Serving the Underserved; Primary Care Outlook

October 6, 2022

Dr. Bruce Gould (photo by Kristin Wallace) Listen now.

The American health care system is facing a shortage of primary care physicians. Preparing the next generation of providers is one of the missions of UConn Health, where the training includes hands-on experience delivering care to historically underserved populations. Dr. Bruce Gould, UConn School of Medicine professor emeritus, founding associate dean for primary care, and founding director of the Connecticut Area Health Education Center, discusses how students serve the needs of today while training to become the providers who serve the needs of tomorrow.

(Dr. Bruce Gould, Chris DeFrancesco, September 2022)

Transcript

Chris: Will we have enough primary care physicians to meet demand? Do we now? Today on the Pulse, we take a look at how we are preparing the next generation of primary care providers.

This is the UConn Health Pulse, a podcast to help you get to know UConn Health and its people a little better, and hopefully leave you with some health information you’ll find useful. I’m Chris DeFrancesco. Now we’ve been hearing about an upcoming primary care physician shortage for years. Some might say we’re already there. But what is UConn Health, which exists in part to produce physicians — a full range of clinical providers actually — what’s UConn Health doing to address this attrition? Today we have a man who’s been in the trenches with the trainees for decades. Dr. Bruce Gould, now UConn School of Medicine professor emeritus, founding associate dean for primary care, and founding director of the Connecticut Area Health Education Center.

Welcome Dr. Gould.

Dr. Gould: Thank you Chris for having me.

Chris: We brought you in because you have a body of work that gives you a terrific perspective on many aspects of primary care and, and training tomorrow’s physicians. Now, you retired from the full-time faculty in June, but are still very much involved, not only with the students, but in the city of Hartford.

So tell us first what retirement looks like for you, because I suspect you’re not exactly putting in a lot of time in the hammock.

Dr. Gould: Well, I do have more time on my hands. So I have been doing gardening and those types of things as well as spending more time with my family. But I am still the pro bono medical director for the Department of Health and Human Services in Hartford, Connecticut. I’m still the chief medical officer for the Community Health Center Association of Connecticut, the federally qualified health centers in the state. And I’m still out there working with our students doing screening in the inner city and in some rural areas, and then, basically doing whatever I’m called upon to do to try and increase access to care and screening and education for those that have the least access to those things.

Chris: Access to care is one of the things I wanted to cover with you today in addition to what we’re looking at for the outlook on primary care. So let’s start with the outlook on primary care. One of the challenges I think that you and I have talked about over the years is getting students to consider primary care, creating an environment that encourages or nurtures that choice. But there are some challenges associated with that.

Dr. Gould: Why does someone choose a certain career? It starts perhaps preconception, if not in the womb. We all get all sorts of inputs, et cetera, and clearly in our society in America, a lot of what you get over the airwaves, television, streaming, et cetera, is not necessarily primary care and public health. It’s more subspecialties, et cetera. And so often students come to us with a little bit more of a spin toward those subspecialties. In part, certainly as associate dean for primary care, and with my colleagues in primary care across UConn and then the community physicians that work with us in our curriculum, it’s to try and really put our best foot forward and give students that sense of primary care as the foundation of a functional health care system. There are lots of inputs that someone uses, and we all know that clearly the indebtedness of medical students and other health profession students as they embark on a career — Will they ever be able to pay back their loans? — primary care is remunerated, is paid — a primary care physician, clinician, PA, whatever it might be — at really a fraction of what a subspecialist might get.

And so that’s something that certainly the health care system seems to be slowly addressing with increasing, uh, salaries. But also, we can advocate, but it’s not something that necessarily we hear at UConn can single-handedly address. The other issues are role modeling and really giving students that global view of the role of primary care, and I really add public health, because as a primary care clinician, even if it’s just for my practice, I’m actually looking at outcomes of care, well-being, and really the public health, the public good, of the community that I serve. And so trying to both select students at the get-go that have more of a history or an interest in that view of health care delivery, but then also hopefully trying to continually improve our culture, our environment, making it more nurturing to any student and to having them pursue their own wants and desires and what will make them happy in the long run, is really what we should be aiming for here at UConn.

Chris: The student experience at the UConn School of Medicine — and dental medicine and nursing and social work and allied health and all the different aspects that UConn educates the next generation of people who are involved in delivering health care — it’s set up in such a way, a lot of it having to do with some of your involvement with the Connecticut AHEC and Urban Service Track and some of those other types of programs, to really expose these students to real-life patient care and dealing with some real-life aspects that might not necessarily show up in the traditional health care education, formal setting, but in the experience in the community and dealing with the underserved. So talk a little bit about the importance of that perspective when a student is making his or her way to becoming a physician.

Dr. Gould: I mean, from my view, and again, I have been really out of medical in medical school and then through probably for 47 years, so I have been around the block a few times. And one gets a sense of what is important to the overall well-being of populations and communities, and I think that’s what we’re really trying to impart to students, is a more global view of the role of a clinician, a physician, dentist, nurse, pharmacist, whatever it might be in trying to improve outcomes for all populations. And that’s our hope, I think, for our students. And the impact that we as faculty might have is that those students, wherever they may land, no matter whether it’s an affluent community, or a poor community in a community health center, wherever they are, they’re going to realize that if they scratch the surface, they’re going to find populations and subpopulations within those communities in which they’re living that have little or no access to care, and we’re hoping that we will have imparted the motivation to try and meet some of those needs.

