Jane Anderson

Watching repeated violence on television and video and in movies can blunt emotional responses to aggression in teenage boys. This desensitization might, in turn, promote aggressive attitudes and behavior, according to study published online Oct. 19.

Photo credit: © Vytenis Slajus/Fotolia.com

Reactions to aggressive media decrease with repetition, which could in turn prevent teens from relating aggressive actions to the consequences from those actions, according to the study, published in Social Cognitive and Affective Neuroscience.

“The important new finding is that exposure to the most violent videos inhibits emotional reactions to similar aggressive videos over time and implies that normal adolescents will feel fewer emotions over time as they are exposed to similar videos,” Jordan Grafman, Ph.D., one of the investigators, said in a statement.

“The implications of this ... include the idea that continued exposure to violent videos will make an adolescent less sensitive to violence, more accepting of violence, and more likely to commit aggressive acts, since the emotional component associated with aggression is reduced and normally acts as a brake on aggressive behavior,” said Dr. Grafman, senior investigator at the National Institute of Neurological Disorders.

The study enrolled 22 healthy male adolescents aged 14-17 years, none of whom had any history of psychiatric or neurologic illness. The subjects were paid to participate (SCAN 2010 [doi:10.1093/scan/nsq079]).

The researchers used 60 mute video snippets, each 4 seconds long, which contained real scenes of aggression, such as fist fights, street brawls, and stadium violence. They divided the videos into groups of 20 depending on their levels of aggression: low, mild, and moderate.

Each subject was asked to quickly view the videos, one after another, and to judge whether each video was more or less aggressive than the one prior to it. The subjects viewed each of the 60 video snippets and rated them.

As the subjects viewed and rated the videos, the investigators used MRIs to measure changes in their lateral orbitofrontal cortexes, the part of the brain thought to govern emotions and emotional responses to events. Electrodes were attached to the subjects’ skin to measure skin conductance responses, which track sweat levels. Sweat levels can accurately indicate people’s emotions and responses to internal or external stimuli.

Data from the MRIs and the skin conductive responses showed that the boys reacted less to the videos the longer they watched them. They also reacted less over time to the mildly and moderately aggressive videos, indicating that they had become desensitized to them.

The study also asked the subjects to rate how much violence they saw on a regular basis in television, movies, video games, books, magazines, and Web sites. Those subjects who had the highest exposure to violence in their normal lives were the most desensitized to violence in the study, the authors wrote.

“We found that as the boys were exposed to more violent videos over time, their activation in brain regions concerned with emotional reactivity decreased and that was reflected in the data from the functional MRI and in the skin conductance responses,” Dr. Grafman said.

Exposure to aggressive media results in a blunting of emotional responses, which in turn might prevent the subjects from connecting the consequences of aggression with an appropriate emotional response, the study said. This, in turn, could increase the likelihood that the subject will see aggression as an acceptable behavior, the study said.

“It remains unknown, however, whether individuals with elevated levels of aggression may be at particular risk for altered desensitization patterns towards media violence, pro-violent attitudes, and the acceptance of real-world violence as normal social behavior,” the study concluded.

The investigators reported no conflicts of interest.

Watching repeated violence on television and video and in movies can blunt emotional responses to aggression in teenage boys. This desensitization might, in turn, promote aggressive attitudes and behavior, according to study published online Oct. 19.

Photo credit: © Vytenis Slajus/Fotolia.com

Reactions to aggressive media decrease with repetition, which could in turn prevent teens from relating aggressive actions to the consequences from those actions, according to the study, published in Social Cognitive and Affective Neuroscience.

“The important new finding is that exposure to the most violent videos inhibits emotional reactions to similar aggressive videos over time and implies that normal adolescents will feel fewer emotions over time as they are exposed to similar videos,” Jordan Grafman, Ph.D., one of the investigators, said in a statement.

“The implications of this ... include the idea that continued exposure to violent videos will make an adolescent less sensitive to violence, more accepting of violence, and more likely to commit aggressive acts, since the emotional component associated with aggression is reduced and normally acts as a brake on aggressive behavior,” said Dr. Grafman, senior investigator at the National Institute of Neurological Disorders.

The study enrolled 22 healthy male adolescents aged 14-17 years, none of whom had any history of psychiatric or neurologic illness. The subjects were paid to participate (SCAN 2010 [doi:10.1093/scan/nsq079]).

The researchers used 60 mute video snippets, each 4 seconds long, which contained real scenes of aggression, such as fist fights, street brawls, and stadium violence. They divided the videos into groups of 20 depending on their levels of aggression: low, mild, and moderate.

Each subject was asked to quickly view the videos, one after another, and to judge whether each video was more or less aggressive than the one prior to it. The subjects viewed each of the 60 video snippets and rated them.

As the subjects viewed and rated the videos, the investigators used MRIs to measure changes in their lateral orbitofrontal cortexes, the part of the brain thought to govern emotions and emotional responses to events. Electrodes were attached to the subjects’ skin to measure skin conductance responses, which track sweat levels. Sweat levels can accurately indicate people’s emotions and responses to internal or external stimuli.

Data from the MRIs and the skin conductive responses showed that the boys reacted less to the videos the longer they watched them. They also reacted less over time to the mildly and moderately aggressive videos, indicating that they had become desensitized to them.

The study also asked the subjects to rate how much violence they saw on a regular basis in television, movies, video games, books, magazines, and Web sites. Those subjects who had the highest exposure to violence in their normal lives were the most desensitized to violence in the study, the authors wrote.

“We found that as the boys were exposed to more violent videos over time, their activation in brain regions concerned with emotional reactivity decreased and that was reflected in the data from the functional MRI and in the skin conductance responses,” Dr. Grafman said.

Exposure to aggressive media results in a blunting of emotional responses, which in turn might prevent the subjects from connecting the consequences of aggression with an appropriate emotional response, the study said. This, in turn, could increase the likelihood that the subject will see aggression as an acceptable behavior, the study said.

“It remains unknown, however, whether individuals with elevated levels of aggression may be at particular risk for altered desensitization patterns towards media violence, pro-violent attitudes, and the acceptance of real-world violence as normal social behavior,” the study concluded.

The investigators reported no conflicts of interest.

Watching repeated violence on television and video and in movies can blunt emotional responses to aggression in teenage boys. This desensitization might, in turn, promote aggressive attitudes and behavior, according to study published online Oct. 19.

Photo credit: © Vytenis Slajus/Fotolia.com

Reactions to aggressive media decrease with repetition, which could in turn prevent teens from relating aggressive actions to the consequences from those actions, according to the study, published in Social Cognitive and Affective Neuroscience.

“The important new finding is that exposure to the most violent videos inhibits emotional reactions to similar aggressive videos over time and implies that normal adolescents will feel fewer emotions over time as they are exposed to similar videos,” Jordan Grafman, Ph.D., one of the investigators, said in a statement.

“The implications of this ... include the idea that continued exposure to violent videos will make an adolescent less sensitive to violence, more accepting of violence, and more likely to commit aggressive acts, since the emotional component associated with aggression is reduced and normally acts as a brake on aggressive behavior,” said Dr. Grafman, senior investigator at the National Institute of Neurological Disorders.

The study enrolled 22 healthy male adolescents aged 14-17 years, none of whom had any history of psychiatric or neurologic illness. The subjects were paid to participate (SCAN 2010 [doi:10.1093/scan/nsq079]).

The researchers used 60 mute video snippets, each 4 seconds long, which contained real scenes of aggression, such as fist fights, street brawls, and stadium violence. They divided the videos into groups of 20 depending on their levels of aggression: low, mild, and moderate.

Each subject was asked to quickly view the videos, one after another, and to judge whether each video was more or less aggressive than the one prior to it. The subjects viewed each of the 60 video snippets and rated them.

As the subjects viewed and rated the videos, the investigators used MRIs to measure changes in their lateral orbitofrontal cortexes, the part of the brain thought to govern emotions and emotional responses to events. Electrodes were attached to the subjects’ skin to measure skin conductance responses, which track sweat levels. Sweat levels can accurately indicate people’s emotions and responses to internal or external stimuli.

Data from the MRIs and the skin conductive responses showed that the boys reacted less to the videos the longer they watched them. They also reacted less over time to the mildly and moderately aggressive videos, indicating that they had become desensitized to them.

The study also asked the subjects to rate how much violence they saw on a regular basis in television, movies, video games, books, magazines, and Web sites. Those subjects who had the highest exposure to violence in their normal lives were the most desensitized to violence in the study, the authors wrote.

“We found that as the boys were exposed to more violent videos over time, their activation in brain regions concerned with emotional reactivity decreased and that was reflected in the data from the functional MRI and in the skin conductance responses,” Dr. Grafman said.

Exposure to aggressive media results in a blunting of emotional responses, which in turn might prevent the subjects from connecting the consequences of aggression with an appropriate emotional response, the study said. This, in turn, could increase the likelihood that the subject will see aggression as an acceptable behavior, the study said.

“It remains unknown, however, whether individuals with elevated levels of aggression may be at particular risk for altered desensitization patterns towards media violence, pro-violent attitudes, and the acceptance of real-world violence as normal social behavior,” the study concluded.

The investigators reported no conflicts of interest.

Risk-adjusted patient outcomes don’t vary between hospitals, regardless of how well they scored on the measures of quality-process compliance that are behind Medicare’s Hospital Compare Web site, researchers have found.

“Despite the intentions of the CMS [Centers for Medicare and Medicaid Services] to provide patients with information that will facilitate patient choice of high-quality hospitals, currently available information on the Hospital Compare Web site will not help patients identify hospitals with better outcomes for high-risk surgery,” wrote the authors, from the University of Michigan and the Michigan Surgical Collaborative for Outcomes Research and Evaluation, both in Ann Arbor.

