For Diana Perez, a physician at Family Health Center in Harlem, a handwritten thank-you note she received from a patient is all the evidence she needs that she’s chosen the right training path.
Perez helped the patient, a homeless West African immigrant who has HIV and other chronic conditions, get the medication and care he needed. He also filed the paperwork documenting his medical needs for the nonprofit that helped him apply for asylum and secure housing.
“I really like caring for the whole person,” said Perez, 31, who has worked at this New York health center for most of the past three years. “I wanted to learn and train, deal with the day-to-day things I would see as a primary care physician and really immerse myself in the community,” he said.
Few primary care residents receive such extensive community-based outpatient training. The vast majority spend most of their stay in hospitals. But Perez, who is trained through the Teaching Health Center Graduate Medical Education program, is among those treating patients at federally licensed health centers and community clinics in medically underserved rural and urban areas across the country. After graduation, these residents are more likely than hospital-trained graduates to stay and practice locally where they are often desperately needed, according to research.
Amid the long-term shift from inpatient to outpatient medical care, training primary care physicians in outpatient clinics rather than hospitals is a no-brainer, according to Robert Schiller, chief academic officer at the Family Health Institute, which administers the Harlem program. THC and operates dozens of other health centers in New York. “Care is brought to the community,” he said, and the THC program “creates a community-based learning environment, and the community is the classroom.”
But because the program, established under the Affordable Care Act of 2010, relies on congressional appropriations for funding, it typically faces financial uncertainty. Despite bipartisan support, it will run out of funds at the end of December unless lawmakers vote to replenish its coffers — no easy task in today’s divided Congress in which getting any kind of legislation passed has proven difficult. Faced with the prospect of not being able to cover three years of residency training, several of the 82 THC programs nationwide have recently put their residency training programs on hold or are phasing them out.
That’s what the DePaul Family and Community Medicine Residency Program did in New Orleans East, an area slow to recover after Hurricane Katrina in 2005. With a start-up grant from the federal Health Resources and Services Administration, the community health center hired staff for the program residency and was accredited last fall. They interviewed more than 50 medical students for residency positions and hoped to enroll the first class of four first-year residents in July. But with funding uncertain, they put the new program on hold this spring, a few weeks before “Race Day,” when residency programs and students are combined.
“It was incredibly frustrating for a lot of reasons,” said Coleman Pratt, director of the residency program, who was hired two years ago to start the initiative.
Until we know we have funding, we’re “treading water,” Pratt said.
“In order to have eligible applications on hand if Congress selects new multiyear funds, HRSA will issue a Funding Opportunity Notice in late summer for both new and expanded programs applying for funding in 2025, subject to availability credits,” Martin Cramer, a spokesman for HRSA, said in an email.
Currently, the Teaching Health Center program has $215 million to spend through 2024.
Instead, the Centers for Medicare & Medicaid Services paid hospitals $18 billion to provide training for primary care physicians and other specialties. Unlike THC funding, which must be appropriated by Congress, Medicare graduate medical education funding is guaranteed as a federal entitlement program.
Trying to maintain THC’s three-year residency programs when congressional funding hits and kicks in puts a heavy burden on facilities trying to participate. These pressures are now reaching extremes.
“The precariousness of funding is an issue,” Schiller said, noting that the Family Health Institute put its own plans for a new THC in Brooklyn on hold this year.
The misalignment between the health care needs of the American population and the hospital medical training that most physicians receive is a long-recognized problem. A 2014 report by the National Academies Press noted that “although the GME system is producing more physicians, it has not produced an increasing proportion of physicians who choose to practice primary care, provide care to underserved populations, or locate in rural or other underserved areas. ».
The Teaching Health Center program has demonstrated success in these areas, with program graduates more likely to practice in medically underserved areas after graduation. According to a study that analyzed the practice patterns of family medicine graduates from traditional GME training programs versus those who participated in the THC program, nearly twice as many THC graduates were practicing in underserved areas three years after graduation, 35.2% versus 18.6 %. Additionally, THC graduates were significantly more likely to practice in rural areas, 17.9% versus 11.8%. They were also more likely to provide substance use treatment, behavioral health care, and outpatient gynecological care than graduates of regular GME programs.
But the lack of reliable, long-term funding is a barrier to the potential of the THC education model, advocates say. For 2024, the Biden administration had proposed three years of mandatory funding, totaling $841 million, to support more than 2,000 residents.
“HRSA is eager to fund new programs and more residents, which is why the President’s Budget has proposed multi-year increased funding for the Teaching Health Center program,” Kramer said in an email.
The American Hospital Association supports expanding the THC program “to help address general workforce challenges,” spokeswoman Sharon Cohen said in an email.
The program is for residents interested in seeking primary and community care in underserved areas.
“There is definitely a selection bias in who picks them [THC] programs,” said Candice Chen, associate professor of health policy and management at George Washington University.
Hospital primary care programs, for example, routinely fail to fill primary care residency slots on game day. But in the THC program, “every year, all the slots fit,” said Cristine Serrano, executive director of the American Association of Teaching Health Centers. On Match Day in March, more than 19,000 primary care places were available. about 300 of these were THC sites.
Amanda Fernandez, 30, has always wanted to work with medically underserved patients. She did her family medicine training at a THC in Hendersonville, North Carolina. She liked it so much that after graduating last year, the Miami native took a job in Sylva, about 60 miles away.
Her mostly rural patients are used to feeling like a stopover for doctors, who often flee to larger metro areas after a few years. But she and her husband, a doctor who works at the nearby Cherokee Indian Hospital, bought a house and plan to stay.
“That’s why I loved the THC model,” Fernandez said. “You end up practicing in a community similar to the one you were trained in.”
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