Chair, UAMS Department of Family and Preventive Medicine

The shortage of family and primary care doctors in Arkansas has become an even more critical problem with 219,000 people added with the private option expansion of Medicaid in Arkansas, many of whom were without access to healthcare in the past. Addressing the need is going to take more equitable reimbursement for primary care, said Arkansas Academy of Family Physicians (AAFP) President Daniel Knight, MD, Garnett Chair and chair of the Department of Family and Preventive Medicine at the University of Arkansas for Medical Sciences (UAMS).

“With more primary care doctors needed in our system because of the Affordable Care Act (ACA), I hope to continue to promote family physicians getting more of what they need in the way of financial resources to adequately care for their patients,” Knight said. “It is problematic that Congress, Medicare and private payers have not been willing to fully support primary care to the extent that is needed to provide chronic and preventive care. Over the past two years, we have seen projects such as AR Medicaid Patient-Centered Medical Home Project and the Medicare Comprehensive Primary Care Initiative that have begun to do this, but it hasn’t been as universal as it needs to be.

“We will continue to try to increase the number of medical students choosing family medicine and family care as their specialty. It has been dropping since 1998 when the previous gatekeeper role was rejected.”

Knight said family doctors are now seeing patients who have been uninsured for years getting critical care for illnesses such as hypertension and diabetes control. But having services covered by insurance is of no value if patients can’t find a family doctor.

UAMS has seen a small, but significant, uptick in the past couple years in interest by medical students in family medicine, and a significant increase in the number of applications to family medicine residencies in the state. Knight said UAMS is also working with the two osteopathic medical schools in the state to increase the number of graduate medical slots, especially for primary care.

A large number of family doctors are nearing retirement age and will need to be replaced. That could increase primary care shortages from what they are today, which is estimated at greater than 500 statewide, with the problem especially acute in rural areas.

“Most rural areas have a lot of Medicare\Medicaid patients, so reimbursement is not as good as in urban areas where there are more people with commercial insurance,” Knight said. “Therefore, trying to keep a rural practice open is hard. There are many considerations for physicians locating in a rural area. Are the schools good? Are there enough things for the family to do? You have to consider the whole family, not just the physician.”

Knight said UAMS has not always had a focus on primary care. In the past, there has been more effort placed on tertiary care. But Knight said both at UAMS and nationally, there is increased recognition of the importance of primary care.

“UAMS is building several new family medicine clinics in Central Arkansas,” he said. “We are soon going to open another outlying clinic. We also want to affiliate with other providers throughout the state to be partners who can help make their practices grow and thrive. We can offer help with services for things like management and Electronic Health Records (EHRs).”

To help promote the Primary Care Medical Home (PCMH) initiative, the AAFP has been working with Community Care of North Carolina to help develop an organization in Arkansas to provide care management assistance to practices. The academy is also exploring how to improve working with Advanced Practice Nurses (APNs).

“We believe APNs are a very important part of the team who should be included,” Knight said. “We also believe APNs should be supervised by physicians. We want them to be in a team. A lot can be done with physicians supervising rural APNs virtually with telecommunications. But a barrier is that we are finding many APNs don’t want to practice in rural areas, either. They have the same issues as physicians.”

Knight came from a family with a lot of bankers, but he didn’t find business very fulfilling. He loves working with people, and has an aptitude for science. He felt like medicine was a merger of those two things.

“Medicine is very stimulating,” Knight said. “I originally chose family medicine because I liked the interactions with people in it and the variety in it.”

It was a long road to leadership in family medicine. He earlier worked in private practice and as an ER doctor. After being hired for a job at UAMS, he fell in love with academics even though he took the job at a time of challenges.

“We were in dire trouble the minute I walked in door,” he said. “I had to work hard to revamp some procedures. I got a big taste of leadership, and found I enjoyed it. That is what led me into the chair position.”

Knight said his management style initially was top down and domineering.

“Then I went to some leadership training and got feedback from my supervisors, and began to change my management style,” Knight said. “Now I feel that I am a very collaborative manager. People don’t work for me; they work with me. I have an idea of what needs to happen, but I let staff members use their skills and assets to be the best they can be. I think overall we are much more successful now with great overall leadership.”

UAMS is undergoing reorganization right now.

“It is a lot of change,” Knight said. “We are trying to come out with a system that is more patient-focused. We will be providing a large amount of care to a larger patient population. We have developed policies and procedures that flow across the enterprise improving access and services for patients. We have developed a patient portal for EHRs that has been a good thing for patient communication with providers.”

One of the accomplishments he is most proud of is taking on a research team when he became chair. That has grown to include five PhD/EdD full-time researchers and a staff of 40 doing research in early childhood development. “We hope to expand more into clinical research in the next few years,” Knight said.

Knight was born at St. Vincent’s in Little Rock, and loves traveling when he has the opportunity. In addition to statewide vacations, he has traveled to China, Peru, Africa, Australia and New Zealand.