The fault may lie in the Surgical Care Improvement Project (SCIP) measures used to generate the Hospital Compare data, which mainly track very rare complications, such as deep venous thrombosis, and less important events, such as superficial surgical site infections, the authors said.

Released Oct. 18, the Archives of Surgery study looked at data from 2,000 U.S. hospitals on three SCIP outcomes measures: 30-day postoperative mortality, venous thromboembolisms, and surgical site infections (Arch. Surg. 2010;145:999-1004).

CMS mandates reporting of two sets of SCIP data – one on infection and one on venous thromboembolism – for hospitals to receive annual payment increases. Hospitals submit their data quarterly, which are then posted on Hospital Compare. However, it’s not clear whether improved compliance with the SCIP measures actually improves outcomes, especially risk-adjusted mortality, the study authors said.

To examine the question, they looked at patient outcomes after six high-risk surgical procedures: abdominal aortic aneurysm repair, aortic valve repair, coronary artery bypass graft, esophageal resection, mitral valve repair, and pancreatic resection.

Compliance rates with the SCIP measures ranged considerably from 53.7% to 91.4%, but the study found little evidence of a consistent relationship between a hospital’s score and its rates of risk-adjusted mortality, venous thromboembolism, or surgical site infection.

The authors also looked at data on extended lengths of stay, which can result from numerous postoperative complications. They found that patients at the hospitals that most often complied with SCIP were 12% less likely to experience an extended stay relative to middle-compliance hospitals, but there was no difference between the middle- and lowest-compliance hospitals.

The lack of correlation between “process compliance,” such as measured by SCIP numbers, will be important as quality measures have increasing impact on reimbursements for care, said the authors. “If there is a weak link between process compliance and surgical outcomes, CMS public reporting and pay-for-performance efforts will be unlikely to stimulate important improvements or to help patients find the safest hospitals,” they wrote.

They advised the CMS to “devote greater attention to profiling hospitals based on outcomes for improved public reporting and pay-for-performance programs.”

The study’s authors were supported by several federal grants and funds from the Robert Wood Johnson Foundation. 

Risk-adjusted patient outcomes don’t vary between hospitals, regardless of how well they scored on the measures of quality-process compliance that are behind Medicare’s Hospital Compare Web site, researchers have found.

“Despite the intentions of the CMS [Centers for Medicare and Medicaid Services] to provide patients with information that will facilitate patient choice of high-quality hospitals, currently available information on the Hospital Compare Web site will not help patients identify hospitals with better outcomes for high-risk surgery,” wrote the authors, from the University of Michigan and the Michigan Surgical Collaborative for Outcomes Research and Evaluation, both in Ann Arbor.

The fault may lie in the Surgical Care Improvement Project (SCIP) measures used to generate the Hospital Compare data, which mainly track very rare complications, such as deep venous thrombosis, and less important events, such as superficial surgical site infections, the authors said.

Released Oct. 18, the Archives of Surgery study looked at data from 2,000 U.S. hospitals on three SCIP outcomes measures: 30-day postoperative mortality, venous thromboembolisms, and surgical site infections (Arch. Surg. 2010;145:999-1004).

CMS mandates reporting of two sets of SCIP data – one on infection and one on venous thromboembolism – for hospitals to receive annual payment increases. Hospitals submit their data quarterly, which are then posted on Hospital Compare. However, it’s not clear whether improved compliance with the SCIP measures actually improves outcomes, especially risk-adjusted mortality, the study authors said.

To examine the question, they looked at patient outcomes after six high-risk surgical procedures: abdominal aortic aneurysm repair, aortic valve repair, coronary artery bypass graft, esophageal resection, mitral valve repair, and pancreatic resection.

Compliance rates with the SCIP measures ranged considerably from 53.7% to 91.4%, but the study found little evidence of a consistent relationship between a hospital’s score and its rates of risk-adjusted mortality, venous thromboembolism, or surgical site infection.

The authors also looked at data on extended lengths of stay, which can result from numerous postoperative complications. They found that patients at the hospitals that most often complied with SCIP were 12% less likely to experience an extended stay relative to middle-compliance hospitals, but there was no difference between the middle- and lowest-compliance hospitals.

The lack of correlation between “process compliance,” such as measured by SCIP numbers, will be important as quality measures have increasing impact on reimbursements for care, said the authors. “If there is a weak link between process compliance and surgical outcomes, CMS public reporting and pay-for-performance efforts will be unlikely to stimulate important improvements or to help patients find the safest hospitals,” they wrote.

They advised the CMS to “devote greater attention to profiling hospitals based on outcomes for improved public reporting and pay-for-performance programs.”

The study’s authors were supported by several federal grants and funds from the Robert Wood Johnson Foundation. 

Risk-adjusted patient outcomes don’t vary between hospitals, regardless of how well they scored on the measures of quality-process compliance that are behind Medicare’s Hospital Compare Web site, researchers have found.

“Despite the intentions of the CMS [Centers for Medicare and Medicaid Services] to provide patients with information that will facilitate patient choice of high-quality hospitals, currently available information on the Hospital Compare Web site will not help patients identify hospitals with better outcomes for high-risk surgery,” wrote the authors, from the University of Michigan and the Michigan Surgical Collaborative for Outcomes Research and Evaluation, both in Ann Arbor.

The fault may lie in the Surgical Care Improvement Project (SCIP) measures used to generate the Hospital Compare data, which mainly track very rare complications, such as deep venous thrombosis, and less important events, such as superficial surgical site infections, the authors said.

Released Oct. 18, the Archives of Surgery study looked at data from 2,000 U.S. hospitals on three SCIP outcomes measures: 30-day postoperative mortality, venous thromboembolisms, and surgical site infections (Arch. Surg. 2010;145:999-1004).

CMS mandates reporting of two sets of SCIP data – one on infection and one on venous thromboembolism – for hospitals to receive annual payment increases. Hospitals submit their data quarterly, which are then posted on Hospital Compare. However, it’s not clear whether improved compliance with the SCIP measures actually improves outcomes, especially risk-adjusted mortality, the study authors said.

To examine the question, they looked at patient outcomes after six high-risk surgical procedures: abdominal aortic aneurysm repair, aortic valve repair, coronary artery bypass graft, esophageal resection, mitral valve repair, and pancreatic resection.

Compliance rates with the SCIP measures ranged considerably from 53.7% to 91.4%, but the study found little evidence of a consistent relationship between a hospital’s score and its rates of risk-adjusted mortality, venous thromboembolism, or surgical site infection.

The authors also looked at data on extended lengths of stay, which can result from numerous postoperative complications. They found that patients at the hospitals that most often complied with SCIP were 12% less likely to experience an extended stay relative to middle-compliance hospitals, but there was no difference between the middle- and lowest-compliance hospitals.

The lack of correlation between “process compliance,” such as measured by SCIP numbers, will be important as quality measures have increasing impact on reimbursements for care, said the authors. “If there is a weak link between process compliance and surgical outcomes, CMS public reporting and pay-for-performance efforts will be unlikely to stimulate important improvements or to help patients find the safest hospitals,” they wrote.

They advised the CMS to “devote greater attention to profiling hospitals based on outcomes for improved public reporting and pay-for-performance programs.”

The study’s authors were supported by several federal grants and funds from the Robert Wood Johnson Foundation. 

Fifteen researchers, clinicians, advocates, and breast cancer survivors have been named to a new advisory committee charged with developing initiatives to increase knowledge of breast health and breast cancer among women under age 40 years, the Centers for Disease Control and Prevention announced Oct. 14.

The Advisory Committee on Breast Cancer in Young Women was mandated by the Affordable Care Act enacted earlier this year, and will target its initiatives toward women at heightened risk for developing the disease, according to the CDC.

Committee members will assist the CDC in developing evidence-based approaches to advance breast cancer awareness among younger women, Director Thomas Frieden said in a statement. These approaches will include prevention research, education for health professionals, and education for the public, Dr. Frieden said.

Dr. Ann Partridge, assistant professor of medicine at Harvard Medical School and clinical director of the Breast Oncology Center at the Dana-Farber Cancer Institute, Boston, will chair the panel, the CDC said.

Dr. Partridge founded and directs the Program for Young Women with Breast Cancer at Dana-Farber/Brigham and Women’s Cancer Center. The program addresses the unique needs of women in their early 40s and younger who have been diagnosed with breast cancer.

Fifteen researchers, clinicians, advocates, and breast cancer survivors have been named to a new advisory committee charged with developing initiatives to increase knowledge of breast health and breast cancer among women under age 40 years, the Centers for Disease Control and Prevention announced Oct. 14.

The Advisory Committee on Breast Cancer in Young Women was mandated by the Affordable Care Act enacted earlier this year, and will target its initiatives toward women at heightened risk for developing the disease, according to the CDC.

Committee members will assist the CDC in developing evidence-based approaches to advance breast cancer awareness among younger women, Director Thomas Frieden said in a statement. These approaches will include prevention research, education for health professionals, and education for the public, Dr. Frieden said.

Dr. Ann Partridge, assistant professor of medicine at Harvard Medical School and clinical director of the Breast Oncology Center at the Dana-Farber Cancer Institute, Boston, will chair the panel, the CDC said.

Dr. Partridge founded and directs the Program for Young Women with Breast Cancer at Dana-Farber/Brigham and Women’s Cancer Center. The program addresses the unique needs of women in their early 40s and younger who have been diagnosed with breast cancer.

