There is nothing remarkable about suite 605 in the Wang Building at Massachusetts General Hospital. Located at the end of a long hallway, its glass door opens to Internal Medicine Associates (IMA), the largest of Mass General’s 18 adult primary care practices. With nearly 200 staff members, the IMA is well known for providing outstanding primary care — handling more than 75,000 appointments annually.
But it’s what happens in the suite on Tuesday evenings that has the potential to change the healthcare system. That’s when the practice becomes home to the Crimson Care Collaborative, where Harvard Medical School (HMS) students and Mass General physicians work side-by-side to treat primary care patients.
Established in 2010, the program serves patients who do not have a primary care physician and IMA patients who need care after hours. Although the clinic sees only about a dozen patients a week, the bigger story is how it gets medical students excited about primary care, a field many have shunned in recent years.
Attracting Medical Students to Primary Care
Programs like Crimson Care can make a difference. Studies show that participating in student-faculty clinics, experience with long-term patient relationships and faculty mentorship help attract medical students to primary care.
Experienced as an HIV test counselor, Jessica O’Brien knew she wanted to work in primary care when she entered HMS four years ago but there were few ways to get involved. “Crimson Care has helped revitalize my interest and connect me to the reason I came to medical school in the first place,” the Michigan native says.
Many students consider primary care careers when they enroll, yet change their plans.
Few students apply to primary care residencies, and even fewer become primary care physicians, choosing instead to specialize.
As a consequence, retiring primary care physicians are not being replaced.
In Massachusetts, the healthcare system is further strained with the influx of insured patients after the passage of the universal health reform bill. Despite having insurance, many residents can’t find a primary care doctor who will see them. The situation is worse for those with MassHealth or CommonwealthCare, the state’s publicly subsidized plans. As a result, patients often end up in the emergency room or delay needed care.
Combining Teaching and Patient Care
Inspiring medical students and improving patient access to health care are a perfect match for Rebecca Berman, MD, Crimson Care founder and executive director. An African American studies major at Harvard College, Dr. Berman considered being a social worker, a teacher or a doctor. Once she decided on medical school, she loved it from the beginning. Primary care appealed because it was community based and fulfilled her interest in helping underserved people. After residency, the desire to combine teaching and patient care led Dr. Berman to team up with Mass General’s Stoeckle Center for Primary Care Innovation, a dynamic group of HMS students and the IMA to start a student–faculty collaborative practice as a way to recruit students into primary care careers.
From the outset, Dr. Berman was determined to address concerns that a student-run clinic might offer substandard care or compete with community health centers.
A needs assessment revealed about a six-month wait for a primary care physician at community health centers.“No competing there,” says Dr. Berman. “In fact, we are partners — we offer ‘Bridge-to-Care’ primary care services (up to a year) for patients while helping them access community services to obtain a long-term primary care physician.”
Support from the IMA and funding from the Stoeckle Center lent credibility. “The fact that the clinic is student run with faculty collaboration is important,” says Thalia Margalit Krakower, MD, attending clinician and preceptor for the program. “It is not a free clinic. If they don’t have insurance, we connect them with resources to obtain Mass Health. Rebecca [Berman] and I treat the Bridge-to-Care patients as our own. During the week when the students are not in the clinic, we follow up, check test results and ensure that patients don’t fall through the cracks.”
A Surge in Participation
Crimson Care was launched soon after Dr. Berman talked with one HMS student who had worked in a student-run clinic at Stanford University. The goal was to generate enough interest to start a similar practice in Boston.
Within two weeks, 40 students requested to become founding members. A year later, 128 students volunteered to participate in the inaugural session. Through creative scheduling and involving students in subcommittees, including administration, lab services and research, the program was able to accommodate 92 students.
“In a year, the clinic made a tangible difference and helped create a new environment at Harvard Medical School,” says Jana Jarolimova, a native of the Czech Republic and a Crimson Care founding member.
Meaghan Burke, an IMA project manager, who helps students with scheduling, enjoys the enthusiasm that the students generate. “When I schedule patients for their first visit, many of them let me know how difficult it is to get a primary care doctor,” she says.
