Harvard looks to lift primary care

Gift to launch center for front-line doctors

By Liz Kowalczyk
Globe Staff / October 28, 2010

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Harvard Medical School has received a $30 million anonymous gift to create a major center to transform primary care medicine, a specialty that provides routine front-line care to millions of people but that many doctors consider unglamorous and underpaid.

Ultimately, Harvard — which some physicians believe has neglected primary care — wants to help fix the nation’s shortage of primary care doctors by raising their status among their peers and improving working conditions, said the dean, Dr. Jeffrey Flier.

He said the center will pay part of the salaries for 20 to 30 faculty, oversee expansion of the curriculum in primary care, and fund research and experiments to test new models of providing primary care. The school hopes to recruit a renowned national leader in the field to head the center, which Harvard planned to announce today. It will open over the next few months.

Primary care “has not been a very splashy way to pursue your career,’’ said Flier, who noted that many students who arrive at medical school interested in the field eventually abandon it for a better-paying specialty. He said the center’s overarching goal will be to change this dynamic just as the country implements a new health insurance law that will rely heavily on a better primary care system to improve quality and contain costs.

Primary care doctors — usually internists, family practitioners, and pediatricians — often are the first stop for patients with undiagnosed problems. They provide continuing care for a wide range of conditions and illnesses, as well as routine exams and tests to prevent disease. The Obama administration is counting on these doctors to help treat more than 30 million newly insured patients and play a bigger role in coordinating their care.

“Right now what our nation needs is highly qualified primary care physicians and a huge, huge number of them,’’ said Dr. Thomas Bodenheimer, a professor of family and community medicine at the University of California San Francisco, who writes extensively about problems in primary care.

This year, just 9 percent of graduating medical students nationwide entered training programs in adult general internal medicine and family medicine, “a disastrously low number,’’ Bodenheimer said, that is partly due to a lack of respect for the field among senior doctors.

“The culture in medical schools is very toxic to primary care,’’ he said. “This is something I hope the new Harvard center can help with.’’

Bodenheimer said the Harvard center is unprecedented in its financial support and scope.

“Because of the prestige of Harvard, which is known as this major research and subspecialty medical school, to put resources into primary care is a pretty big deal. I can see a lot of other medical schools saying, ‘Wow, we have to step up to the plate and deal with this issue.’ ’’

Medical school graduates are also deterred by primary care’s grueling hours — doctors have to be available nights and weekends. The average hourly wage for an internist is about $58, compared with $87 for an emergency room physician, about $112 for an allergist/immunologist, and $108 for an orthopedic surgeon, according to data gathered by researchers at the University of California Davis and published this week in the Archives of Internal Medicine.

The number of medical students going into primary care has dropped over the past decade. And at top medical schools, the message students sometimes get from faculty and mentors doesn’t help.

“People would ask me what I was planning on doing,’’ said Dr. Andrew Morris-Singer, who graduated from Harvard Medical School and completed his training in internal medicine at Brigham and Women’s Hospital last year. “I’d tell them. And they would say, ‘You are really smart, you could do something better.’ ’’

Morris-Singer started a protest petition in 2009 when administrators at the medical school eliminated $200,000 in funding for the Division of Primary Care, a tiny program that included a speakers series and mentoring. At the time, Harvard officials said they were not abandoning primary care, but stepping back to evaluate the school’s approach. Flier appointed an advisory group to recommend ways to improve primary care at Harvard.

The group made a series of recommendations this past spring, including opening the center, providing stipends for students conducting primary care research, and requiring first- and second-year students to spend time in primary care doctors’ practices, following groups of patients over many months.

“A lot of people are very excited about primary care when they try it out for the first time,’’ said Dr. David Bates, an internist at Brigham and Women’s who cochaired the group.

“Harvard has not really played a leadership role in primary care. This is an effort to change that.’’

Countries with good primary care systems have lower medical costs and provide better care, he said. Even so, primary care receives less funding in the United States in proportion to specialized disciplines than in any other developed nation.

Harvard officials said the medical school cannot single-handedly change the fees insurers pay to doctors or reduce workloads. But it can, for example, evaluate different payment systems and recommend to policy makers the models that are fairest to both specialists and primary care doctors.

And they said it can fund innovative practices that improve care for patients and working conditions for doctors by, for example, employing physician assistants to take on some of the workload.

Flier said many details of the new center won’t be decided until a director is found. He said he disagrees that Harvard hasn’t invested in primary care, but many of the programs have been dispersed among the school’s affiliated teaching hospitals.

“We didn’t present it to our students as a coordinated field that the medical school had an interest in,’’ he said.

Liz Kowalczyk can be reached at

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