Fifteen researchers, clinicians, advocates, and breast cancer survivors have been named to a new advisory committee charged with developing initiatives to increase knowledge of breast health and breast cancer among women under age 40 years, the Centers for Disease Control and Prevention announced Oct. 14.

The Advisory Committee on Breast Cancer in Young Women was mandated by the Affordable Care Act enacted earlier this year, and will target its initiatives toward women at heightened risk for developing the disease, according to the CDC.

Committee members will assist the CDC in developing evidence-based approaches to advance breast cancer awareness among younger women, Director Thomas Frieden said in a statement. These approaches will include prevention research, education for health professionals, and education for the public, Dr. Frieden said.

Dr. Ann Partridge, assistant professor of medicine at Harvard Medical School and clinical director of the Breast Oncology Center at the Dana-Farber Cancer Institute, Boston, will chair the panel, the CDC said.

Dr. Partridge founded and directs the Program for Young Women with Breast Cancer at Dana-Farber/Brigham and Women’s Cancer Center. The program addresses the unique needs of women in their early 40s and younger who have been diagnosed with breast cancer.

Fifteen researchers, clinicians, advocates, and breast cancer survivors have been named to a new advisory committee charged with developing initiatives to increase knowledge of breast health and breast cancer among women under age 40 years, the Centers for Disease Control and Prevention announced Oct. 14.

The Advisory Committee on Breast Cancer in Young Women was mandated by the Affordable Care Act enacted earlier this year, and will target its initiatives toward women at heightened risk for developing the disease, according to the CDC.

Committee members will assist the CDC in developing evidence-based approaches to advance breast cancer awareness among younger women, Director Thomas Frieden said in a statement. These approaches will include prevention research, education for health professionals, and education for the public, Dr. Frieden said.

Dr. Ann Partridge, assistant professor of medicine at Harvard Medical School and clinical director of the Breast Oncology Center at the Dana-Farber Cancer Institute, Boston, will chair the panel, the CDC said.

Dr. Partridge founded and directs the Program for Young Women with Breast Cancer at Dana-Farber/Brigham and Women’s Cancer Center. The program addresses the unique needs of women in their early 40s and younger who have been diagnosed with breast cancer.

Fifteen researchers, clinicians, advocates, and breast cancer survivors have been named to a new advisory committee charged with developing initiatives to increase knowledge of breast health and breast cancer among women under age 40 years, the Centers for Disease Control and Prevention announced Oct. 14.

The Advisory Committee on Breast Cancer in Young Women was mandated by the Affordable Care Act enacted earlier this year, and will target its initiatives toward women at heightened risk for developing the disease, according to the CDC.

Committee members will assist the CDC in developing evidence-based approaches to advance breast cancer awareness among younger women, Director Thomas Frieden said in a statement. These approaches will include prevention research, education for health professionals, and education for the public, Dr. Frieden said.

Dr. Ann Partridge, assistant professor of medicine at Harvard Medical School and clinical director of the Breast Oncology Center at the Dana-Farber Cancer Institute, Boston, will chair the panel, the CDC said.

Dr. Partridge founded and directs the Program for Young Women with Breast Cancer at Dana-Farber/Brigham and Women’s Cancer Center. The program addresses the unique needs of women in their early 40s and younger who have been diagnosed with breast cancer.

Fifteen researchers, clinicians, advocates, and breast cancer survivors have been named to a new advisory committee charged with developing initiatives to increase knowledge of breast health and breast cancer among women under age 40 years, the Centers for Disease Control and Prevention announced Oct. 14.

The Advisory Committee on Breast Cancer in Young Women was mandated by the Affordable Care Act enacted earlier this year, and will target its initiatives toward women at heightened risk for developing the disease, according to the CDC.

Committee members will assist the CDC in developing evidence-based approaches to advance breast cancer awareness among younger women, Director Thomas Frieden said in a statement. These approaches will include prevention research, education for health professionals, and education for the public, Dr. Frieden said.

Dr. Ann Partridge, assistant professor of medicine at Harvard Medical School and clinical director of the Breast Oncology Center at the Dana-Farber Cancer Institute, Boston, will chair the panel, the CDC said.

Dr. Partridge founded and directs the Program for Young Women with Breast Cancer at Dana-Farber/Brigham and Women’s Cancer Center. The program addresses the unique needs of women in their early 40s and younger who have been diagnosed with breast cancer.

Implementing the patient-centered medical home is not enough to improve health care quality – physician education also needs to emphasize team-based approaches to medical care, participants said at a summit to discuss training gaps in primary care, behavioral health care, and health promotion.

The summit, held at the Carter Center in Atlanta, examined whether medical students are being trained appropriately to function efficiently and effectively in the newly reformed health care environment.

“Purchasers are actively choosing to buy different kinds of care” because they can't find the types of health care they need in the current system, said Dr. John Bartlett, senior adviser for the Primary Care Initiative at the Carter Center.

“Private purchasers are getting tired of paying the price of poor-quality medical education,” Dr. Bartlett said in a conference call convened to discuss the meeting's conclusions.

Meeting participants identified several key deficits in the U.S. medical education system, according to Dr. Michael Barr, senior vice president for medical practice, professionalism, and quality at the American College of Physicians.

“We train people separately and expect them to work together,” Dr. Barr said. “The current education system doesn't seem to value that type of training environment.”

In many programs, physicians-in-training don't meet actual patients until relatively late in their training, and many curricula don't emphasize the types of mental health issues that primary care physicians will need to practice, he added.

Some medical schools have implemented educational programs worth emulating, although implementing those programs on a large-scale basis might require changes in medical school accreditation requirements and regulatory requirements, Dr. Barr said.

For example, the University of Wisconsin, which uses patients as educators, introduces medical students to patients on their first day in class, Dr. Barr said. This helps to sensitize medical students very early in their careers to issues that will arise in primary care.

Dr. Barr pointed out several changes in medical education that could be implemented relatively quickly:

▸ Providing more training for med students with nonphysician mental health professionals.

▸ Emphasizing wellness and prevention.

▸ Developing faculty members who can teach within the patient-centered medical home model of care.

Dr. Bartlett added that medical schools also need to focus on ambulatory mental health issues, such as mild to moderate depression, that primary care physicians are most likely to encounter in practice.

Implementing the patient-centered medical home is not enough to improve health care quality – physician education also needs to emphasize team-based approaches to medical care, participants said at a summit to discuss training gaps in primary care, behavioral health care, and health promotion.

The summit, held at the Carter Center in Atlanta, examined whether medical students are being trained appropriately to function efficiently and effectively in the newly reformed health care environment.

“Purchasers are actively choosing to buy different kinds of care” because they can't find the types of health care they need in the current system, said Dr. John Bartlett, senior adviser for the Primary Care Initiative at the Carter Center.

“Private purchasers are getting tired of paying the price of poor-quality medical education,” Dr. Bartlett said in a conference call convened to discuss the meeting's conclusions.

Meeting participants identified several key deficits in the U.S. medical education system, according to Dr. Michael Barr, senior vice president for medical practice, professionalism, and quality at the American College of Physicians.

“We train people separately and expect them to work together,” Dr. Barr said. “The current education system doesn't seem to value that type of training environment.”

In many programs, physicians-in-training don't meet actual patients until relatively late in their training, and many curricula don't emphasize the types of mental health issues that primary care physicians will need to practice, he added.

Some medical schools have implemented educational programs worth emulating, although implementing those programs on a large-scale basis might require changes in medical school accreditation requirements and regulatory requirements, Dr. Barr said.

For example, the University of Wisconsin, which uses patients as educators, introduces medical students to patients on their first day in class, Dr. Barr said. This helps to sensitize medical students very early in their careers to issues that will arise in primary care.

Dr. Barr pointed out several changes in medical education that could be implemented relatively quickly:

▸ Providing more training for med students with nonphysician mental health professionals.

▸ Emphasizing wellness and prevention.

▸ Developing faculty members who can teach within the patient-centered medical home model of care.

Dr. Bartlett added that medical schools also need to focus on ambulatory mental health issues, such as mild to moderate depression, that primary care physicians are most likely to encounter in practice.

Implementing the patient-centered medical home is not enough to improve health care quality – physician education also needs to emphasize team-based approaches to medical care, participants said at a summit to discuss training gaps in primary care, behavioral health care, and health promotion.

The summit, held at the Carter Center in Atlanta, examined whether medical students are being trained appropriately to function efficiently and effectively in the newly reformed health care environment.

“Purchasers are actively choosing to buy different kinds of care” because they can't find the types of health care they need in the current system, said Dr. John Bartlett, senior adviser for the Primary Care Initiative at the Carter Center.

“Private purchasers are getting tired of paying the price of poor-quality medical education,” Dr. Bartlett said in a conference call convened to discuss the meeting's conclusions.

Meeting participants identified several key deficits in the U.S. medical education system, according to Dr. Michael Barr, senior vice president for medical practice, professionalism, and quality at the American College of Physicians.

“We train people separately and expect them to work together,” Dr. Barr said. “The current education system doesn't seem to value that type of training environment.”

In many programs, physicians-in-training don't meet actual patients until relatively late in their training, and many curricula don't emphasize the types of mental health issues that primary care physicians will need to practice, he added.

Some medical schools have implemented educational programs worth emulating, although implementing those programs on a large-scale basis might require changes in medical school accreditation requirements and regulatory requirements, Dr. Barr said.

For example, the University of Wisconsin, which uses patients as educators, introduces medical students to patients on their first day in class, Dr. Barr said. This helps to sensitize medical students very early in their careers to issues that will arise in primary care.

