Residents Can Attest to Demand for FPs
I recently served as a panelist during National Primary Care Week activities at my alma mater, Marshall University's Joan C. Edwards School of Medicine. During our session, one of the medical school students asked me how family medicine might change in light of more mid-levels providing primary care. Specifically, the student wanted to know if demand for family physicians might fizzle.
Family physicians are in demand more than any other
specialty and have been for seven years running, according to Merritt Hawkins. The health care search and consulting firm
said in a report last month that the growing demand for family physicians stems
from the need for employed FPs in hospitals and health care systems.
The number of medical students choosing family medicine increased for the fourth straight year in the 2013 National Resident Matching Program, and more U.S. seniors matched to family medicine than in any year since 2002.
Despite those positive signs, the supply of family physicians is nowhere near balanced with the demand. Researchers estimate that the country needs 52,000 more primary care physicians by 2025.
The fact that family physicians are in demand should come as no surprise to family medicine residents. I receive solicitations daily from recruiters, despite the fact that I'm not looking for a job. I signed a contract more than a year ago for a position that will start in August 2014. Most residents don't sign that early, but I found exactly the kind of practice I wanted to join. The federally qualified health center is a patient-centered medical home with a physician friendly electronic health record. Its reimbursement model includes per-member, per-month fees.
The practice is continually pursuing, and receiving, innovation grants and trying new things, so I'm happy with my choice. I'm not circulating my resume. I don't even have a LinkedIn account. And yet, the calls, e-mails and snail mail keep coming at home and at work every day.
One of my fellow third-year residents -- who is looking for a family medicine job -- said she receives more than a dozen e-mails a day from recruiters.
So what did I tell that student during our panel discussion?
I said that nurse practitioners often specialize, so they can't necessarily improve access to primary care in areas of need.
I said family physicians should work to appropriately incorporate mid-levels into our practices because they can play a vital role on our health care teams.
And, I pointed out that many patients prefer to see a physician, and some will switch practices if they don't think they have proper access to their doctor.
We are in demand by patients and employers, and that isn't likely to change.
Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.
National Event Can Open Students' Eyes to What Primary Care Is Really About
I came to medical school knowing that I would become a family physician. That goal was driven, in part, by the diversity and complexity of the work family physicians do, caring for patients from birth to end of life. I want to take that comprehensive approach back to rural Alabama, where I'm from, and family medicine is the specialty that allows me to do that.
The choice isn't as clear for many medical students, who often aren't exposed to primary care in their first two years because family medicine and other primary care faculty are underrepresented in most medical schools during the preclinical years.
So, how do we get students more -- and earlier -- exposure to primary care and family medicine?
Next week offers one opportunity to
do just that. National Primary Care Week will be
celebrated at medical school campuses around the country Oct. 7-11, giving
students an opportunity to learn about, and experience, primary care. It's also an opportunity to highlight primary care physicians in leadership positions. For example, family physician and State Health Commissioner Cynthia Romero, M.D. -- pictured here with family medicine interest group leader Penelope Carter -- was the keynote speaker at the University of Virginia School of Medicine's Primary Care Week last month. (UVA celebrated a bit early).
During my second year at the University of Alabama, Birmingham, I was responsible for planning National Primary Care Week activities on our campus. Each day, we brought in a speaker from a different primary care specialty -- family medicine, internal medicine, OB/Gyn and pediatrics -- who talked about why primary care is the foundation of patient-centered care and how each specialty plays an important role.
There is a myth perpetuated in some academic settings that family physicians treat coughs and colds and refer everything else, but family physicians do so much more than most students realize. It's a powerful experience to have a physician from the community come to campus and describe a typical day in practice, which could include seeing patients in clinic, making hospital rounds, doing procedures, delivering babies and practicing broad-scope primary care.
Although I knew about that extensive scope of practice early on, I had numerous students come to me throughout the week, saying, "I didn't know this about family medicine," or, "I didn't know that about internal medicine."
The upcoming nationwide event has the potential to open students' eyes to what primary care really is about and what it looks like outside of an academic medical center.
So what's on tap for this year's National Primary Care Week? We've heard from family medicine interest groups around the country, and some obvious themes stand out. Students want more information about health care reform, and several schools are featuring speakers or panels that will look at how the Patient Protection and Affordable Care Act will affect primary care. Academy resources available for National Primary Care Week include a PowerPoint presentation with facts and analysis of the Affordable Care Act.
The AAFP also has presentation materials designed to educate students about the patient-centered medical home, which is another common topic for National Primary Care Week activities.
Team-based care and interdisciplinary panels also appear to be popular choices. Other intriguing offerings include residency fairs, flu-shot clinics and clinical skills workshops.
I encourage my fellow medical students to seek out activities on your campus during National Primary Care Week (and bring a friend) and throughout the year. Your colleagues have worked hard to design programming that will give you key insights and understanding you will need to make an informed specialty choice within the next few years. Regardless of whether you choose family medicine like me, we're all going to be working together in an evolving health care system characterized by an increasing demand for family physicians to carry us to better patient health outcomes, better patient experience of care and lower health care costs.
