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Published September 23rd, 2015
Local Physician Leads Program to Tackle Family Medicine Doctor Shortage
Dr. Jeremy Fish Photo provided

The boon and blessing of President Obama's health care law has come with a cost in California. The expanding girth of the state's Covered California health exchange, record-setting Medi-Cal enrollments and young doctors with medical school debt as high as $250,000 have combined to expose a serious, partially predictable deficit: an extreme shortage of family medicine physicians.
A new Family Medicine Residency Program based at John Muir Health's Walnut Creek Outpatient Center aims to fill and fortify the gap for future generations. Led by Moraga resident and Program Director Dr. Jeremy Fish, the program will provide hands-on-learning for eight medical students starting July 2017. A similar-size class will be added each year: by 2019, there will be 24 students working alongside John Muir teaching doctors and University of California at San Francisco physicians. Treating insured, many of them underserved, vulnerable patients in the East Bay, the residents will access and learn from a newly-formed program patients have helped to design.
"The practice is being designed by leadership and patients on the team," Fish says. "They have a vote in how it's structured. Instead of just reacting, we're insuring the doctors are trained in non-traditional skills like patient safety, quality management, leadership and high reliability leading to communications that reduce errors."
Family medicine doctors are generalists, whose broad-spectrum knowledge allows them to treat people of any age and condition before referring patients to specialists as needed. During 20 years in the field, Fish has held multiple appointments, including 10 years as the Family Medicine Residency Director for Contra Costa County Health Services. The 51-year-old physician received his medical degree from UC Irvine and completed his residency at Contra Costa Regional Medical Center. He and his wife, Susan, are the parents of a 16-year-old son, a junior at Campolindo High School.
With more people gaining access to health care, Fish says the need for general practice services has swelled. Medi-Cal alone has grown by approximately 2.7 million patients since January 2014. The high volume of people presenting with multiple conditions are overwhelming hospitals and clinics. "They have heart disease, lung disease, diabetes and other things at the same time. That's the clearest place where family medicine can make a difference," says Fish.
A segment of the patient population also has mental and emotional health issues. Fish says family medicine physicians receive more communication skills training than specialists. "Openness to behavioral health challenges makes us great partners. Most medical research is of a single disease; it's less clear how to rap it up with complex care. Our added value is that we comfortably ride the bridges between multiple conditions."
At the same time, salaries for family medicine doctors are typically a third or less than salaries paid to specialists. Fish says a perceived lack of prestige for family physicians compounds the problem and is wide spread. He doesn't deny the stigma's power - if anything, it proves that the new residency program is critically important. The number of college graduates headed for general medicine programs in med school is down 15 percent, he says.
"It's common for people to say to those entering family medicine, 'You'll only end up wiping people's noses,' or, 'You're too smart; you should be a surgeon.' Specialists are thought to have more structured, predictable, lucrative lifestyles," says Fish.
If the new program is to attract students and retain doctors after they graduate, it will require more than the Bay Area's attractive amenities that include good schools, beautiful surroundings, active cultural offerings and the like. Robust structures, electronic records, a highly functional system and the ability to practice at the top of their capability are necessary to draw strong applicants and hold onto doctors. "Where you train predicts where you practice. You can draw a circle and if you get out to a 50-mile radius, you get about 50 percent retention," Fish says.
It might also require young doctors with a passion similar to Fish's, who grew up in Berkeley and whose family for a time was on welfare. "I had personal experience with the inhumanity of social welfare. My family also came from farmers, so pragmatism and idealism were part of my experience." Combined with a medical degree, the influences resulted in a philosophy about medical care. "Family medicine allows us to mold our practices to the community instead of asking the community to fit our specialties. It has a social justice flavor. I've spent my career working primarily in underserved, underinsured communities."
With several top family medical programs established in the Bay Area (Contra Costa Regional Medical Center in Martinez, approaching 40 years in operation and training roughly 40 students every year is one example), Fish says it's still not enough. "There are over 50 family medicine programs in the state already, but they may be only half of what is needed to cover all the Californians in need." Retirements and other attrition - let alone the booming number of patients in need - aren't entirely offset by shifting to nurse practitioners, online health care, or team-style health care centers that put multiple services in one office complex. With everyone playing catch up, Fish says residency programs are a vital part of the solution.


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