Dr. Barr pointed out several changes in medical education that could be implemented relatively quickly:

▸ Providing more training for med students with nonphysician mental health professionals.

▸ Emphasizing wellness and prevention.

▸ Developing faculty members who can teach within the patient-centered medical home model of care.

Dr. Bartlett added that medical schools also need to focus on ambulatory mental health issues, such as mild to moderate depression, that primary care physicians are most likely to encounter in practice.

Access Doesn't Guarantee Care

Making sure that patients visit a primary care physician regularly does not guarantee they will receive recommended care or have better outcomes, according to a report from the Dartmouth Atlas Project. For example, the report found no relationship between a population's amount of visits per year to a primary care provider and the likelihood that women would have mammograms done. The report also found no relationship between this measure of delivered primary care and the rate of hemoglobin A_1c testing among Medicare beneficiaries with diabetes. “Our findings suggest that the nation's primary care deficit won't be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage,” Dr. David Goodman, lead author of the study, said in a statement.

E-Prescribing Varies by State

Massachusetts physicians conveyed more than 11 million prescriptions electronically in 2009, nearly one-third of their total, to lead all states, according to the operator of the nation's largest e-prescribing network. Michigan, Rhode Island, Delaware, and North Carolina rounded out the top five e-prescribing states, the company Surescripts announced. The technology is growing rapidly everywhere, Surescripts said: In 2009, 47 states more than doubled their use of electronic prescription routing while 39 more than doubled their use of computer-generated prescription benefit information. More than 300 million prescriptions nationwide were sent electronically in 2009, compared with just 500,000 prescriptions in 2004, Surescripts said.

Study: Nutrition Education Lacking

Only 27% of 105 surveyed U.S. medical schools reported providing the minimum of 25 hours of nutrition instruction recommended by the National Academy of Sciences, according study results in Academic Medicine. That represents a drop from 2004, when 38% of medical schools provided the recommended minimum number of hours in nutrition education, said researchers of the Nutrition in Medicine Project at the University of North Carolina at Chapel Hill. Almost all the medical schools surveyed offered some form of nutrition education, although only one-quarter required a dedicated nutrition course. On average, students received less than 20 hours of nutrition instruction during their medical school careers, although one school provided up to 70 hours.

Claims Processors Deemed So-So

About 70% of physicians reported they were satisfied with the contractors who process their Medicare claims, in the annual Centers for Medicare and Medicaid Services survey on contractor performance. Meanwhile, 14% of physicians said they were neither satisfied nor dissatisfied, and more than 15% said they were dissatisfied with contractor performance. Hospitals were slightly happier, with three-quarters saying they were satisfied with contractor performance. Improvements in several areas would increase satisfaction, according to the CMS. For example, providers said they don't like having to make multiple inquiries of claims processors to resolve problems. They also want better information through an automated telephone system, promptly returned calls, and consistently correct information.

Report Cards Weak on Quality

Information provided in public physician report cards, such as education, board certification, and malpractice history, related only weakly or not at all to those physicians' performance on clinical quality measures, according to a study in the Archives of Internal Medicine. The researchers calculated overall performance scores on 124 quality measures for more than 10,000 Massachusetts physicians making 1.1 million health insurance claims. They then compared those data with the recorded characteristics of the physicians. On a mean overall quality score of 62%, board certification boosted a physician by 3.3%, female sex accounted for 1.6% over male sex, and graduation from a domestic medical school gave a 1% better score. There was no significant association between physician performance and malpractice claims.

Suit Targets California Blue Shield

The California Medical Association has filed a class action lawsuit against Blue Shield of California, claiming the health insurer's Blue Ribbon Recognition Program harms physicians and their patients by failing to accurately assess patient care. The program places blue ribbons next to the profiles of physicians who score above average in preventive screening and other categories. The ratings are based on quality information and do not consider cost information, according to Blue Shield of California. But the medical association pointed out that the rating system does not use chart reviews or evaluate patient outcomes. It doesn't use enough claims data to make valid ratings and doesn't give physicians a fair chance to correct errors, the CMA charged. “I found that my ratings report was inaccurate after spending significant time reviewing the report against my patient records,” Dr. Richard Stern, a San Pablo cardiologist and one of two doctors named as plaintiffs in the suit, said in a statement. The lawsuit seeks an injunction against the rating system and unspecified monetary relief.

Access Doesn't Guarantee Care

Making sure that patients visit a primary care physician regularly does not guarantee they will receive recommended care or have better outcomes, according to a report from the Dartmouth Atlas Project. For example, the report found no relationship between a population's amount of visits per year to a primary care provider and the likelihood that women would have mammograms done. The report also found no relationship between this measure of delivered primary care and the rate of hemoglobin A_1c testing among Medicare beneficiaries with diabetes. “Our findings suggest that the nation's primary care deficit won't be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage,” Dr. David Goodman, lead author of the study, said in a statement.

E-Prescribing Varies by State

Massachusetts physicians conveyed more than 11 million prescriptions electronically in 2009, nearly one-third of their total, to lead all states, according to the operator of the nation's largest e-prescribing network. Michigan, Rhode Island, Delaware, and North Carolina rounded out the top five e-prescribing states, the company Surescripts announced. The technology is growing rapidly everywhere, Surescripts said: In 2009, 47 states more than doubled their use of electronic prescription routing while 39 more than doubled their use of computer-generated prescription benefit information. More than 300 million prescriptions nationwide were sent electronically in 2009, compared with just 500,000 prescriptions in 2004, Surescripts said.

Study: Nutrition Education Lacking

Only 27% of 105 surveyed U.S. medical schools reported providing the minimum of 25 hours of nutrition instruction recommended by the National Academy of Sciences, according study results in Academic Medicine. That represents a drop from 2004, when 38% of medical schools provided the recommended minimum number of hours in nutrition education, said researchers of the Nutrition in Medicine Project at the University of North Carolina at Chapel Hill. Almost all the medical schools surveyed offered some form of nutrition education, although only one-quarter required a dedicated nutrition course. On average, students received less than 20 hours of nutrition instruction during their medical school careers, although one school provided up to 70 hours.

Claims Processors Deemed So-So

About 70% of physicians reported they were satisfied with the contractors who process their Medicare claims, in the annual Centers for Medicare and Medicaid Services survey on contractor performance. Meanwhile, 14% of physicians said they were neither satisfied nor dissatisfied, and more than 15% said they were dissatisfied with contractor performance. Hospitals were slightly happier, with three-quarters saying they were satisfied with contractor performance. Improvements in several areas would increase satisfaction, according to the CMS. For example, providers said they don't like having to make multiple inquiries of claims processors to resolve problems. They also want better information through an automated telephone system, promptly returned calls, and consistently correct information.

Report Cards Weak on Quality

Information provided in public physician report cards, such as education, board certification, and malpractice history, related only weakly or not at all to those physicians' performance on clinical quality measures, according to a study in the Archives of Internal Medicine. The researchers calculated overall performance scores on 124 quality measures for more than 10,000 Massachusetts physicians making 1.1 million health insurance claims. They then compared those data with the recorded characteristics of the physicians. On a mean overall quality score of 62%, board certification boosted a physician by 3.3%, female sex accounted for 1.6% over male sex, and graduation from a domestic medical school gave a 1% better score. There was no significant association between physician performance and malpractice claims.

Suit Targets California Blue Shield

The California Medical Association has filed a class action lawsuit against Blue Shield of California, claiming the health insurer's Blue Ribbon Recognition Program harms physicians and their patients by failing to accurately assess patient care. The program places blue ribbons next to the profiles of physicians who score above average in preventive screening and other categories. The ratings are based on quality information and do not consider cost information, according to Blue Shield of California. But the medical association pointed out that the rating system does not use chart reviews or evaluate patient outcomes. It doesn't use enough claims data to make valid ratings and doesn't give physicians a fair chance to correct errors, the CMA charged. “I found that my ratings report was inaccurate after spending significant time reviewing the report against my patient records,” Dr. Richard Stern, a San Pablo cardiologist and one of two doctors named as plaintiffs in the suit, said in a statement. The lawsuit seeks an injunction against the rating system and unspecified monetary relief.

Access Doesn't Guarantee Care

Making sure that patients visit a primary care physician regularly does not guarantee they will receive recommended care or have better outcomes, according to a report from the Dartmouth Atlas Project. For example, the report found no relationship between a population's amount of visits per year to a primary care provider and the likelihood that women would have mammograms done. The report also found no relationship between this measure of delivered primary care and the rate of hemoglobin A_1c testing among Medicare beneficiaries with diabetes. “Our findings suggest that the nation's primary care deficit won't be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage,” Dr. David Goodman, lead author of the study, said in a statement.

E-Prescribing Varies by State

Massachusetts physicians conveyed more than 11 million prescriptions electronically in 2009, nearly one-third of their total, to lead all states, according to the operator of the nation's largest e-prescribing network. Michigan, Rhode Island, Delaware, and North Carolina rounded out the top five e-prescribing states, the company Surescripts announced. The technology is growing rapidly everywhere, Surescripts said: In 2009, 47 states more than doubled their use of electronic prescription routing while 39 more than doubled their use of computer-generated prescription benefit information. More than 300 million prescriptions nationwide were sent electronically in 2009, compared with just 500,000 prescriptions in 2004, Surescripts said.