So, what is your medical school doing?
Tate Hinkle is the student member of the AAFP Board of Directors.
COGME Report Puts Family Medicine on Priority List
In family medicine, we've known for years that the United States isn't getting the proper return for its $13 billion annual investment in graduate medical education. Federal funds paid to hospitals for training purposes too often result in the expansion of the subspecialty residencies hospitals need to maximize their own bottom lines -- cardiologists, radiologists and a slew of other "ologists" -- instead of producing the balanced workforce our health care system actually needs.
If legislators haven't already heard this message from the AAFP, the Council on Graduate Medical Education (COGME) -- which was created by Congress to provide assessments of physician workforce trends and training issues -- has recently spelled it out for them again.
Three years ago, COGME released a report that highlighted the worsening shortage of primary care physicians and recommended addressing the shortage by narrowing the gap in incomes between primary care physicians and subspecialists and reforming medical education.
In a new report released last month, the physician-led panel continued its call for more primary care physicians. In doing so, COGME was critical of Congress for underinvesting in GME. It also took aim at teaching hospitals for not emphasizing primary care and offering curriculum that was inadequate in related areas, including population health, care coordination and team-based care. COGME also questioned why national accrediting organizations have not taken the lead in bringing about these necessary changes.
There are numerous recommendations in the 28-page report, and we will have a more detailed report this week in AAFP News Now. But here are a few highlights:
- COGME recommends that Congress should continue funding existing GME positions and increase funding to support 3,000 more graduates per year.
- The report recommends that overall GME funding be prioritized based on workforce needs, specifically calling for family medicine and other "high priority specialties" and for programs whose graduates go on to practice in underserved areas.
- The report also recommends that any increases in GME funding should be directed toward training programs that produce a high proportion of physicians who continue in one of the prioritized specialties, which also include geriatrics, general internal medicine, general surgery, pediatric subspecialists and psychiatry.
COGME's recommendations are well timed. The Institute of Medicine is expected to release a review of the governance and financing of GME early next year. That report, which was requested by Congress, should prompt legislative reform.
The need is clear. Despite the fact that more than half of patient visits are for primary care, only 7 percent of U.S. medical school graduates are choosing careers in primary care. A study published last year in the Annals of Family Medicine stated that the United States will need more than 50,000 additional primary care physicians by 2025 -- 33,000 to account for population growth, 10,000 to accommodate an aging population and more than 8,000 just to care for people who will be newly insured because of health care reform.
Additional residency positions also are needed to keep pace with number of new medical schools and expanding medical school class sizes. In fact, by 2016, the United States likely will have more medical school graduates than residency slots!
Tax payers are investing billions of dollars each year in physician training as a public good. For this level of investment, shouldn't we expect a physician workforce that meets our country's needs?
Jeff Cain, M.D., is President of the AAFP.
Medical Students Need Washington to Do More
As a recent medical school grad, I spend a great deal of time thinking about my educational debt. I owe $234,000 (and the total is increasing even as I write this). There are many ways I can pay off this debt: National Health Service Corps (NHSC), Public Service Loan Forgiveness, arrangements with future employers, escaping to Mexico, etc.
what about those who are unable to secure a NHSC slot or a job that qualifies for
loan forgiveness? For many students considering careers in medicine, the high
cost will be a burden or even a barrier.
The Student Loan Certainty Act cleared the House and Senate last month, and President Obama signed it into law Aug. 9. The Academy supported the legislation because interest rates on federally subsidized student loans had doubled from 3.4 percent to 6.8 percent on July 1. The new legislation ties undergraduate and graduate loan rates to U.S. Treasury notes and retroactively lowers them -- for now -- to 3.86 percent and 5.4 percent, respectively.
The new law, however, isn't perfect, which is why the AAFP is continuing to advocate for related measures. Specifically, the Academy is asking lawmakers to
- expand funding for federal loan programs targeted to support family medicine and primary care,
- allow deferment of interest and principal payments on medical student loans until after completion of postgraduate training, and
- grant tax-deductibility for interest on principal payment for such loans.
The potential problem with the law is that federally subsidized student loans now will be tied to 10-year U.S. Treasury notes. If bond rates rise, so will the interest rates on this type of loan, which accounts for roughly one-fourth of federal student loans.
The rates are capped at 8.25 percent and 9.5 percent for undergraduates and graduates, respectively, but those potential rates would be significantly higher than current rates and could make education more expensive and more unattainable for some low- and middle-income students.
That scenario could present a problem for our already unbalanced workforce because we know that students with lower income expectations are more likely to choose family medicine as a specialty. Today, our workforce stands at roughly 70 percent subspecialists and 30 percent primary care physicians. What will the workforce ratio be in the future if interest rates approach double figures, making the cost of education an even bigger hurdle?
Three-fourths of medical students come from the top two quintiles of parental income.
Without scholarships, low- and middle-income families disproportionately feel the hit of tuition. A 2002 study from the U.S. Department of Education found that high-achieving, low-income students were five times less likely than high-achieving, wealthy students to enter college in their first two years after high school.
