Training Residents in Community Health Centers: Facilitators and Barriers

We use GE Centricity and participate in MQIC. After the initial installation, this automates the uploading of our EHR data to a central repository, scrubbed of identifiers to assure HIPAA compliance, and feeds back MONTHLY benchmarked data from all users on our quality performance, as well as generating a small income from researchers using the database. Recently, CDC began using MQIC to track the H1N1 epidemic. Other EHRs such as Practice Partners have similar capability. MQIC is painless, timely, pays us, and provides faster and better data than any health plan or the Puget Sound Health Alliance.

Competing interests:   None declared

While this article represents the culmination of years of effort, the timing of its publication is near perfect. Speaking from 20 years of FMR administration, with the last 7 years occurring in a CHC system, I appreciate the challenges of both worlds, and the ways in which they can complement one another. Dr.'s Morris and Chen have ably described the obstacles and the oppotunities before us, and have begun to show the path forward.

We are seeing unprecedented appreciation of the necessity of primary care. We are seeing encouraging responses in our allopathic and osteopathic schools of medicine. We need Family Medicine residencies to be a pipeline, not a bottleneck.

Recognition of the importance of our community and migrant health care centers, and their proven ability to respond efficiently and effectively to national health priorities, is positioning the safety net system prominently in the vision of a reformed health system. Their demand for primary care providers will be even more insatiable.

FMR's and CHC's need to buddy-up to secure their own futures, and to serve the nation. No, it's not easy. If it were, everbody would have done it by now.

The authors quote a CHC administrator who cites "worrying about money" as problematic in the relationship. This is not a trite comment. Let's be clear. CHC's and FMR's live on the thin edge. Today, it is razor sharp. While a FMR may offer a lot of advantages to the CHC, efficiency is NOT one of them. The authors correctly point out that funding such programs must be a priority.

It appears highly likely that pending legislation will provide just that sort of support. My advice to FMR's and CHC's out there: Find a buddy.

Competing interests:   None declared

Morris and Chen have spotlighted the benefits and challenges of family medicine residencies (FMRs) affiliated with community health centers (CHCs). 1 Morris and Chen identify four themes that impact CHC-FMR affiliations; mission money, quality, and administrative/governance complexity. As touched upon in the article, while these four themes may be barriers at one level, they are potential strengths when viewed from another perspective.

Mission: The participants in this qualitative study pointed out the tension between service and education inherent in FMR-CHC affiliations. However, as was also noted in the article, both have an overarching mission of meeting the primary care needs of their community. The synergy between FMR clinicians and the CHC ambulatory care delivery system allows both to more fully and effectively carry out their primary care mission.

Money: We have heard the saying once too often, “no money no mission”. Its all about the economy, right? We will no doubt see continued skirmishes over scarce resources between those entities providing care to underserved communities. However, you can make a strong argument that FMR- CHC affiliations are a very cost effective way to train residents.2 Furthermore, at a macro level, CHCs are a cost-effective means to furnish primary care, which can lead to better health and lower health care expenditures.3 The participants in this study note that FMR-CHC affiliations support CHCs through primary care workforce development, and more could be done to enhance this effect through creative, expanded loan repayment programs.

Quality-The authors point out the positive impact on quality of care when family medicine residents train in settings designed to provide ambulatory care. One can also cite the work of Starfield to suggest that by supporting primary care, the FMR-CHC linkages improve quality in their region as well. 4

Administrative/governmental complexity. The irony of administrative/governmental complexity in FMR-CHC affiliations is that when you trace their support, both FMRs and CHCs are answerable to the same boss, Uncle Sam! Unfortunately, the right hand doesn’t seem to know what the left hand is doing. The differing missions of separate branches of the federal government including the Health Resources Services Administration (HRSA)supporting service in CHCs, and Medicare funding of graduate medical education in FMRs makes it difficult for CHCs and primary care training programs to work together. In addition, the Bureau of Health Professions (BHPr) specifically supports primary care residencies through training grants, but the level of funding is miniscule compared to total funding for graduate medical education. Better communication and collaboration between HRSA, Medicare, and BHPr, coupled with the types of reimbursement strategies called for by the participants in Morris and Chen’s article could dramatically increase the number of primary care residents in training generally, and in CHCs in particular. FMR-CHC affiliations are a cost effective strategy to address costs of training, expand the number of primary care physicians, and help meet the ever-increasing demand for ambulatory care services. Thanks to Morris and Chen for reminding us of the facilitators and barriers in creating FMR and CHC affiliations.

1. Morris CG, Chen FM. Training residents in community health centers: facilitators and barriers. Ann Fam Med. 2009;7(6):488–494.
2. Zweifler J. Family practice residencies in community health centers—an approach to cost and access concerns. Public Health Rep. 1995;110(3):312–318
3. Ku L,Richard P,Dor A,Tan E,Shin P,Rosenbaum S.Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion on Health Care Costs. The George Washington University School of Public Health and Health Services Geiger Gibson / RCHN Community Health Foundation Research Collaborative.September 1, 2009
4 Starfield B, Shi L, Macinko J. Contribution of Primary Care to Health Systems and Health. The Milbank Quarterly. Vol. 83, No. 3 (2005), pp. 457- 502

Competing interests:   None declared