One Grateful Couple’s Story
The grateful include Christos and Georgia Flabouris, married for 38 years, who live in Lowell. Born and raised in Greece, Mr. Flabouris, 63, came to Crimson Care in fall 2010.
Earlier that year, Mr. Flabouris had seen his long-time primary care physician to refill a prescription for hypertension. At that time, he felt fine. “A month later, Chris complained of being tired,” says Mrs. Flabouris. “We thought maybe he was overdoing it, working in his garden.”
Laid off from his job as a cook in a sub shop, Mr. Flabouris had no insurance and was unable to follow up with his doctor. At a Labor Day barbeque, Mr. Flabouris felt dizzy and had trouble breathing after pushing his twin grandsons in a double stroller up a hill. He wasn’t able to swallow his steak dinner.
The Flabourises’ daughter-in-law, who works in the outpatient department at Mass General, was adamant that Mr. Flabouris go to the hospital. His red blood count was dangerously low when he arrived at the emergency department. He was immediately admitted.
During his stay, his physicians diagnosed pernicious anemia and iron deficiency anemia. The hospital staff also helped get him insured though Mass Health. However, Mr. Flabouris’ local primary care physician would not accept Mass Health and told him to come back in two years when he would be eligible for Medicare.
Persuaded to Choose Primary Care
The Mass General staff gave Mr. Flabouris the option to participate in Crimson Care, which turned out to be a great decision. Mr. Flabouris smiles when asked how he feels. He credits the students for their professional attitude and eagerness to learn. “Look for yourself — I have nothing to complain about,” he says.
Crimson Care students offered to help Mr. Flabouris find a primary care physician closer to home, but he and his wife preferred that he stay in the program as long as possible. They like the convenience of having his records in one place as well as the access to specialists. “What better place — people from all over the world come here,” says Mrs. Flabouris. “It was meant to be.”
Like Mr. Flabouris, Crimson Care patients are not in and out in 10 minutes. Medical students work in pairs and are supervised by the attending doctors. “We have so many people to take care of patients,” says Dr. Krakower. “We also get into the life stresses that actually matter.”
The program includes a resource center staffed by students, which provides information on food pantries, jobs, housing, legal services, childcare, and assistance with heat and electricity. Working in the resource center has offered a new perspective for second-year medical student John Gubatan, a biochemistry major who grew up in Guam. He is able to think of patients as a whole, not just the biochemical factors that he studies as a scientist and is thrilled to “be part of a group that is willing to change medicine.”
Experience at Crimson Care has helped persuade Luis Ticona to apply to primary care and general medicine residency programs. A fourth-year medical student with a master’s degree in public policy from Harvard’s Kennedy School, he is helping the program expand to other sites. Another one, at Chelsea Health Center, opened in October 2011. Chelsea is the first of five potential clinics that students and faculty are designing. Each will have a different focus, including refugees, former prisoners and pediatrics.
A Changing Tide
It would be hard to find someone more passionate about primary care than second-year student Janine Knudsen who focuses on the clinic’s research and quality assurance efforts. From a physician’s perspective, “primary care is exciting because of the need to have broad knowledge of all conditions and problems,” she says. “It goes beyond medical challenges with lots of room for innovation to improve how the system works for patients.”
“We are ready for change. Primary care is one field in which young people can have an impact and help figure out solutions. Their more senior colleagues welcome them with open arms.”
The tide is starting to change. According to Valerie Stone, MD, director of the Primary Care Residency Program at Mass General and associate chief, General Medicine Division, three times as many HMS students applied to the residency program from 2009 to 2010. “What’s more,” she says, “it’s exciting that the students who are applying are genuinely interested in primary care. In past years, as many as half the primary care residents ended up specializing. This year, all 10 senior residents are going into primary care.”
Dr. Berman is optimistic about the future of the Crimson Care model, for attracting more students to primary care and for easing the transition to more universal health care in the United States. “The current system is dysfunctional,” she says.