I was fortunate enough to earn a full-tuition scholarship to Saint Louis University as an undergraduate. Without that scholarship, there is no way I could have afforded the $36,000 annual tuition. My parents did not earn the "big bucks." My mom is a speech pathologist and my dad is an economics professor at a community college. The scholarship award was much needed.
So what's the bottom line for family medicine? A 2009 study by the Robert Graham Center evaluated what influences specialty choices and found that as long as debt did not exceed $250,000, students were not deterred from a family medicine career. What we don't know, however, is how many students who are interested in primary care careers are deterred from even entering medical school because of the high cost.
Exposure to the NHSC was one of the strongest predictors of careers in family medicine in the Graham Center study. I know several students who have no medical student debt because of the NHSC's Students to Service Loan Repayment Program, which provides assistance to fourth-year medical students dedicated to working in areas with physician shortages.
It's worth noting that the Academy has a Web page devoted to debt management. As for me, I will enroll in the Public Service Loan Forgiveness program. As long as I work at a nonprofit organization, my loans will be forgiven after I make 10 years of qualifying monthly payments -- if the program is not discontinued, that is. Signed into law in 2007, this program soon will start to see its first wave of enrollees apply for loan forgiveness. My fear is that the program could be discontinued before I have the chance to apply, and then, since I was able to enroll in a discounted payment plan, I will have significantly more interest to pay. I feel very uncertain going forward.
And if I'm feeling uncertain, what are students from low-income families experiencing? When parents discuss undergraduate and medical school debt burden with their children, what are the results of those dinner table conversations?
Lowering the interest rates on student loans, at least temporarily, was a first step, but more work is needed to create a physician workforce that is diversified and represents the population. The time is now to let your voice be heard. Talk to your House and Senate representatives about the importance of a strong primary care workforce. Talk to them about how education should be valued just as much as a home purchase. I encourage you to act.
Aaron Meyer, M.D., is the student member of the AAFP Board of Directors.
From Classroom to Med School and Back: Why I Love Teaching
I recently started a job that combines two things that I love: teaching and medicine. Although I've known for a long time what I wanted to do, it took me a while to get here.
More than 13 years ago, I decided to leave graduate
school at the University of North Carolina to pursue admission to medical
school. At the time, I was three months into a master's degree in linguistics
when I realized pursuing my doctorate in the field just wasn't for me. Although
I needed the opportunity that graduate school had afforded me to be analytical
and thoughtful, I didn’t see myself sitting in an office pouring over
transcriptions of computer-mediated communication (i.e., Internet chat -- the
topic of my master's thesis) for the rest of my life.
I was ready to turn around and head back to Kentucky when my mother, in that way that parents do, mentioned that medical schools might be less likely to admit a student who already bailed out of graduate school.
Best advice ever. Not because I loved linguistics, which I did, but because it made me stay at UNC. During my second year there, I became a teacher, and it changed my perspective completely.
The first time I stood in a class of my own, in front of 22 college freshmen, I sweated bullets. I felt insanely underqualified and unprepared despite hundreds of hours of education pedagogy and at least three weeks of completed lesson plans. Considering that I was teaching English composition, one of the classically hated requirements of college, the great triumph of that first day was capturing the attention of every student by correctly identifying that the Nigerian student in my class spoke Yoruba.
I loved spending that first semester learning to disseminate information, but also being a part of the development of my students' lives.
After realizing that my teaching style really could include me sitting on a desk in the front of the room, answering students' cell phones that rang during my lecture and confiscating anything that didn't explicitly pertain to that day's subject matter, I never questioned that teaching is where I belong.
But I did question what I should be teaching.
I started medical school, four years after finishing that master's degree, knowing that I would graduate looking to return to education. So, this past year, when the job search was finally upon me, I looked exclusively for academic jobs.
I had been bombarded by countless job solicitations beginning in my first year of residency promising no call, no weekends, no OB, no inpatient, exotic parts of the country, the possibility of loan repayment. And, believe me, a future of no late-night awakenings and uninterrupted Saturdays had a certain appeal, but by the end of residency, I loved the hospital, labor and delivery, late nights, early mornings and the satisfaction of the breadth of what I can do.
The search began late for me; it was November before I started looking and March before I interviewed anywhere in person. I know many residents who did substantially more interviews than I did, who cultivated contacts for years, keeping up with hometown doctors who might be their ticket to a perfect job. I went to three in-person interviews, having done a few more phone interviews, but I knew I was not the right match for those places. I found two really wonderful job possibilities in interesting places, both very different from Milwaukee where I had been living.
I'm excited to start anew, finished with medical school and residency (and any other degree programs for a while!) as an assistant professor in the Department of Family Medicine at the University of Kansas School of Medicine. I’m excited to be able to continue in as full a spectrum of practice as I can and to teach and learn from medical students and residents.
Sometime close to the end of my intern year, I was contacted through Facebook by a young man who had been in one of the last English classes I taught. He wanted to tell me that he had decided to become an English teacher based, at least in some part, on his experience in my course. He added that he was still in contact with many of those classmates and that during a number of years of discussion, they all felt that my classroom had become a community. That conversation, and the hope that someday I might be honored with another like it, is why I continue to teach, to help students find that community, whether in medicine, linguistics, or life.