Study: Nutrition Education Lacking

Only 27% of 105 surveyed U.S. medical schools reported providing the minimum of 25 hours of nutrition instruction recommended by the National Academy of Sciences, according study results in Academic Medicine. That represents a drop from 2004, when 38% of medical schools provided the recommended minimum number of hours in nutrition education, said researchers of the Nutrition in Medicine Project at the University of North Carolina at Chapel Hill. Almost all the medical schools surveyed offered some form of nutrition education, although only one-quarter required a dedicated nutrition course. On average, students received less than 20 hours of nutrition instruction during their medical school careers, although one school provided up to 70 hours.

Claims Processors Deemed So-So

About 70% of physicians reported they were satisfied with the contractors who process their Medicare claims, in the annual Centers for Medicare and Medicaid Services survey on contractor performance. Meanwhile, 14% of physicians said they were neither satisfied nor dissatisfied, and more than 15% said they were dissatisfied with contractor performance. Hospitals were slightly happier, with three-quarters saying they were satisfied with contractor performance. Improvements in several areas would increase satisfaction, according to the CMS. For example, providers said they don't like having to make multiple inquiries of claims processors to resolve problems. They also want better information through an automated telephone system, promptly returned calls, and consistently correct information.

Report Cards Weak on Quality

Information provided in public physician report cards, such as education, board certification, and malpractice history, related only weakly or not at all to those physicians' performance on clinical quality measures, according to a study in the Archives of Internal Medicine. The researchers calculated overall performance scores on 124 quality measures for more than 10,000 Massachusetts physicians making 1.1 million health insurance claims. They then compared those data with the recorded characteristics of the physicians. On a mean overall quality score of 62%, board certification boosted a physician by 3.3%, female sex accounted for 1.6% over male sex, and graduation from a domestic medical school gave a 1% better score. There was no significant association between physician performance and malpractice claims.

Suit Targets California Blue Shield

The California Medical Association has filed a class action lawsuit against Blue Shield of California, claiming the health insurer's Blue Ribbon Recognition Program harms physicians and their patients by failing to accurately assess patient care. The program places blue ribbons next to the profiles of physicians who score above average in preventive screening and other categories. The ratings are based on quality information and do not consider cost information, according to Blue Shield of California. But the medical association pointed out that the rating system does not use chart reviews or evaluate patient outcomes. It doesn't use enough claims data to make valid ratings and doesn't give physicians a fair chance to correct errors, the CMA charged. “I found that my ratings report was inaccurate after spending significant time reviewing the report against my patient records,” Dr. Richard Stern, a San Pablo cardiologist and one of two doctors named as plaintiffs in the suit, said in a statement. The lawsuit seeks an injunction against the rating system and unspecified monetary relief.

Physicians who practice in clinics where patients pay a set monthly fee for virtually unlimited primary care services say that the practice model, which they’ve dubbed “direct primary care medical home,” can provide high-quality care and potentially can lower health care costs more effectively than the patient-centered medical home model.

The direct payments completely eliminate the insurance middleman, and unlimited primary care means that patients can spend far more time with their physicians, often preventing medical problems completely or taking care of them at an earlier, less costly stage, said Dr. Erika Bliss, director of clinical operations for Qliance Medical Management Inc. in Seattle.

Courtesy of Nazaret Medina

For example, the affiliated medical practice, Qliance Medical Group, analyzed internal data from 2009 and found that its direct primary care model lowered emergency department visits by 62% and hospital days by 26% for patients on its plan, when compared with regional averages for the same year, Dr. Bliss said. The group also cut specialist referrals by 55% and advanced radiology services by 48%, compared with regional averages.

“Insurance really doesn’t work for primary care; it’s meant to protect you from catastrophic events. It just adds a whole lot of administrative cost, not only on the doctors’ office side but also on the insurance side,” Dr. Bliss said in an interview. “Primary care is 90% of what people need, and we can provide that.”

The direct primary care practice model resembles the concierge medical practice model, but – unlike concierge practices – direct primary care practices cater to a lower-income demographic and attempt to provide almost all necessary care for a flat monthly fee. Many concierge practices charge a monthly or annual retainer, but also bill for services provided to the patient.

The direct primary care practice model also follows some of the same principles as the patient-centered medical home model. However, the direct primary care model does not team physicians with other health care professionals, such as social workers and pharmacists.

“One of the things that really strikes me with the move to the patient-centered medical home is, there’s an assumption that in order to take better care of patients, you need to put together a multidisciplinary team,” said Dr. Bliss. “We assume you need a pharmacist, a nutritionist, and a social worker, but while it’s nice to have those people around, they’re not really necessary, and they also add a lot of cost. When you spend time with someone, you can solve their problems without them seeing a nutritionist.”

At Qliance, patients pay monthly fees of $44-$129, depending on their age and service preferences, for unrestricted access to physicians and nurse practitioners. The three Qliance clinics, with their nine physicians and three nurse practitioners, provide all routine care including vaccinations, routine blood tests, women’s health services, pediatric care, broken bone setting, and ongoing management of chronic diseases like diabetes and obesity, Dr. Bliss said.

In-person appointments run for a minimum of 30 minutes, and the physicians also communicate with their patients via e-mail and phone.

The model takes insurance out of the picture completely. About 70%-75% of patients on Qliance’s plan also have insurance, but many have only high-deductible plans that will pay only for catastrophic illnesses or injuries. Qliance also negotiates with specialists and suppliers on behalf of patients for lower rates on ancillary services and equipment.

Insurance companies and hospitals started out being indifferent or even hostile to Qliance’s direct primary care model, but now some are actively seeking to work with the company, said Norman Wu, president and CEO of Qliance Medical Management Inc.

Mr. Wu said he knows of about 10 direct primary care practices in the United States that offer nearly unlimited primary care to patients for less than $100 a month.

Dr. John Muney, a board-certified surgeon who now serves as president of AMG Medical Group, a direct primary care group with five locations in New York City, said that his group provides nearly unlimited preventive care for $79 or $119 a month, depending on the additional services desired.

The direct primary care model saves money because it eliminates vast amounts of unnecessary services, Dr. Muney said. For example, in the last year, he’s seen only two patients who really needed an MRI, but patients with insurance frequently demand the imaging technology. AMG Medical Group also has negotiated with specialists and hospitals for discounted MRIs, CT scans, and other services. For example, patients can get an MRI for $350 and a colonoscopy for $450.

Dr. Muney said that the direct primary care model could represent “the salvation of the health care system,” because it saves costs while significantly enhancing the physician-patient relationship. However, to make the model work well, patients would need to resist the urge to demand unnecessary tests and specialist visits, and insurance would need to be restructured to eliminate primary care.

In addition, insurers may view new direct primary care clinics as competition, which could lead to fights between insurers and the clinics if the model were to be adopted in many locations, advocates of the approach say. And the clinics themselves would need to resist the urge to add too many patients to their panels, or physicians could find themselves spending less time with each patient.

Despite these obstacles, Dr. Bliss said she also believes that the direct primary care model can solve the inherent problems in the current health care system, and solve them better than the patient-centered medical home model.

In fee-for-service practice, “the only way you can make money is to lay eyes on the patient, and the only way to see enough patients is to have all those people tee up the patients for you,” said Dr. Bliss, who said she became burned out after a few years of fee-for-service practice despite a deep commitment to primary care. “This model can fix what’s wrong with health care. It can make patients happy and it can make primary care physicians enjoy practicing again.”

Physicians who practice in clinics where patients pay a set monthly fee for virtually unlimited primary care services say that the practice model, which they’ve dubbed “direct primary care medical home,” can provide high-quality care and potentially can lower health care costs more effectively than the patient-centered medical home model.

The direct payments completely eliminate the insurance middleman, and unlimited primary care means that patients can spend far more time with their physicians, often preventing medical problems completely or taking care of them at an earlier, less costly stage, said Dr. Erika Bliss, director of clinical operations for Qliance Medical Management Inc. in Seattle.

Courtesy of Nazaret Medina

For example, the affiliated medical practice, Qliance Medical Group, analyzed internal data from 2009 and found that its direct primary care model lowered emergency department visits by 62% and hospital days by 26% for patients on its plan, when compared with regional averages for the same year, Dr. Bliss said. The group also cut specialist referrals by 55% and advanced radiology services by 48%, compared with regional averages.

“Insurance really doesn’t work for primary care; it’s meant to protect you from catastrophic events. It just adds a whole lot of administrative cost, not only on the doctors’ office side but also on the insurance side,” Dr. Bliss said in an interview. “Primary care is 90% of what people need, and we can provide that.”

The direct primary care practice model resembles the concierge medical practice model, but – unlike concierge practices – direct primary care practices cater to a lower-income demographic and attempt to provide almost all necessary care for a flat monthly fee. Many concierge practices charge a monthly or annual retainer, but also bill for services provided to the patient.

The direct primary care practice model also follows some of the same principles as the patient-centered medical home model. However, the direct primary care model does not team physicians with other health care professionals, such as social workers and pharmacists.

“One of the things that really strikes me with the move to the patient-centered medical home is, there’s an assumption that in order to take better care of patients, you need to put together a multidisciplinary team,” said Dr. Bliss. “We assume you need a pharmacist, a nutritionist, and a social worker, but while it’s nice to have those people around, they’re not really necessary, and they also add a lot of cost. When you spend time with someone, you can solve their problems without them seeing a nutritionist.”

At Qliance, patients pay monthly fees of $44-$129, depending on their age and service preferences, for unrestricted access to physicians and nurse practitioners. The three Qliance clinics, with their nine physicians and three nurse practitioners, provide all routine care including vaccinations, routine blood tests, women’s health services, pediatric care, broken bone setting, and ongoing management of chronic diseases like diabetes and obesity, Dr. Bliss said.

In-person appointments run for a minimum of 30 minutes, and the physicians also communicate with their patients via e-mail and phone.

