of family medicine specialists and students.
Family medicine actually thrived at Harvard in the 1950s and ’60s, according to Dr. Katherine Miller, Harvard Med’s family medicine advisor, who researched the history. The school launched one of the first family medicine residencies in the country in 1965, but the program folded a decade later, after the federal government deemed it inadequate and yanked the funding, she found.
Student Kate Majzoub, who’s about to graduate and start a family medicine residency in Seattle, said she was drawn to the specialty, in part, because it encourages doctors to see patients in the context of their families and communities, and examine outside factors influencing their health, such as poverty, unemployment, and access to healthy food. She was one of just a couple of students in her class to train with Miller, a family physician at Cambridge Health Alliance. But other students reach their fourth year without learning what family medicine is: When it came time to apply to residencies, she said, some classmates told her they were interested in the specialty but found out about it too late.
“To have people who are interested and motivated simply not apply due to lack of exposure is a loss,” Majzoub said.
Meanwhile, the Affordable Care Act has sent droves of previously uninsured patients to community health clinics in urban and rural areas. This, combined with an aging physician population, has led some to sound alarms about a primary care shortage.
That’s why the Icahn School of Medicine at Mount Sinai in New York launched a family medicine residency in 2012, said Dr. Neil Calman, chair of its new department of family medicine and community health.
He said the move was also inspired by student interest, and by a shift to value-based insurance payments that reimburse for health outcomes, rewarding systems that keep patients healthy.
“In order to do that, you need patients to go to primary care centers, not to go to the emergency room when they’re sick,” Calman said.
Family medicine is “not some weird science program,” he added. It’s the second-largest specialty, behind internal medicine.
“It’s bizarre to me that you have these institutions that don’t really feel that there’s a requirement to introduce their students to the second-largest specialty in the United States,” Calman said.