Tully Marks, M.D., is the resident member of the AAFP
Board of Directors.
First-year Residents Set Expectations for Themselves
A new academic year started this month at family medicine residencies across the country. The new year means a new crop of first-year residents, who bring with them a great deal of energy, excitement and -- of course -- nervousness about their new roles.
As chair of the Department of Family and Community Medicine at the University of Nevada School of Medicine, Reno, I recently sat down with our new residents and asked them how they are adjusting.
It's worth noting that four of our seven interns are from Caribbean medical schools. I asked them if they felt any disadvantage compared to our American medical school graduates. They all said no and added that their rotations in U.S. hospitals had more than adequately prepared them.
Here is what they all had to say.
Q: Do you feel confident? Are you appropriately prepared for internship?
A: Meghan Ward, M.D.
I just feel pretty ready to start. I wouldn’t say that I'm overconfident, however, and I know that I have a lot to learn. I do feel that my training has prepared me well. I am sure there will be times when I feel inadequate, but I realize that this is a learning environment and there is a lot of support to make sure I am successful. I am up for the challenge.
Q: As you become an intern, it can be nerve racking. How would you rank your level of nervousness being an intern? Do you think this is a lot of responsibility to take on, or do you feel ready for it?
A: J. Kevin Daniels, M.D.
I'm pretty nervous about it just because being responsible for all these patients is a big deal, and you are doing it for real the first time. It will make you kind of nervous. I think that I'm ready for it because I feel that I'm well supported on the rotation. The senior residents and faculty are here and seem very willing to help and make sure I succeed. I'm not just out there by myself, so that makes me feel a little more confident.
Q: What have you learned so far that has taken you by surprise in the first two weeks of your internship?
A: Benjamin Hansen, M.D.
I think the most profound thing to me is that we understand that family medicine's emphasis is on treating the whole patient. Treating the social aspect of the disease -- not just the diseases themselves -- is important, but I never realized just how important that really is in terms of promoting wellness. People have a real desire to just have a conversation with you, to interact with you on a personal level. If you can get to understand people in that regard, they are little bit more passionate about taking care of themselves, a little more passionate about getting well. And I think that it promotes wellness a little more than antibiotics can do alone or whatever you are treating with.
Q: Internship takes a lot of time, and a lot of interns have trouble with time management and getting into their personal life with this year of heavy study. How do you plan on managing your time?
A: Umar Nasir, M.D.
First year is a huge transition from medical school to being a doctor, so it's basically a huge learning curve. The first priority should be learning new stuff and getting more comfortable with practicing family medicine. It can get difficult to manage your own personal life along with working; however, I think our first focus should be just learning medicine and becoming better. I think that you can have time for personal life; however, it all depends on individuals and how they manage time between their work and how efficient they are. I think it is different with everyone.
Q: When you start a new training program and you are thrown into a hospital where a lot of people are accustomed working together and you're the new kid on the block, sometimes people don't get treated the best. How do you feel like you're being treated?
A: Kyle Baron, M.D.
I think that I've been very fortunate since I've only so far been working on the pediatric floor. All the staff up there -- from the nurses, MAs (medical assistants) to the techs -- have been very helpful and incredibly friendly. There are times when you get ignored a little bit. What I found is a lot of times when they do not know who you are, they don't make the effort to figure out who you are. Sometimes they think you are just a medical student and were given a task, so they don't need to help you or talk to you or it might be some other similar situation. As soon as you make yourself known, introduce yourself to everyone and be polite with everybody, they will get to know who you are. What I have experienced so far is that everyone is very friendly and helpful, and they know we are all there for the same reason. Even though I wouldn't say they go out of their way, I have found that if you ask for help, they will give it. I have not experienced any situation where someone wasn't willing to give help.
Q: Why did you choose family medicine? Also, how do you balance internship and personal life?
A: Stephanie Reinhardt, M.D.
I chose family medicine mostly because of my experience at medical school. I just loved being able to see an adult patient with multiple chronic diseases, then pediatric kids that weren’t well and then going in and seeing a pregnant patient. I just loved the variety and being able to be good at a lot of little things. It's kind of what I envisioned doctors being when I was growing up, so it is kind of neat to have all the variety that we get in family medicine and all the prevention that we get to work with. I'm pretty passionate about preventing the long-term diseases that we treat, and I think that family medicine definitely does the best job with that over all the fields that I have seen. The first week is a little hard because we are working so much, but I've managed to always have dinners together at home every night. It is just something we do. My husband and I decided to make dinner together every night so we just have time together, and then we take the dogs for a walk. I think it's just making priorities. For me, my priority is medicine and my husband, so when I have free time, it's just where it goes. You have to have balance in your life.
Q: Are you happy you chose family medicine? How do you see that evolving during the next four years?
A: Satu Salonen, M.D.