Chris: What I especially recall from before the pandemic — you and I would cross past a number of years doing this — the migrant farm worker clinic, which was an example of finding a population that otherwise might not have access to basic care or preventive care, and also showing the different elements of delivery of care, not just a physician, but a physician and a nurse and a dentist, and the interprofessionality of it, which is another big thing in how we train students here.

Dr. Gould: AHEC has been an incredible opportunity and vehicle for me. We started the latest iteration in 1996, 97. It’s a pipeline program funded by the federal government, authorized by Congress in 1971, really focusing at first on rural populations in access and quality of care, and then expanding to urban. And we have a very robust system that evolved, again 96, 97, with the first grant that we received from the feds, and really is all about exposing students, whether it is junior high, high school, or up to health professions, and then even into practicing physicians, clinicians, social workers, et cetera, to both interprofessional team-based care as well as care of underserved populations. And we do a whole bunch of stuff. We have our Urban Service Track, where students from the schools of medicine, nursing, pharmacy, dental medicine, social work, and the Quinnipiac PA program all study and learn together, often in a retreat format, formally four retreats a year, focusing through the lens of different underserved populations, whether it’s HIV populations or elders or children or veterans, et cetera, about how to care for those populations.

We often invite in teams, primary care teams that are actually caring for those populations real time. The VA from West Haven brings its whole primary care team and veterans into work with our students, but it goes beyond that. They learn about it in those retreats, but then we sponsor about 80 events a year out in the community, whether it is migrant farm worker or whether, we were just Friday night in Keney Park with the Keney Park Sustainability Project Urban Ecology and Wellness Center doing screenings for diabetes, hypertension, education around, diet, et cetera, with those community groups. And then Saturday morning we were out doing door-to-door vaccination in Hartford with the Hartford Department of Health, actually going into the North End of Hartford cold knocking on doors and saying, “Hi, we’re here from the Health Department and we’re here to just answer any questions you might have about COVID. And by the way, are you vaccinated? Are you boosted?” And if somebody wasn’t, “What are your concerns about it? And if we’ve answered those concerns, might you be willing to be vaccinated? Because we have the vaccine with us right now.”

So we spent the morning actually vaccinating people on their doorsteps in the North End of Hartford, and that’s incredibly fulfilling. It’s role modeling. We had probably three physicians. We had a doctor of pharmacy, we had faculty from the school of nursing, et cetera. We had visiting nurses with us. It was an amazing interprofessional experience around health care delivery and outreach and we did a lot of talking and sort of huddling with the students so they wouldn’t walk away with just, “Oh, great, we went out and gave a bunch of shots,” but rather, “We understand the context of what is community,” that the community is not just who comes into your waiting room or your exam room, but the community is actually who lives in the total catchment that that practice might be serving going forward, wherever you land.

And that’s the message we hope they’re taking that no matter what they go into, whether it’s primary care or a subspecialty, whether it’s medicine or nursing or pharmacy or whatever, that their responsibility is not just to those sitting in front of them, paying them for that service, but for all the other members of the community that may never have access to care, to at least try to provide some of that access and to advocate for equity in our health care system.

Chris: That’s a great summary, Dr. Gould. I think anybody who has any doubt about the value that UConn Health delivers to the public that you really can’t measure, that you can’t quantify in terms of dollars. Maybe go back and listen to like the last three minutes of this conversation, because there’s no question of the value that anyone can objectively look at it in a way that you can’t measure with numbers. But it’s so important, and I congratulate you for the work that you’ve been doing in that. It’s fantastic.

Dr. Gould: It truly is a win-win-win-win, and I think one of the most incredible lessons to the students is to go out into neighborhoods in which they have never been, probably, and the response from folks answering their doors is it first surprise. “Who are you in white coats and stethoscopes at our doorstep at nine o’clock on a Saturday morning?” But also this heartfelt, and it really touched me, is that folks are just saying, “Gee, the fact that anyone cares,” that they’re surprised that the health department is physically there, that physicians and nurses and pharmacists on a Saturday morning are knocking on their doors to make sure they’re OK, is just such of a beginning of a relationship with the community that I think will bear fruit going forward.

Chris: Based on your experience in your multiple roles over the years, many of which you still currently hold, what kind of outlook do you have on the future of primary care medicine, just kind of globally?

Dr. Gould: I think it’s clear if one looks internationally that health care systems in the world where primary care is the broad base of their health care delivery system, and that all the other functions and subspecialties are sort of almost like a pyramid going forward and above that, tend to get much better outcomes. The U.S. health care system is really rated at the bottom of health care systems internationally amongst industrialized nations. And I think reforming our health care system, and it certainly is not something that I or UConn can do alone, but we’re working toward that to build a broader foundation of primary care for health care and public health delivery and then moving forward, making sure that everyone has access to that by looking at the economics and national health insurance or other ways of funding that, is really going to be primary to assuring that there’s access to care and really access to outcomes and well-being for everyone that lives in in the United States going forward.

Chris: We have covered quite a bit here with Dr. Bruce Gould, associate dean emeritus for primary care from the UConn School of Medicine, founding associate dean for primary care from the UConn School of Medicine, founding director of the Connecticut Area Health Education Center. We’re going to put the links of all the things that you heard Dr. Gould reference in the notes of the show, so you can click and learn more about them. But that is our time for today. Dr. Gould, thank you so much for joining us.

Dr. Gould: A real pleasure, Chris. Thank you for having me.

Chris: And for Dr. Bruce Gould. I’m Chris DeFrancesco. Thank you for listening to the UConn Health Pulse. Now be sure to subscribe so you can catch next time, and please share with a friend.