Urban health residencies aim to create primary care leaders

Where: Johns Hopkins University in Baltimore

The issue: Creating residency tracks that focus specifically on urban primary care

Background

When Leonard Feldman, MD, FACP, an associate professor of medicine and pediatrics and founding director of the urban health residency programs at Johns Hopkins University in Baltimore, arrived in 2004, the institution was not necessarily known for educating primary care clinicians. “You name a subspecialty and we've produced leaders in it, but we weren't producing leaders in primary care in the same way, at the same level,” he said.

That's changing in part due to an initiative spearheaded in 2009 by Myron Weisfeldt, MD, FACP, then chair of medicine, and some help from the Josiah Macy Jr. and Bunting Family Foundations and the federal Health Resources and Services Administration, leading first to the creation of an urban health primary care medicine/pediatrics program in 2010 and then, a year later, to the development of an urban health internal medicine primary care track, Dr. Feldman said.

While the federal Recovery Act, which included a grant to expand primary care training, paid salaries of residents in the program for the first five years, those costs are now covered by Johns Hopkins, Dr. Feldman noted.

“Hopkins decided that it was important enough to the institution's strategic goals and that we were achieving our stated outcomes of producing leaders in urban health primary care that the institution should then fully invest in it,” he said.

How it works

In many ways, the urban health program follows the pattern of any other residency, particularly in the first year, said ACP Member Benjamin J. Oldfield, MD, a graduate of the program and a coauthor with Dr. Feldman of an article describing its results that was published in January by the Journal of General Internal Medicine.

“As an internal medicine/pediatrics resident, you start off as an intern and spend most of the time as an intern doing what other interns do. It's just being on call, being on various services within the hospital,” he said.

In ensuing years, however, that starts to change, as residents spend an increasing amount of time in urban health electives. The elective rotations address medical problems or community-based problems that are of high prevalence or importance in East Baltimore communities, such as substance use disorders, incarceration, and homelessness, Dr. Oldfield said.

Residents in the internal medicine program spend at least 28 weeks of their three-year program and residents in the med/peds program spend at least 34 weeks of their four-year program outside the hospital, working within the community at organizations such as Health Care for the Homeless and the House of Ruth.

In addition, “Academic Half-Days,” featuring resident-led discussions with community partners, are held every two weeks. Residents, faculty, and alumni participate in urban health book clubs and a monthly urban health journal club. Graduates of the urban health programs who choose to practice in community clinics in Baltimore and Washington, D.C., are offered a tuition-free part-time master's degree of their choice at Johns Hopkins.

“One of the things that we wanted to make sure with this program … was that [the residents] weren't going to stay at the ivory tower, at the mothership, for all of their training but that they would get out into the community and that they would be exposed to many different ways of practicing medicine and really get to understand the lay of the land,” Dr. Feldman said.

The result, said Dr. Oldfield, “is this sort of unique program where, yes, we do go through all the requirements that ACGME [the Accreditation Council for Graduate Medical Education] feel need to be done to create a med/peds resident or an internal medicine resident, but we also spend a significant amount of time in these community organizations learning about the context in which health care happens in communities like Baltimore.”

The program helps residents learn more about the social issues that can affect health, providing “a broad education of many topics that for physicians are really black boxes, but if you get to spend a little bit of time in them, it becomes much easier to understand our intricate health care system,” Dr. Feldman said. “And you're able to then get your patients connected to the resources that they really need to thrive.”

Dr. Oldfield, who is now a postdoctoral fellow in the National Clinician Scholars Program at Yale University in New Haven, Conn., called the relationships between Johns Hopkins and the community organizations one of the program's key features.

“The importance of that can't be overstated, because the program depends on the infrastructure and the energy and excitement of people in these organizations to survive,” he said. “If that's not there, that's a necessary ingredient that's missing.”

Results

As of 2017, 16 internal medicine residents and 14 med-peds residents had graduated from the urban health program, and a majority, 56% of the former and 79% of the latter, have chosen careers in primary care. Eight are working for community organizations, and seven hold leadership positions. Dr. Feldman reported that this year, all of the program's available residency positions were filled on Match Day.

“We've been doing this for eight years now, and we've graduated 30 people. Thirty people is not going to fix the primary care deficit. So I'm not under any illusion that that's what our goal is,” Dr. Feldman said. “Our goal actually is to create leaders in urban health primary care, people who are going to lead primary care for the next decades to come.”

Challenges

“We continue to do better and better every year, but recruitment is always a challenge,” Dr. Feldman said. “To create this climate where primary care can thrive is always an uphill battle.”

Another challenge is in maintaining relationships with community organizations, which often experience a lot of staff turnover, he said. “For example, the Planned Parenthood folks that we were working with a year ago, none of them are there anymore. So I just sent an email the other day to the new team there to see if we can take them out to dinner, to see if we can get to know each other and create a new relationship.”

From the standpoint of someone who's been through the program, Dr. Oldfield said it can sometimes be overwhelming to keep up with the clinical side of things while also learning to work effectively within a community.

“It's a challenge sometimes to feel like you're sufficient in both the latest cardiovascular care advances but also the ethics of doing community-based work and how to form equitable and accountable relationships with people who grew up in Baltimore City and have been doing this kind of work for decades,” he said. “That's partly why it does help to be in a setting where these relationships have already been formed.”

Next steps

Dr. Feldman said he hopes to continue to build on the program's reputation. “I think with the folks who applied to us and interviewed [this year], it really felt like at this point many of them perceived that we've been around forever … we are now an established program,” he said.

He also plans to talk to program graduates to find out what worked for them and what didn't. “We need to do more surveying of our graduates to have them look back on their education here and say, ‘Are there other key topics that need to be included? Are there gaps in our curriculum?’ … We need to address those gaps, keep building the curriculum,” he said.

Resilience training for the residents is also incredibly important, Dr. Feldman said. “I think it's important not only for them as residents but as they get out into practice. It is a huge cognitive load, an emotional load, to take care of patients every day who are struggling with many of the issues that our community is, the social determinants of health that are really impacting them on a daily basis.”

Words of wisdom

Dr. Feldman said the most important advice he can give applicants to an urban health program is to demonstrate their commitment to primary care medicine in this setting.

“I want to see that they've walked the walk and not just talked the talk while they're in medical school … that they've been involved in the community,” he said. “We want people who are pretty sure that when they interview with us they're set on what their future might look like, at least in the sense of ‘I want to be a leader in urban health primary care.’ And then our job is to help them figure out how to become the leaders that they want to be.”

For those considering building a program, “I guess my biggest word of advice is just give me a call,” Dr. Feldman said. “There's a lot that we've learned over the last eight years that I'm willing to share.”