I am happy that I chose family medicine. Well, I started on family medicine wards so I'm actually getting to see what family medicine really is. I like the fact that we see newborns, then we see pediatric patients, the obstetrical patients and then adults, so you really do get the whole scope of medicine, which is what I wanted. Hopefully, I will become more confident and comfortable. As you know, just as you're starting out, it can be a bit overwhelming trying to tackle all the different patients from newborns to adults and multiple different situations. I feel pretty good now. I have a great senior resident, who is helping me out a lot, and I see myself growing as I go along.
Daniel Spogen, M.D. , is a member of the AAFP Board of Directors.
Sharing My Dream -- and a Bathroom, a Kitchen and a Living Room
I recently had laser eye surgery, which means I no longer need glasses. Finally! It also should mean no more jokes comparing me to Harry Potter -- unless people visit my apartment.
Although J.K. Rowling's bespectacled boy wizard had a bed in a tiny room under the stairs, my new bedroom is in a tiny room above the stairs. To be exact, it's 6-by-10. The ceiling is so low, I can't stand up. But there is just enough room to lie down.
What about my room downstairs? That space features a desk and, well, that's it -- unless you count the closet.
Of course, there is more to my new home than just a bed and a desk. There also is a shared kitchen, shared living area and shared bathroom. If you're in the market for an apartment, my housemate -- a 60-year-old retired limo driver -- and I are looking for a third person to share our limited space.
Why would a young, single physician willingly pick
such a Spartan place?
Welcome to my life as a resident, complete with medical school debt. I plan to save as much money as possible during the next five years because that's how long it will take me to complete the combined family medicine and psychiatry residency at St. Vincent de Paul's Family Health Center, a medical clinic in a homeless shelter that is affiliated with the University of California, San Diego.
My new apartment will cost me only $600 a month -- less than half the price of a decent one-bedroom apartment in this coastal city.
As for the space under the stairs, that's where my bicycle will be stored when I'm not using it for the five-mile ride to work. The bike figures to get plenty of work since it's in better shape than my 1997 Honda Civic and costs a lot less to operate. The car -- following the 1,800-mile, six-state drive from St. Louis -- now has more than 114,000 miles on it.
The four-day trek -- interrupted by a family vacation in Denver -- just about finished off the Civic. The car overheated in the Nevada desert and had to be serviced before I could complete my journey.
After that, the Civic's temperature gauge stayed in the normal range. But, just to be safe, I was on the road each morning by 4 a.m. and stopped during the hottest part of the day. My modest goal was for the Civic to make it to San Diego.
Luckily, it held together, which allowed me to experience the joys of California traffic. (I already found out that driving in San Diego is nothing compared to driving in Los Angeles, though.)
So, why am I here? Last fall, I completed a four-week rotation at St. Vincent de Paul's. Although I interviewed with more than a dozen residency programs, I knew I wanted to return to San Diego. When I matched into St. Vincent de Paul's -- my first choice of residencies -- in March, I was thrilled.
After the long drive west, I finally arrived last Thursday. The first thing I did was head for the ocean, where I soaked my feet in the surf. Standing there in the wet sand, the change in scenery was striking. The beach and palm trees reminded me that I am a long way from home, and things are about to change in a big way.
Orientation at my residency begins next week, and I'll start training on our electronic health records system, receive instruction in emergency management and listen to pearls of wisdom from current residents. Clinical rotations start July 8.
My situation is an odd mix of purgatory and vacation. I am nervous, excited and eager for my new life to start. At the same time, I am trying to take in as much of my new city and have some fun while I can before I am expected to work 60 to 80 hours a week.
I have been to a production of Les Miserables, and I plan to visit Balboa Park soon. There will be opportunities to meet and build rapport with my fellow residents at social events. I already attended a hot yoga class with the outgoing chief resident. Never in my life have I sweated so much -- not even in an overheated car in the Nevada desert.
I've made it this far. I feel like I'm ready for whatever comes next.
Aaron Meyer, M.D., is the student member of the AAFP Board of Directors.
Family Medicine Wins … or Loses?
On the day before graduation at the University of Nevada School of Medicine, where I am Chairman of the Department of Family and Community Medicine, the school recognizes students who have performed well during an awards ceremony. The ceremony also offers an opportunity for students from both our Reno and Las Vegas campuses to recognize the faculty mentors who were important to them during their training through individual and departmental awards.
This year, I was honored to receive the Tow Humanism award and the Clinical Faculty Teacher of the Year award for Reno, while Kate Martin, M.D., assistant professor in family and community medicine, won the clinical teaching award for Las Vegas. Amanda Magrini, M.D., the chief resident in our family medicine residency, received the Resident Teacher of the Year award.
Not one clinical award was presented to a department other than family medicine, which also won Clinical Department of the Year awards for both Reno and Las Vegas.
You might think with this level of recognition that our family medicine program would be well on its way to recruiting more students into our specialty.
Not so fast. Only five of our 64 graduates this year chose family medicine.
Our country has recognized the need for more physicians -- specifically, primary care physicians -- and our medical schools have responded by increasing enrollments. In 2009, there were 15,638 U.S. medical school graduates who participated in the National Resident Matching Program. This year, that number increased by nearly 2,000 to 17,487, an increase of almost 12 percent.