The model takes insurance out of the picture completely. About 70%-75% of patients on Qliance’s plan also have insurance, but many have only high-deductible plans that will pay only for catastrophic illnesses or injuries. Qliance also negotiates with specialists and suppliers on behalf of patients for lower rates on ancillary services and equipment.

Insurance companies and hospitals started out being indifferent or even hostile to Qliance’s direct primary care model, but now some are actively seeking to work with the company, said Norman Wu, president and CEO of Qliance Medical Management Inc.

Mr. Wu said he knows of about 10 direct primary care practices in the United States that offer nearly unlimited primary care to patients for less than $100 a month.

Dr. John Muney, a board-certified surgeon who now serves as president of AMG Medical Group, a direct primary care group with five locations in New York City, said that his group provides nearly unlimited preventive care for $79 or $119 a month, depending on the additional services desired.

The direct primary care model saves money because it eliminates vast amounts of unnecessary services, Dr. Muney said. For example, in the last year, he’s seen only two patients who really needed an MRI, but patients with insurance frequently demand the imaging technology. AMG Medical Group also has negotiated with specialists and hospitals for discounted MRIs, CT scans, and other services. For example, patients can get an MRI for $350 and a colonoscopy for $450.

Dr. Muney said that the direct primary care model could represent “the salvation of the health care system,” because it saves costs while significantly enhancing the physician-patient relationship. However, to make the model work well, patients would need to resist the urge to demand unnecessary tests and specialist visits, and insurance would need to be restructured to eliminate primary care.

In addition, insurers may view new direct primary care clinics as competition, which could lead to fights between insurers and the clinics if the model were to be adopted in many locations, advocates of the approach say. And the clinics themselves would need to resist the urge to add too many patients to their panels, or physicians could find themselves spending less time with each patient.

Despite these obstacles, Dr. Bliss said she also believes that the direct primary care model can solve the inherent problems in the current health care system, and solve them better than the patient-centered medical home model.

In fee-for-service practice, “the only way you can make money is to lay eyes on the patient, and the only way to see enough patients is to have all those people tee up the patients for you,” said Dr. Bliss, who said she became burned out after a few years of fee-for-service practice despite a deep commitment to primary care. “This model can fix what’s wrong with health care. It can make patients happy and it can make primary care physicians enjoy practicing again.”

Physicians who practice in clinics where patients pay a set monthly fee for virtually unlimited primary care services say that the practice model, which they’ve dubbed “direct primary care medical home,” can provide high-quality care and potentially can lower health care costs more effectively than the patient-centered medical home model.

The direct payments completely eliminate the insurance middleman, and unlimited primary care means that patients can spend far more time with their physicians, often preventing medical problems completely or taking care of them at an earlier, less costly stage, said Dr. Erika Bliss, director of clinical operations for Qliance Medical Management Inc. in Seattle.

Courtesy of Nazaret Medina

For example, the affiliated medical practice, Qliance Medical Group, analyzed internal data from 2009 and found that its direct primary care model lowered emergency department visits by 62% and hospital days by 26% for patients on its plan, when compared with regional averages for the same year, Dr. Bliss said. The group also cut specialist referrals by 55% and advanced radiology services by 48%, compared with regional averages.

“Insurance really doesn’t work for primary care; it’s meant to protect you from catastrophic events. It just adds a whole lot of administrative cost, not only on the doctors’ office side but also on the insurance side,” Dr. Bliss said in an interview. “Primary care is 90% of what people need, and we can provide that.”

The direct primary care practice model resembles the concierge medical practice model, but – unlike concierge practices – direct primary care practices cater to a lower-income demographic and attempt to provide almost all necessary care for a flat monthly fee. Many concierge practices charge a monthly or annual retainer, but also bill for services provided to the patient.

The direct primary care practice model also follows some of the same principles as the patient-centered medical home model. However, the direct primary care model does not team physicians with other health care professionals, such as social workers and pharmacists.

“One of the things that really strikes me with the move to the patient-centered medical home is, there’s an assumption that in order to take better care of patients, you need to put together a multidisciplinary team,” said Dr. Bliss. “We assume you need a pharmacist, a nutritionist, and a social worker, but while it’s nice to have those people around, they’re not really necessary, and they also add a lot of cost. When you spend time with someone, you can solve their problems without them seeing a nutritionist.”

At Qliance, patients pay monthly fees of $44-$129, depending on their age and service preferences, for unrestricted access to physicians and nurse practitioners. The three Qliance clinics, with their nine physicians and three nurse practitioners, provide all routine care including vaccinations, routine blood tests, women’s health services, pediatric care, broken bone setting, and ongoing management of chronic diseases like diabetes and obesity, Dr. Bliss said.

In-person appointments run for a minimum of 30 minutes, and the physicians also communicate with their patients via e-mail and phone.

The model takes insurance out of the picture completely. About 70%-75% of patients on Qliance’s plan also have insurance, but many have only high-deductible plans that will pay only for catastrophic illnesses or injuries. Qliance also negotiates with specialists and suppliers on behalf of patients for lower rates on ancillary services and equipment.

Insurance companies and hospitals started out being indifferent or even hostile to Qliance’s direct primary care model, but now some are actively seeking to work with the company, said Norman Wu, president and CEO of Qliance Medical Management Inc.

Mr. Wu said he knows of about 10 direct primary care practices in the United States that offer nearly unlimited primary care to patients for less than $100 a month.

Dr. John Muney, a board-certified surgeon who now serves as president of AMG Medical Group, a direct primary care group with five locations in New York City, said that his group provides nearly unlimited preventive care for $79 or $119 a month, depending on the additional services desired.

The direct primary care model saves money because it eliminates vast amounts of unnecessary services, Dr. Muney said. For example, in the last year, he’s seen only two patients who really needed an MRI, but patients with insurance frequently demand the imaging technology. AMG Medical Group also has negotiated with specialists and hospitals for discounted MRIs, CT scans, and other services. For example, patients can get an MRI for $350 and a colonoscopy for $450.

Dr. Muney said that the direct primary care model could represent “the salvation of the health care system,” because it saves costs while significantly enhancing the physician-patient relationship. However, to make the model work well, patients would need to resist the urge to demand unnecessary tests and specialist visits, and insurance would need to be restructured to eliminate primary care.

In addition, insurers may view new direct primary care clinics as competition, which could lead to fights between insurers and the clinics if the model were to be adopted in many locations, advocates of the approach say. And the clinics themselves would need to resist the urge to add too many patients to their panels, or physicians could find themselves spending less time with each patient.

Despite these obstacles, Dr. Bliss said she also believes that the direct primary care model can solve the inherent problems in the current health care system, and solve them better than the patient-centered medical home model.

In fee-for-service practice, “the only way you can make money is to lay eyes on the patient, and the only way to see enough patients is to have all those people tee up the patients for you,” said Dr. Bliss, who said she became burned out after a few years of fee-for-service practice despite a deep commitment to primary care. “This model can fix what’s wrong with health care. It can make patients happy and it can make primary care physicians enjoy practicing again.”

More minority students enrolled as first-year medical students in 2010, with Hispanic male medical students especially increasing their numbers, according to new data released Oct. 13 by the Association of American Medical Colleges.

The number of black/African American and American Indian first-year medical students also grew this year, and every U.S. region saw increases in medical school enrollment diversity, said AAMC President and CEO Dr. Darrell Kirch.

"The bottom line is, we see more minority students pursuing a career in medicine," Dr. Kirch said in a telephone press briefing to announce the findings.

Improved diversity will help communities meet their health needs, especially with the increased need for physicians triggered by the Affordable Care Act, he said.

"You don’t improve the health of a community without having a workforce that reflects the diversity of that community," Dr. Kirch said, adding that it's not enough for health care reform to provide insurance if there aren't enough physicians. "An insurance card can’t take care of you – you need to have a physician to do that."

Hispanic men increased their enrollment in medical school by 17.1%, while enrollment by Hispanic women grew by 1.6% over 2009, according to the AAMC report. Total Hispanic enrollment rose by 9%. First-year Hispanic enrollees in U.S. medical schools totaled 1,539 in 2010, compared with 1,412 in 2009, according to AAMC.

Black/African American enrollment, meanwhile, grew by 2.9% over 2009. A total of 1,350 black/African American students enrolled in medical school as first-year students in 2010, compared with 1,312 students in 2009.

American Indian enrollment remained small, with just 191 first-year students in 2010, according to AAMC. However, that represented a 25% increase over last year’s enrollment of 153 students, AAMC said.

Asian students also saw gains, with enrollment increasing 2.4% in 2010 to 4,214 from 4,114 in 2009, according to the AAMC report.

Overall, the level of applicants to U.S. medical schools has remained steady for at least the past 4 years, although the total number of first-time applications increased by 2.5% in 2010, said Dr. Kirch.

"Medical school remains a very compelling career choice," he said. About 42,000 potential students, including 31,063 first-time applicants, competed for about 18,000 openings, he said.

About 53% of applicants were male and 47% were female; men also outnumbered women first-year enrollees by 53% to 47%, the report showed.

One new medical school – the Virginia Tech Carilion Medical School – accepted its first class this year, and two more are in line to accept their first classes next year, Dr. Kirch said. Another seven medical schools are in the accreditation process, he said.

"This effort to expand medical school enrollment will enable us to add 7,000 more annual graduates," he said, adding, "we're not focused solely on new schools. We’re also focused on [increasing enrollment at] existing schools."

But increased medical school enrollment won’t help the looming shortage of physicians unless the number of residency slots also increases, Dr. Kirch warned. AAMC advocates about a 15% increase in the number of residency slots, he said.

