Q&A with Thomas F. Curtin, MD, Senior Vice President & Chief Medical Officer of Clinical Affairs for the National Association of Community Health Centers

By Laura Trude, HWIC Information Specialist

In the midst of the current and upcoming shortage of primary care providers, the number of community health centers is expected to double in the next five years. Health Workforce News had the opportunity to interview Dr. Tom Curtin about issues facing community health centers and initiatives such as the National Health Service Corps, long-distance learning, and selective admissions programs like the one used by A.T. Still University.

What are some of the major workforce challenges community health centers are currently facing?

With fewer young professionals thinking of going into primary care, and family medicine in particular, I think the main challenge we’re facing at this time is the threat to primary care as we know it. We have an older primary care workforce and many are starting to reach retirement age. This combination–fewer going into primary care and more looking at retiring–is probably the greatest environmental factor contributing to the shortage. However, if you add health care reform into that, health centers will be expected to serve 40 million people by the year 2015. We’re expected to basically double the clinical workforce while facing the two problems I mentioned in the beginning. This is going to be a challenge.

How are community health centers addressing these workforce issues?

We are trying to take a comprehensive approach, looking at both immediate, short- and long-term strategies, and operationalize that from the pipeline all the way through retirement. In order to do that, it will require that we transform our practices to use fewer physicians and more nurse practitioners or physician assistants. We have to leverage our relationship with schools so that they start admitting individuals who will go into primary care and support them as they move towards that education. We’re going to need to develop more learning opportunities utilizing distance learning. Those are the big areas.

To drill down, we work with other supporting groups on enhancing the pipeline to increase interest in primary care. That’s very difficult. It’s not our primary job, so we work with other groups like explorehealthcareers.org. The established schools are very slow to transform, so we have to influence the new schools. NACHC is looking at starting their own distance-learning program so that we would be able to have a career ladder for individuals in our health centers.

Residency is another issue. We have to continue looking at comprehensive graduate medical education reform. If the National Health Service Corps is supplying a significant part of our clinical workforce and we are now starting to do more health professional training, that means we need greater flexibility in the amount of time they can teach residents or medical students, whether they are scholars or loan repayors. Under the Affordable Care Act, up to 50% of their time can be spent teaching, but if they’re not in a teaching health center, which is defined as operating a residency, they can only spend 20% of their time teaching. We would like to see greater flexibility there.

Our health centers have to become more effective at recruiting. They need to use the National Health Service Corps more than they are at this time. Then, after we’ve recruited providers for our health centers, we would hope that the health centers would work to make themselves not only the medical home for patients, but the professional home for our providers with a modern work environment including electronic health records, modern facilities, etc. We have to develop strategies to offer more competitive salaries, as well. We must support our staff if we want to retain them through their retirement, so we are exploring the options available to us.

Can you give me some idea of what the distance-learning program with career ladders might look like?

We have some existing distance-learning programs which will allow an LPN to get a BSN. We’re hopeful about distance-learning programs where individuals, for the majority of the time, can stay in the community where they’ve been working at the health center. We’re hoping they would continue to work at the health center or return to work there after school and be able to get their clinical education at the health center. We have other schools we’re working with that take registered nurses, and through distance learning, help them become nurse practitioners.

Theoretically, we could have someone who is an LPN at a health center successfully matriculate through programs. That LPN could get her RN degree and practice for a while, and if she wanted to pursue further education, she could go back and get her nurse practitioner degree. We think that would be very beneficial to the individual, the community, and the health center.

The Affordable Care Act supports the development of teaching health centers. How might that impact the community health center workforce?

We have some regulatory and policy concerns around that piece. We have concerns related to the sponsoring institution and the amount of funding that they are initially proposing to pay per resident. But this is all still in a developmental stage, so nothing is final yet. We would like a preference for health centers in that funding, but the current interpretation of the legislation is that community health centers are not prioritized.

The health centers are concerned about what will happen after the five-year funding period. In our forty-plus year history, we’ve been doing service and now we’re expected by many to also be doing teaching. This is not an easy process for us, to transform ourselves in that way when the grant is only guaranteed for five years. It can be worrisome, like buying a house without knowing whether you will be able to make the mortgage payments.

Do you see teaching health centers as something that might be helpful in resolving the primary care crises?

I believe if we work together with the American Academy of Family Practice and the American Osteopathic Association and their different subgroups, we can design a residency for the future that will meet not only the needs of America, but reinforce why many people go into medicine. Many go into medicine saying, “I want to help the neediest people. I want to serve.” And yet, we see that being trained out of them while they’re in medical school and in their residency. If we can show them how a comprehensive system of primary care like a health center is a career option and provides the support that they need, then more people will go into primary care. If they utilize the National Health Service Corps and come work with the health center, this can create a situation where they’re not also burdened by debt. Many of these young people finish school with something like $150,000 in debt. They can now join the Corps and have most of that relieved over a six-year period of time.

Does the National Health Service Corps have any changes on the horizon?

The Corps has really improved in the last year in their marketing and their website; it is much more interactive and intuitive. They have also started to allow part-time loan repayment, which is very valuable. Certainly for many young professionals, when they get out of school, they are still in their child-bearing years. They want to get on with their career and start their family. Part-time has been something we wanted for a long time.

Are there any other National Association of Community Health Centers initiatives you would like to highlight?

NACHC has been in partnership with A.T. Still University for the past decade. They started a new dental school called ASDOH (Arizona School of Dentistry and Oral Health). The students do the majority of their clinical training in community health centers. The outcome of this education is that many of their students are going into general dentistry and working in underserved communities. We feel really happy with that model.

Building on that, we started SOMA, the School of Osteopathic Medicine in Arizona, with A.T. Still four years ago. It’s a medical school where students go to the campus for the first year, but do their second, third, and fourth years in community health centers around the nation. We won’t know the success of that program for about four or five more years, because we have to wait for the first class to graduate from their residencies, but we’re hopeful because we saw that sort of model work for the dental school.

What really helps feed the model is a NACHC program called Hometown Partnerships for Health. Hometown is an admissions program that A.T. Still University has for the dental and medical school which asks health centers to endorse an applicant by saying that they think this applicant is committed to primary care and caring for the underserved. This puts the applicant in a special admissions category, because this is who they are looking for as far as students. We keep hoping our health centers will help us identify people from their communities who aspire to be a doctor or dentist and see if we can’t facilitate the admissions process.

Is there anything else you would like to add?

I think health centers’ immediate need will be met primarily through the use of the National Health Service Corps. While we’re doing that as an immediate solution, we need to leverage our relationship with health professional schools to work with us to transform education to produce healers who want to go into primary care and care for the underserved. That will help meet our intermediate and our longer-term needs. Simultaneously, we feel we need to develop a career ladder for our health center staff exploring long-distance learning to help meet our future workforce needs.

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.