Meanwhile, family medicine residency training programs increased the number of available slots by almost 300 (from 2,764 in 2012 to 3,062 in 2013). The number of U.S. graduates going into family medicine also increased compared with last year's figure, but only by 39.
That slight increase in U.S. graduates filling family medicine positions combined with the much larger increase in the number of U.S. graduates overall means that the percentage of U.S. graduates choosing family medicine actually went down, from 48.4 percent in 2012 to 44.9 percent in 2013.
The bottom line is that we have a need for more family physicians, and we have more available students to match to family medicine. And yet, a lower percentage of U.S. graduates are choosing our specialty.
Five years ago, 20 percent of Nevada graduates chose family medicine. Now we are down to 7 percent.
Obviously, there is a huge disconnect. Our family medicine program is being recognized for excellence in patient care and teaching, so why aren't more of our graduates choosing family medicine?
The Future of Family Medicine project pointed out two main reasons students don't choose family medicine: lifestyle and income.
Students perceive family doctors as always being available for patients, working late hours, taking frequent phone calls and having our personal lives interrupted by patient care issues in the middle of the night, on holidays and weekends. To address this issue, a more patient-centered approach with an emphasis on prevention in the office might improve our lives outside of it.
Income is an even bigger issue. The disparities in income between specialties can be huge, with several hundred thousand dollar differences between the average primary care physician income and that of certain subspecialists. Narrowing that gap is definitely on the Academy's agenda.
We are looking to create primary care-specific evaluation and management codes that support the increased complexity of the family physician encounter. In addition, we are advocating a CPT uplift for primary care physicians. As we move to a value-based system of payment, this should improve payment to primary care by paying for care coordination and population management of chronic disease.
In our department, we take exit surveys from our resident applicants who decide not to match our program. Three factors have emerged that touch on those issues of lifestyle and money: insufficient financial support for family medicine education, lack of an electronic health records (EHR) system and incomplete patient-centered medical home (PCMH) transformation.
The budget to support medical education in family medicine is lacking for both residents' and students' education. This shortfall relates to the income issue because our students see the faculty struggling to increase clinical revenue so they can carry out the mission of education.
We have not yet implemented our EHR, and our PCMH is in its infancy. There are plenty of data that show the practice environment and physician and patient satisfaction improve dramatically when technology is used and a practice transforms into a PCMH. We are working toward that goal.
So, what do we need to do, both at our local level and nationally, to attract more students into family medicine?
- Continue to be great role models and teachers in family medicine.
- Work to protect and increase graduate medical education funding so that students see that family medicine is valued.
- Continue to move forward with information technology and the PCMH, and work to improve practice environments.
- Move forward with the transition to a value-based system of payment. In the meantime, advocate that family physicians' income be increased and that the income gap between our specialty and others be closed.
Family physicians make great role models and teachers, but that isn't enough to encourage a sufficient number of students to go into family medicine. What else do you think could be done to draw more students to our specialty?
Daniel Spogen, M.D., is a member of the AAFP Board of Directors.
Duke Students Show Keen Interest in Family Medicine
I am always impressed with the passion of medical students and family medicine residents, and my recent trip to Duke University was no exception.
Duke's Family Medicine Interest Group (FMIG) invited me to be a speaker at their annual awards meeting in Durham, N.C. This created an opportunity for me to meet with the school's chair of community and family medicine, Lloyd Michener, M.D., (who recently made news for his work on integrating primary care and public health) and to spend some time with family medicine residents.
This trip, however, was primarily about students. There was a great deal of excitement and enthusiasm about this year’s Match and what it may mean for Duke's future. The school had four students match into family medicine residencies, including one who will be staying on at Duke.
Although four may not sound like a big number, it doubled last year's total and matched the school's highest number of students matching into family medicine residencies during the past six years. (For some perspective, Duke produced zero family medicine residents out of a class of 112 students in 2009.)
The students asked good questions about ways to stimulate interest in family medicine and invigorate their FMIG. We talked extensively about leadership opportunities at the AAFP's National Conference of Family Medicine Residents and Medical Students, which is scheduled for Aug. 1-3 in Kansas City, Mo., and how this can extend to students regardless of career choice. However, once students come and participate in this event, it is hard not to get excited about family medicine.
We also talked about ways of handling the usual challenges students face in family medicine. Even early in their careers, students are hearing the usual refrain of "You are too smart to go into family medicine" from their faculty and peers. This is a very real issue for our students, and it is difficult to withstand over time.
We talked about one way of reframing the situation, which is to recognize that family medicine is the largest specialty. Second, most folks who go into internal medicine, for example, subspecialize. Another way of looking at that choice would be to talk about becoming a limited practice specialist. This allows an opportunity for students interested in family medicine to say how they truly don't want to limit themselves. They want the excitement and the challenge of doing more than "just" being an orthopedist. And they could praise their peers who recognize that they need to limit their options by subspecializing. It is good to know one’s boundaries.
Most important, however, is a message that we all need to hear -- not just the students. What we have been doing for many years is critical to the creation of a true health care system in this country. It has been, and continues to, be difficult at times. People don't always understand what we do. However, for the first time, people in power are talking about primary care and the patient-centered medical home. Even if they don't fully understand what those terms mean, it is a start.
