Olivia Dhaliwal hopes to maintain the word "family" in family medicine.
Her late grandfather was a family doctor in rural Pennsylvania, a path that Dhaliwal aims to follow as a fourth-year medical student at Case Western Reserve University. That's why she's concerned by University Hospitals' recent decision to end the family medicine residency program at its main campus in Cleveland.
Dhaliwal was among a group of more than 160 CWRU students who penned a letter to UH leadership asking them to reconsider their decision last week. The letter was delivered to UH Tuesday.
The hospital system confirmed Sept. 19 that residents currently in the family medicine program will continue to receive training, but the hospital won't select future family medicine residents for the main campus. Family medicine residencies will continue at UH's St. John and Geauga medical centers, but Cleveland area family physicians, professors and CWRU medical students have voiced opposition to the decision.
Overall interest in family medicine is waning due to its generalist nature, said Lisa Navracruz, an assistant professor of family medicine in the Center for Medical Education at CWRU, who has been teaching medicine since she completed her residency with UH in 2003. Students tend to be more interested in specialist procedural medicine, which has caused a nationwide decline in primary care doctors, she said.
"We are the first point of contact for anything," Navracruz explained. "You're always triaging all the things that the patient's coming in with. What can you help with? What can you solve? What do you need more help to figure out? And that's a challenging thing to want to step into, student-wise."
The hospital's decision hasn't deterred Dhaliwal from wanting to become a primary care doctor. She said she performed well in her clinical rotations in various specialties but took a generalist approach to them to better understand patients' ailments in the context of their lives — something she says her patients appreciated.
"I can't tell you how many patients commented on that," Dhaliwal said. "To me, that is the kind of care that people want and the kind of care that people need. And that is not the kind of care that they are getting in the majority of cases at hospitals."
The decision to end the residency program at UH's main campus was based on changes in family medicine over the last decade, noting a greater focus on outpatient care, said UH.
"The contention that this change will dramatically impact either the pipeline of doctors treating families or access to care in Cleveland is false," UH said in a statement issued to Ideastream Public Media, adding that the UH Cleveland family medicine program currently has 18 residents. "We are committed to training primary care physicians at UH Cleveland Medical Center through our internal medicine (147 residents) and pediatrics (85 residents) programs. Training programs in internal medicine at UH St. John (23 residents), UH Geauga (24 residents), and UH Parma (23 residents) also add to our robust primary care pipeline."
The share of primary care physicians among all doctors is about 25%, a number that has "been declining for years," according to the Kaiser Family Foundation.
Nearly 90% of private practice physicians were family doctors in the 1930s, a number that dipped to 50% by the 1960s, according to Dr. Gregg Coodley, a family physician and author of Patients in Peril: The Demise of Primary Care in America. Starting in 1960, increases in specialists began to outpace primary care, Coodley wrote.
More than 100 million Americans don’t have usual access to primary care, a number that has nearly doubled since 2014, according to KFF.
The decline in inpatient hospital admissions, which began before the COVID-19 pandemic, is causing hospitals to shift resources, said Tom Campanella, healthcare executive-in-residence at Baldwin Wallace University. On top of that, Campanella said patients who are admitted to hospitals tend to have more acute diagnoses.
"From that standpoint, the growth area for health care is the outpatient arena and care in the home setting," Campanella explained. "That phenomenon will probably continue in the future, and there probably will be more of an increased role for nurse practitioners in the inpatient setting."
Advocates for keeping the family medicine residency program in Cleveland said it's important to train residents on the needs of patients within urban environments like Cleveland, where underserved patients often face access barriers and have diverse needs.
Domonic Hopson, president and CEO of Neighborhood Family Practice, noted the importance of hiring staff familiar with these issues.
"It's important for us that physicians and medical providers get exposure to treating patients that are navigating some of those challenges that our patients navigate, whether that be poverty or all of the other things that come along with that," Hopson explained.
Neighborhood Family Practice provides family care to neighborhoods across Cleveland's West Side and Lakewood.
"It is going to be even harder for the folks on the ground trying to set up community and community health centers, like Neighborhood Family Practice, like the many MetroHealth community clinics around, to be able to fully staff those places and to have them staffed with trained folks who know full spectrum family medicine, and to have them staffed by folks who are coming out of training programs locally so that they understand the regional area," Navracruz added.
MetroHealth President and CEO Airica Steed sent an internal email to employees last week noting the hospital system will maintain its support for its family medicine residency program.
"We will do what we have done for almost 200 years: provide high-quality care to everyone in this community," Steed wrote. "We also remain deeply committed to training the next generation of primary care providers with an intentional focus on health equity and community service."
UH's statement noted that its family medicine residents at St. John and Geauga will have the opportunity to do rotations at UH Cleveland Medical Center "in order to care for the highest acuity patients and conditions." The statement also listed UH's primary care locations in Cleveland, including the Otis Moss Jr. Health Center and Community Wellness Center at Glenville.
Campanella has written about challenges faced within rural communities, where he says family medicine remains crucial. He predicts that a focus on family medicine in rural areas will continue. Since those areas lack the same concentration of specialists as in larger cities, family doctors there are often tasked with more holistic care, something that may appeal to some.
"You have in many ways a much more satisfying experience because all those talents and skills that you got in residency and in medical school, you're utilizing," Campanella said.
The system discourages medical students from choosing family medicine over specialized care, said Kurt Stange, director of CWRU's Center for Community Health Integration and member of the Northeast Ohio Academy of Family Physicians.
"They see this as the hospital turning its back on one of the big needs that the country has," Stange said. "For those that are considering becoming family physicians, it's a slap in the face, frankly."
Patients are also concerned, said Patty Kellner, a retired former UH family physician who also teaches family medicine at CWRU.
"They're outraged," Kellner said. "What they say over and over again is when there's such a primary care shortage. Why are they closing family medicine? If you talk to people about their experiences in health care, everybody's aggravated by either they don't have a doctor who listens or they can't get in to see their doctor."
Dhaliwal contends that she's seeing a resurgence in interest in family medicine among students, noting a record number of CWRU students attended the American Academy of Family Physicians Conference for Medical Students and Residents this year.
Advocates for retaining UH's family medicine residency are now rallying for additional support, Stange said. He's been through similar situations twice before in his career and said both of those decisions were reversed following an outcry from patients and their community.
"We'd hoped that this decision would be reversed by talking quietly internally," Stange said. "Since that's not the case, we're trying to get larger advocacy."