More minority students enrolled as first-year medical students in 2010, with Hispanic male medical students especially increasing their numbers, according to new data released Oct. 13 by the Association of American Medical Colleges.

The number of black/African American and American Indian first-year medical students also grew this year, and every U.S. region saw increases in medical school enrollment diversity, said AAMC President and CEO Dr. Darrell Kirch.

"The bottom line is, we see more minority students pursuing a career in medicine," Dr. Kirch said in a telephone press briefing to announce the findings.

Improved diversity will help communities meet their health needs, especially with the increased need for physicians triggered by the Affordable Care Act, he said.

"You don’t improve the health of a community without having a workforce that reflects the diversity of that community," Dr. Kirch said, adding that it's not enough for health care reform to provide insurance if there aren't enough physicians. "An insurance card can’t take care of you – you need to have a physician to do that."

Hispanic men increased their enrollment in medical school by 17.1%, while enrollment by Hispanic women grew by 1.6% over 2009, according to the AAMC report. Total Hispanic enrollment rose by 9%. First-year Hispanic enrollees in U.S. medical schools totaled 1,539 in 2010, compared with 1,412 in 2009, according to AAMC.

Black/African American enrollment, meanwhile, grew by 2.9% over 2009. A total of 1,350 black/African American students enrolled in medical school as first-year students in 2010, compared with 1,312 students in 2009.

American Indian enrollment remained small, with just 191 first-year students in 2010, according to AAMC. However, that represented a 25% increase over last year’s enrollment of 153 students, AAMC said.

Asian students also saw gains, with enrollment increasing 2.4% in 2010 to 4,214 from 4,114 in 2009, according to the AAMC report.

Overall, the level of applicants to U.S. medical schools has remained steady for at least the past 4 years, although the total number of first-time applications increased by 2.5% in 2010, said Dr. Kirch.

"Medical school remains a very compelling career choice," he said. About 42,000 potential students, including 31,063 first-time applicants, competed for about 18,000 openings, he said.

About 53% of applicants were male and 47% were female; men also outnumbered women first-year enrollees by 53% to 47%, the report showed.

One new medical school – the Virginia Tech Carilion Medical School – accepted its first class this year, and two more are in line to accept their first classes next year, Dr. Kirch said. Another seven medical schools are in the accreditation process, he said.

"This effort to expand medical school enrollment will enable us to add 7,000 more annual graduates," he said, adding, "we're not focused solely on new schools. We’re also focused on [increasing enrollment at] existing schools."

But increased medical school enrollment won’t help the looming shortage of physicians unless the number of residency slots also increases, Dr. Kirch warned. AAMC advocates about a 15% increase in the number of residency slots, he said.

More minority students enrolled as first-year medical students in 2010, with Hispanic male medical students especially increasing their numbers, according to new data released Oct. 13 by the Association of American Medical Colleges.

The number of black/African American and American Indian first-year medical students also grew this year, and every U.S. region saw increases in medical school enrollment diversity, said AAMC President and CEO Dr. Darrell Kirch.

"The bottom line is, we see more minority students pursuing a career in medicine," Dr. Kirch said in a telephone press briefing to announce the findings.

Improved diversity will help communities meet their health needs, especially with the increased need for physicians triggered by the Affordable Care Act, he said.

"You don’t improve the health of a community without having a workforce that reflects the diversity of that community," Dr. Kirch said, adding that it's not enough for health care reform to provide insurance if there aren't enough physicians. "An insurance card can’t take care of you – you need to have a physician to do that."

Hispanic men increased their enrollment in medical school by 17.1%, while enrollment by Hispanic women grew by 1.6% over 2009, according to the AAMC report. Total Hispanic enrollment rose by 9%. First-year Hispanic enrollees in U.S. medical schools totaled 1,539 in 2010, compared with 1,412 in 2009, according to AAMC.

Black/African American enrollment, meanwhile, grew by 2.9% over 2009. A total of 1,350 black/African American students enrolled in medical school as first-year students in 2010, compared with 1,312 students in 2009.

American Indian enrollment remained small, with just 191 first-year students in 2010, according to AAMC. However, that represented a 25% increase over last year’s enrollment of 153 students, AAMC said.

Asian students also saw gains, with enrollment increasing 2.4% in 2010 to 4,214 from 4,114 in 2009, according to the AAMC report.

Overall, the level of applicants to U.S. medical schools has remained steady for at least the past 4 years, although the total number of first-time applications increased by 2.5% in 2010, said Dr. Kirch.

"Medical school remains a very compelling career choice," he said. About 42,000 potential students, including 31,063 first-time applicants, competed for about 18,000 openings, he said.

About 53% of applicants were male and 47% were female; men also outnumbered women first-year enrollees by 53% to 47%, the report showed.

One new medical school – the Virginia Tech Carilion Medical School – accepted its first class this year, and two more are in line to accept their first classes next year, Dr. Kirch said. Another seven medical schools are in the accreditation process, he said.

"This effort to expand medical school enrollment will enable us to add 7,000 more annual graduates," he said, adding, "we're not focused solely on new schools. We’re also focused on [increasing enrollment at] existing schools."

But increased medical school enrollment won’t help the looming shortage of physicians unless the number of residency slots also increases, Dr. Kirch warned. AAMC advocates about a 15% increase in the number of residency slots, he said.

More minority students enrolled as first-year medical students in 2010, with Hispanic male medical students especially increasing their numbers, according to new data released Oct. 13 by the Association of American Medical Colleges.

The number of black/African American and American Indian first-year medical students also grew this year, and every U.S. region saw increases in medical school enrollment diversity, said AAMC President and CEO Dr. Darrell Kirch.

“The bottom line is, we see more minority students pursuing a career in medicine,” Dr. Kirch said in a telephone press briefing to announce the findings.

Improved diversity will help communities meet their health needs, especially with the increased need for physicians triggered by the Affordable Care Act, he said.

“You don’t improve the health of a community without having a workforce that reflects the diversity of that community,” Dr. Kirch said, adding that it’s not enough for health care reform to provide insurance if there aren’t enough physicians. “An insurance card can’t take care of you – you need to have a physician to do that.”

Hispanic men increased their enrollment in medical school by 17.1%, while enrollment by Hispanic women grew by 1.6% over 2009, according to the AAMC report. Total Hispanic enrollment rose by 9%. First-year Hispanic enrollees in U.S. medical schools totaled 1,539 in 2010, compared with 1,412 in 2009, according to AAMC.

Black/African American enrollment, meanwhile, grew by 2.9% over 2009. A total of 1,350 black/African American students enrolled in medical school as first-year students in 2010, compared with 1,312 students in 2009.

American Indian enrollment remained small, with just 191 first-year students in 2010, according to AAMC. However, that represented a 25% increase over last year’s enrollment of 153 students, AAMC said.

Asian students also saw gains, with enrollment increasing 2.4% in 2010 to 4,214 from 4,114 in 2009, according to the AAMC report.

Overall, the level of applicants to U.S. medical schools has remained steady for at least the past 4 years, although the total number of first-time applications increased by 2.5% in 2010, said Dr. Kirch.

“Medical school remains a very compelling career choice,” he said. About 42,000 potential students, including 31,063 first-time applicants, competed for about 18,000 openings, he said.

About 53% of applicants were male and 47% were female; men also outnumbered women first-year enrollees by 53% to 47%, the report showed.

One new medical school – the Virginia Tech Carilion Medical School – accepted its first class this year, and two more are in line to accept their first classes next year, Dr. Kirch said. Another seven medical schools are in the accreditation process, he said.

“This effort to expand medical school enrollment will enable us to add 7,000 more annual graduates,” he said, adding, “we’re not focused solely on new schools. We’re also focused on [increasing enrollment at] existing schools.”

But increased medical school enrollment won’t help the looming shortage of physicians unless the number of residency slots also increases, Dr. Kirch warned. AAMC advocates about a 15% increase in the number of residency slots, he said.

More minority students enrolled as first-year medical students in 2010, with Hispanic male medical students especially increasing their numbers, according to new data released Oct. 13 by the Association of American Medical Colleges.

The number of black/African American and American Indian first-year medical students also grew this year, and every U.S. region saw increases in medical school enrollment diversity, said AAMC President and CEO Dr. Darrell Kirch.

“The bottom line is, we see more minority students pursuing a career in medicine,” Dr. Kirch said in a telephone press briefing to announce the findings.

Improved diversity will help communities meet their health needs, especially with the increased need for physicians triggered by the Affordable Care Act, he said.

“You don’t improve the health of a community without having a workforce that reflects the diversity of that community,” Dr. Kirch said, adding that it’s not enough for health care reform to provide insurance if there aren’t enough physicians. “An insurance card can’t take care of you – you need to have a physician to do that.”

Hispanic men increased their enrollment in medical school by 17.1%, while enrollment by Hispanic women grew by 1.6% over 2009, according to the AAMC report. Total Hispanic enrollment rose by 9%. First-year Hispanic enrollees in U.S. medical schools totaled 1,539 in 2010, compared with 1,412 in 2009, according to AAMC.

Black/African American enrollment, meanwhile, grew by 2.9% over 2009. A total of 1,350 black/African American students enrolled in medical school as first-year students in 2010, compared with 1,312 students in 2009.

American Indian enrollment remained small, with just 191 first-year students in 2010, according to AAMC. However, that represented a 25% increase over last year’s enrollment of 153 students, AAMC said.

Asian students also saw gains, with enrollment increasing 2.4% in 2010 to 4,214 from 4,114 in 2009, according to the AAMC report.