Winston Churchill once said, "You can always count on Americans to do the right thing -- after they've tried everything else." We are getting to the point where our country has tried everything else to create a health care system instead of a disease-management process.
Ultimately, what family physicians have been doing all along is what our country needs most. Now, people are finally turning to true primary care.
Reid Blackwelder, M.D., is president-elect, of the AAFP.
Primary Care Physician Shortage Requires Bold Action
If we build it, they will come.
For the first time in more than 100 years, a new medical school will open this summer in Indiana. Marian University's College of Osteopathic Medicine has a decided focus on primary care. The dean, the associate dean and two of the trustees -- including me -- are family physicians. We have taken a deliberate approach to screening, looking for students who not only have an interest in primary care but who also are interested in staying in the Hoosier State to practice medicine. We hope the new school will produce more than 90 primary care physicians per year, starting in 2017.
Student interest in the school has been encouraging. For the 150 spots available in Marian's first class, we received more than 3,200 applications.
This effort is an important step in addressing a glaring need. Indiana University's School of Medicine, the state's only med school (until now), boasts the nation's second-largest student body, but the school has not produced enough primary care doctors to meet demand.
That demand is going to increase dramatically in the near future as veteran physicians retire, the Patient Protection and Affordable Care Act expands access to health care and an aging baby boomer population becomes eligible for Medicare. By 2020, the state is expected to face a shortage of 2,000 primary care physicians.
Health care leaders in my state are well aware of the need, and opening a new med school is one strategy to address it.
Indiana isn't alone. The United States is facing a shortage of 45,000 primary care physicians by the year 2020. Marian is one of three osteopathic med schools opening this year, and more than a dozen new allopathic medical schools are in various stages of development.
Of course, it won't do much good to churn out more medical school graduates if we don't also increase the number of residency slots available. Although there are bills under consideration in Congress that would increase the number of Medicare-funded residency positions, there is no guarantee that such legislation will produce more family physicians.
Here in Indiana, we're taking steps to do just that.
Marian -- a small Catholic school in Indianapolis -- won't offer a residency program, but the new medical school has partnered with two hospital systems that do. St. Vincent Health is a network of 20 hospitals, and Community Health Network has eight. (I am the chief medical officer of the latter.)
Community Health Network has two family medicine residencies -- one allopathic and one osteopathic. We recently expanded our allopathic residency from seven slots per class to eight per class.
We also successfully applied and received CMS funding for 22 additional residency positions. We now must decide whether to expand our existing programs or develop a new residency program. Whichever way we decide to go, we need to act quickly before Marian's first class graduates in 2017.
It's becoming increasingly clear that it will take bold action and creative thinking to address the looming physician shortage. What is happening in your state?
Clif Knight, M.D., is a member of the AAFP Board of Directors.
Match Opens Door to New Challenges
It should have been easy, but it wasn't.
On Friday afternoon, I was sitting with my parents, who had driven 100 miles to watch me perform the simple, mundane task of opening an envelope. This, of course, was no ordinary piece of mail. The letter inside was the culmination of eight years of hard work and a lifetime of dreams.
This was The Match.
It took me less than 10 seconds to open that envelope, but it seemed much longer. I knew what I wanted, and I felt confident that I would get the result I had hoped for. But until you pull out that letter, there is uncertainty.
Where was I going? There were plenty of choices.
Last fall, I completed four-week rotations at clinics in Pennsylvania and California and interviewed at a dozen other residency programs in between (as well as another in Alaska).
The letter in the envelope held the answer and would influence my life and career for years to come. The entire day had been one big swell of emotion. I was exhausted, and it was only 2 p.m. when it was over.
I have wanted to be a doctor for as long as I can remember. It's not surprising considering the amount of time I spent around physicians during my childhood. I was born with a heart defect and had open heart surgery when I was 2. That led to annual visits with a cardiologist. I also was fortunate to have a great pediatrician.
So when I headed to Saint Louis University as a college freshman, I already knew I would become a doctor. The question was what kind.
The answer -- family medicine -- came during the year I spent working at the Nativity House, a homeless shelter in Tacoma, Wash. I also developed an interest in psychiatry while working at the U.S. Department of Veterans Affairs during my third year in medical school.
When it was time to look for a residency, my goal was to match into a program that combined family medicine and psychiatry. I found it in November during my rotation at St. Vincent de Paul's Family Health Center, a medical clinic in a homeless shelter that is affiliated with the University of California, San Diego.
It is a challenging, five-year program. And there were only two spots available. By the time Match Day rolled around, San Diego was my first choice.
When I opened my envelope and saw San Diego on the letter inside, it was a huge relief. This is the program that gives me the best opportunity to be the person and physician I hope to become.
I have less than two months of medical school left. I have a three-week rotation in rural family medicine in Illinois and then a two-week primary care course before my residency program starts in San Diego.
I'm excited for the transition. It is thrilling and terrifying at the same time.
Here I come.
Aaron Meyer is the student member of the AAFP Board of Directors.
