HMS Suspends Funding for Primary Care Division

Harvard Medical School has suspended funding for its Primary Care Division as part of a broader departmental restructuring effort, prompting students and faculty to circulate a petition calling on HMS Dean Jeffrey S. Flier to reaffirm the School's commitment to primary care education.

According to Nancy J. Tarbell, dean for academic and clinical affairs at HMS, the School had provided roughly $200,000 in funding each year to the Division. She said that the Division, which has not been disbanded but whose structure and administration is being reviewed, will remain affiliated with HMS. The Division has always been funded exclusively by the Medical School, according to HMS spokesman David J. Cameron.

"The reorganization of this division is really a narrow administrative issue," said HMS Dean of Medical Education Jules L. Dienstag. "It has nothing to do with the commitment of HMS to primary care, which is unchanged, undiluted, and undiminished."

Nevertheless, as of Thursday afternoon, over 450 individuals had signed the online petition, including students, residents, faculty, and physicians from HMS and its affiliated hospitals. The petition calls for the School's administration to present a detailed plan of action for expanding institutional support despite the budget cut, expand loan forgiveness initiatives that financially enable students to pursue primary care specialties, support efforts to strengthen primary care in a reformed national health care system, and solicit and implement proposals from the HMS community to improve primary care education.

"We all realize right now that any serious health care reform that's going to take place in this country will require invigoration of the field of primary care," said Andrew F. Singer, a third-year medical resident training in primary care at the Harvard affiliated Brigham and Women's Hospital. "We think that HMS and other leading medical institutions have an important role to play in paving the way forward for primary care."

Singer, who said he has signed the petition, is also leading the recently-organized Harvard Primary Care Reform Working Group, which aims to collect and synthesize specific ideas and recommendations from individuals across HMS and its affiliated hospital community in order to aid the administration in promoting primary care education.

The Division was previously part of the HMS-HPHC jointly administered Department of Ambulatory Care and Prevention (DACP), which Tarbell said was recently restructured and renamed as the Department of Population Medicine and placed solely under HPHC's administrative purview in order to better reflect its core research and teaching activities. Sharon Torgerson, a spokeswoman for HPHC, said that there are no plans for her organization to financially support the Primary Care Division since they have not in the past, but she did emphasize that HPHC has always supported DACP, and will continue to support it under its new name.

Tarbell, who seemed unclear about what actual services were provided by the Division, said that the HMS administration is conducting a "comprehensive review" of the its programs and that the Division has historically been "relatively small."

'When you look at [HMS's primary care initiatives] as a whole, at the big picture, you can't make the argument that funding has decreased for primary care training at HMS," Tarbell said, adding that the school is expanding its funding this year for a required third-year medical clerkship from $600,000 to $800,000. Tarbell and Dienstag said that the number of people taking the clerkship, which lasts for eight months and provides students with one-on-one faculty interaction in treating patients, would be increasing by 20 percent this year.

"That [increase] is us making sure that our students are getting the maximal required attention to having this major component in their medical education on primary care," Tarbell said.

She also emphasized that the Primary Care Division was not singled out for budget cuts, noting that other divisions have seen reductions as well while some traditionally receive no funding whatsoever. She said that HMS may resume funding for the Division in the future, after administrators and the Division's leadership reevaluate how the unit is structured and how primary care education and research can best be fit into HMS's broader educational mission. HMS traditionally uses divisions to help researchers, educators, and departments convene and collaborate from across HMS and its affiliated institutions.

But despite administrators' reassurances that primary care education remains a top priority at the Medical School, some students and faculty maintain that the cut sends a negative message about the School's priorities, which they say have traditionally centered on specialty medicine and research. And the petition expressed concern about the future of outreach activities previously coordinated by the Division, including a Primary Care Mentorship Program, if funding or a Divisional home were to be eliminated.