Overall, the level of applicants to U.S. medical schools has remained steady for at least the past 4 years, although the total number of first-time applications increased by 2.5% in 2010, said Dr. Kirch.

“Medical school remains a very compelling career choice,” he said. About 42,000 potential students, including 31,063 first-time applicants, competed for about 18,000 openings, he said.

About 53% of applicants were male and 47% were female; men also outnumbered women first-year enrollees by 53% to 47%, the report showed.

One new medical school – the Virginia Tech Carilion Medical School – accepted its first class this year, and two more are in line to accept their first classes next year, Dr. Kirch said. Another seven medical schools are in the accreditation process, he said.

“This effort to expand medical school enrollment will enable us to add 7,000 more annual graduates,” he said, adding, “we’re not focused solely on new schools. We’re also focused on [increasing enrollment at] existing schools.”

But increased medical school enrollment won’t help the looming shortage of physicians unless the number of residency slots also increases, Dr. Kirch warned. AAMC advocates about a 15% increase in the number of residency slots, he said.

More minority students enrolled as first-year medical students in 2010, with Hispanic male medical students especially increasing their numbers, according to new data released Oct. 13 by the Association of American Medical Colleges.

The number of black/African American and American Indian first-year medical students also grew this year, and every U.S. region saw increases in medical school enrollment diversity, said AAMC President and CEO Dr. Darrell Kirch.

“The bottom line is, we see more minority students pursuing a career in medicine,” Dr. Kirch said in a telephone press briefing to announce the findings.

Improved diversity will help communities meet their health needs, especially with the increased need for physicians triggered by the Affordable Care Act, he said.

“You don’t improve the health of a community without having a workforce that reflects the diversity of that community,” Dr. Kirch said, adding that it’s not enough for health care reform to provide insurance if there aren’t enough physicians. “An insurance card can’t take care of you – you need to have a physician to do that.”

Hispanic men increased their enrollment in medical school by 17.1%, while enrollment by Hispanic women grew by 1.6% over 2009, according to the AAMC report. Total Hispanic enrollment rose by 9%. First-year Hispanic enrollees in U.S. medical schools totaled 1,539 in 2010, compared with 1,412 in 2009, according to AAMC.

Black/African American enrollment, meanwhile, grew by 2.9% over 2009. A total of 1,350 black/African American students enrolled in medical school as first-year students in 2010, compared with 1,312 students in 2009.

American Indian enrollment remained small, with just 191 first-year students in 2010, according to AAMC. However, that represented a 25% increase over last year’s enrollment of 153 students, AAMC said.

Asian students also saw gains, with enrollment increasing 2.4% in 2010 to 4,214 from 4,114 in 2009, according to the AAMC report.

Overall, the level of applicants to U.S. medical schools has remained steady for at least the past 4 years, although the total number of first-time applications increased by 2.5% in 2010, said Dr. Kirch.

“Medical school remains a very compelling career choice,” he said. About 42,000 potential students, including 31,063 first-time applicants, competed for about 18,000 openings, he said.

About 53% of applicants were male and 47% were female; men also outnumbered women first-year enrollees by 53% to 47%, the report showed.

One new medical school – the Virginia Tech Carilion Medical School – accepted its first class this year, and two more are in line to accept their first classes next year, Dr. Kirch said. Another seven medical schools are in the accreditation process, he said.

“This effort to expand medical school enrollment will enable us to add 7,000 more annual graduates,” he said, adding, “we’re not focused solely on new schools. We’re also focused on [increasing enrollment at] existing schools.”

But increased medical school enrollment won’t help the looming shortage of physicians unless the number of residency slots also increases, Dr. Kirch warned. AAMC advocates about a 15% increase in the number of residency slots, he said.

Implementing the patient-centered medical home is not enough to improve health care quality – physician education also needs to change, emphasizing team-based approaches to medical care, participants said at a summit to discuss training gaps in primary care, behavioral health care, and health promotion.

The summit, held at The Carter Center in Atlanta Oct. 5-6, examined whether medical students are being trained appropriately to function efficiently and effectively in the newly reformed health care environment.

“Purchasers are actively choosing to buy different kinds of care” because they can’t find the types of health care they need in the current system, said Dr. John Bartlett, senior adviser for the Primary Care Initiative at The Carter Center.

“Private purchasers are getting tired of paying the price of poor-quality medical education,” Dr. Bartlett told reporters in a conference call convened Oct. 6 to discuss the meeting’s conclusions.

Meeting participants identified several key deficits in the U.S. medical education system, according to Dr. Michael Barr, senior vice president for medical practice, professionalism, and quality at the American College of Physicians.

“We train people separately and expect them to work together,” Dr. Barr said. “The current education system doesn’t seem to value that type of training environment.”

In many programs, physicians-in-training don’t meet actual patients until relatively late in their training, and many curricula don’t emphasize the types of mental health issues that primary care physicians will need to practice, he added.

Some medical schools have implemented educational programs worth emulating, although implementing those programs on a large-scale basis might require changes in medical school accreditation requirements and regulatory requirements, Dr. Barr said.

For example, the University of Wisconsin, which uses patients as educators, introduces medical students to patients on their first day in class, Dr. Barr said. This helps to sensitize medical students very early in their careers to issues that will arise in primary care.

Dr. Barr pointed out several changes in medical education that could be implemented relatively quickly:

• Providing more training for medical students with nonphysician mental health professionals.

• Emphasizing wellness and prevention.

• Developing faculty members who can teach within the patient-centered medical home model of care.

Dr. Bartlett added that medical schools also need to focus on ambulatory mental health issues, such as mild to moderate depression, that primary care physicians are most likely to encounter in practice, as opposed to providing only experience on the psychiatric ward.

Implementing the patient-centered medical home is not enough to improve health care quality – physician education also needs to change, emphasizing team-based approaches to medical care, participants said at a summit to discuss training gaps in primary care, behavioral health care, and health promotion.

The summit, held at The Carter Center in Atlanta Oct. 5-6, examined whether medical students are being trained appropriately to function efficiently and effectively in the newly reformed health care environment.

“Purchasers are actively choosing to buy different kinds of care” because they can’t find the types of health care they need in the current system, said Dr. John Bartlett, senior adviser for the Primary Care Initiative at The Carter Center.

“Private purchasers are getting tired of paying the price of poor-quality medical education,” Dr. Bartlett told reporters in a conference call convened Oct. 6 to discuss the meeting’s conclusions.

Meeting participants identified several key deficits in the U.S. medical education system, according to Dr. Michael Barr, senior vice president for medical practice, professionalism, and quality at the American College of Physicians.

“We train people separately and expect them to work together,” Dr. Barr said. “The current education system doesn’t seem to value that type of training environment.”

In many programs, physicians-in-training don’t meet actual patients until relatively late in their training, and many curricula don’t emphasize the types of mental health issues that primary care physicians will need to practice, he added.

Some medical schools have implemented educational programs worth emulating, although implementing those programs on a large-scale basis might require changes in medical school accreditation requirements and regulatory requirements, Dr. Barr said.

For example, the University of Wisconsin, which uses patients as educators, introduces medical students to patients on their first day in class, Dr. Barr said. This helps to sensitize medical students very early in their careers to issues that will arise in primary care.

Dr. Barr pointed out several changes in medical education that could be implemented relatively quickly:

• Providing more training for medical students with nonphysician mental health professionals.

• Emphasizing wellness and prevention.

• Developing faculty members who can teach within the patient-centered medical home model of care.

Dr. Bartlett added that medical schools also need to focus on ambulatory mental health issues, such as mild to moderate depression, that primary care physicians are most likely to encounter in practice, as opposed to providing only experience on the psychiatric ward.

Implementing the patient-centered medical home is not enough to improve health care quality – physician education also needs to change, emphasizing team-based approaches to medical care, participants said at a summit to discuss training gaps in primary care, behavioral health care, and health promotion.

The summit, held at The Carter Center in Atlanta Oct. 5-6, examined whether medical students are being trained appropriately to function efficiently and effectively in the newly reformed health care environment.

“Purchasers are actively choosing to buy different kinds of care” because they can’t find the types of health care they need in the current system, said Dr. John Bartlett, senior adviser for the Primary Care Initiative at The Carter Center.

“Private purchasers are getting tired of paying the price of poor-quality medical education,” Dr. Bartlett told reporters in a conference call convened Oct. 6 to discuss the meeting’s conclusions.

Meeting participants identified several key deficits in the U.S. medical education system, according to Dr. Michael Barr, senior vice president for medical practice, professionalism, and quality at the American College of Physicians.

“We train people separately and expect them to work together,” Dr. Barr said. “The current education system doesn’t seem to value that type of training environment.”

In many programs, physicians-in-training don’t meet actual patients until relatively late in their training, and many curricula don’t emphasize the types of mental health issues that primary care physicians will need to practice, he added.

Some medical schools have implemented educational programs worth emulating, although implementing those programs on a large-scale basis might require changes in medical school accreditation requirements and regulatory requirements, Dr. Barr said.

For example, the University of Wisconsin, which uses patients as educators, introduces medical students to patients on their first day in class, Dr. Barr said. This helps to sensitize medical students very early in their careers to issues that will arise in primary care.

Dr. Barr pointed out several changes in medical education that could be implemented relatively quickly:

• Providing more training for medical students with nonphysician mental health professionals.

• Emphasizing wellness and prevention.

• Developing faculty members who can teach within the patient-centered medical home model of care.

Dr. Bartlett added that medical schools also need to focus on ambulatory mental health issues, such as mild to moderate depression, that primary care physicians are most likely to encounter in practice, as opposed to providing only experience on the psychiatric ward.