"Primary care, from the perspective of the Medical School, was sort of a stepchild [in the past], and not much was done to provide students with information about primary care careers or to connect them with role models in primary care," said Susan Edgman-Levitan, executive director at The John D. Stoeckle Center for Primary Care Innovation. "[The cut] comes at a time when there is huge national concern about the role of primary care in the health care system going forward. Most other schools and organizations are doing everything they can to strengthen the primary care base, attracting not only doctors but other professionals in primary care, and here we are cutting the division."

The Primary Care Division previously collaborated with the Stoeckle Center in organizing the monthly Cabot Primary Care Lecture Series for faculty and students, but Edgman-Levitan said that because of the funding cuts, her Center would likely be forced to sponsor all the lectures in the fall.

Health care experts and faculty interviewed by The Crimson cited the growing primary care crisis in the U.S. and the accelerating health care reform movement as factors driving the enthusiasm behind the growing petition, as well as reasons that HMS ought to commit more firmly to improving primary care education. According to a 2008 study published in the Journal of the American Medical Association, only 2 percent of medical students said that they were planning on becoming general internal medicine physicians, even while the number of older Americans who depend on such first-stop doctors is expected to double between 2005 and 2030. A similar study two decades earlier had seen roughly 9 percent of students saying they would be entering primary care, according to a 2008 Associated Press report.

Experts say that this dwindling supply of primary care doctors, largely due to the traditionally unappealing pay and work hours for those in the field, has exacerbated a crisis in the nation's health care system, which is already dealing with tens of millions of aging baby boomers and uninsured Americans. Increasing the number of primary care doctors and researchers is seen as vital to supporting a reformed national health care system, as well as improving patients' everyday health.

"The data shows that primary care, effective primary care, is central to an effective health care system. Where primary care is strong, the data shows that costs are lower, outcomes are better, and there's less disparity of care," said Allan H. Goroll, a professor at MGH and a general internist at Mass. General Hospital, where he initiated the nation's first residency track in primary care internal medicine. He also said that while the financing of health care reform may be controversial, the need to strengthen and reform primary care is well-recognized and enjoys bipartisan support.

Yet at Harvard, where specialty medicine and research have traditionally been heralded, some continue to feel that HMS can and needs to do more to support primary care by providing financial support and elevating the field's stature within the community. The HMS Joseph B. Martin Loan Forgiveness Initiative allows third-year students pursuing specialties in primary care, family medicine, and psychiatry to receive up to $60,000 in debt reduction, but the circulating petition states that loan forgiveness can only be "one component of a multi-pronged strategy to boost student interest" and that HMS must work to do so throughout the four years of medical education.

"Harvard's goal has always been to create leaders in medicine, with regards to basic science and new developing fields. Primary care has never really been a major emphasis, although I think on a global basis, Harvard has put a major emphasis on reaching out to the rest of the world," said Martin P. Solomon, an assistant clinical professor of medicine at the Brigham. "People like Jim Kim and Paul Farmer are all very important and have had an enormous impact on primary care worldwide, but in our own backyard, Harvard has had very little impact. [Primary care] is not as glamorous, but it's the grease that keeps the system going."

But Solomon said that he has been in frequent contact and communication with Dean Flier, whom he known for over two decades, and says that the Dean definitely "understands the value and importance of primary care" and is looking to find ways to support primary care in a difficult financial environment.

"They're sensitive to [the value of primary care education], and they're trying to come up with something working with the entire Harvard community to develop a realistic approach to supporting primary care," Solomon said. "In the meantime, it's incumbent on people in the community to support this."

David H. Gellis, a former Crimson managing editor and MD/MBA joint-degree candidate who helped organize the petition, said that "we have not gotten a response from the Dean providing further explanation of the funding cut or the status of the Division of Primary Care, so I think there still is a lot of uncertainty within the community about where things stand exactly."

He said that once Singer's working group provides formal proposals to support primary care education, the HMS administration should provide a detailed response and action plan for implementation going forward.

"The message we're trying to send is that we believe that primary care is integral to the mission of Harvard Medical School and that more than specific programs or services, Harvard needs a high-profile, centralized home for efforts to raise the profile of primary care at the institution," Gellis said.

—Staff writer Peter F. Zhu can be reached at pzhu@fas.harvard.edu.