Docs Seeking Strong Connection to Patients Could Find it in Rural Practice
I was sitting in a meeting in Austin, Texas, 90 miles from home, when one of my patients was injured by a piece of metal that blew off a roof. My nurse called and said that this older gentleman's head needed stitches. I asked her to refer him to the nearest emergency room, which is about 20 miles from my office.
"He says if you won't do it, he's going home," she said.
Such is life for a family physician in a small, rural community. Patients can be incredibly loyal, especially when you have been around for a while. I couldn't let that patient go home with a three-inch laceration on his head, so I drove the 90 miles home, treated him and drove back to my meeting.
Rural Texas, like many small towns and farming communities around our country, desperately needs primary care physicians, so I'm happy to precept six or seven medical students each year at my clinic in Castroville.
Most of them come from the University of Texas Health Science Center in San Antonio specifically because they want to experience rural practice. They see things here they likely would not in an urban or suburban primary care office because, by necessity, I do more urgent and emergent care than my big city peers.
I was the only primary care doc in town when I opened my clinic 27 years ago. Today, Castroville (population 3,000) has a county health clinic and an urgent care that is open on the weekends. But people still come to me with chest pain, strains, sprains, fractures and just about everything else a full scope practice could expect.
My nurse, Donna Winters, and I both grew up in this area, and I've known her since we were kids. Donna and my office manager, Cheryl Fournier, both have been with me for more than 25 years, and I suppose we've seen it all.
One day, Donna pulled me out of an exam room, although I was with a patient.
"Come with me right now," she said.
She led me to another exam room where a female patient was on the table writhing in pain.
"I have appendicitis!" the patient said.
Donna looked at me and shook her head.
"No, she doesn’t," she said.
The patient, in fact, was about to give birth. It was a breech delivery, but we managed it right there in the office, and both the mother and child did fine. That's not the way it would have happened on the third floor of a professional building in San Antonio, but you have to be prepared for anything in a small town.
One day, a man came in with a sack and said, "I've been bit by a snake. I killed it, and it's in this sack."
I told a staff member to put the sack in the nurse's station sink, and I went in to an exam room to look at the man's wound. I discerned that it was not a rattlesnake bite and went back to the nurse's station get a look at the snake. The sack, however, was now empty.
Like I said, prepare for everything.
When the medical students come here, I encourage them to consider rural practice. I tell them it can be a wonderful life experience, but I tell them the negatives as well as the positives.
In a town this small, you have to know that everyone is going to know your business. I've never had an unlisted home phone number. People don't abuse it, but they will call if they need something important. Occasionally, I have had people show up at my door.
If that level of connectedness makes you uncomfortable, small-town practice probably isn't for you.
I never have to ask medical students if they are going to practice in a town like mine. My patients do that for me.
"Are you going to do this?" they say. "We need docs in small towns."
I tell students that I love being a small town family physician. Hopefully, they will witness some of the moments that make me feel that way.
I recently lost a patient to esophageal cancer. When the chemo stopped working and things started to go badly, I worked with him and helped him make decisions about end-of-life care. After he passed, his widow asked me when I was planning to retire.
"I'm not," I said.
"Good," she said, "because when my time comes, I want you to do for me what you did for my husband."
When things like that happen, you go to bed at night thinking, "I'm doing the right thing."
I meant what I told that woman. I have no plans to retire. I see 30 to 40 patients a day. I hired a second physician several years ago, and together, we have more than 6,000 patients. I hope to grow the practice so that I can scale back my hours as age demands it, but as long as my mind and body are fit, I plan to keep doing what I love.
Hopefully, there will be someone to take my place when I can't do it any longer. Employed physicians account for 60 percent of the AAFP's membership, and less than 20 percent of our members are solo docs. Neither trend bodes well for our rural communities.
Before I opened my practice in 1985, seven banks turned down my request for a start-up loan. The eighth bank I visited made it possible to build and open a practice. Today, it's even more difficult for young physicians to get started.
But not impossible.
If a new physician interested in rural medicine could find one or two like-minded colleagues, the expenses, and risks, of starting a new practice could be shared.
If you can make it work, it's an amazing life.
Lloyd Van Winkle, M.D., is a member of the AAFP Board of Directors.
Preparing for Match Grueling but Rewarding
Sadly for us mere mortals here in the real world, there is no Harry Potter-style sorting hat to magically place every medical school graduate into the residency program that would be an ideal fit for both the resident and the program.
Instead, we have the Match.
So last week, I, along with more than 16,000 other fourth-year med students, started ranking my list of potential destinations. The questions we face seem endless, but here are a few of the big ones:
- What specialty will I select? (OK, I know the answer to that one, but some of my peers may still be struggling with it.)
- What region of the country will I live in? (And how is the weather there?)
- Who will train us and mentor us once we get there?
- What job options will I have when I'm through?
have until Feb. 20 to finalize our
lists, and then the system starts churning out potential iterations before
finally selecting the one with the most successful number of matches on March 15.
In the end, it's an algorithm -- not a hat -- that will determine how we are dispersed across the country. So it's up to the applicant to do as much homework -- or road work -- as possible before making those rankings. The average medical student interviews with 14 residency programs.
I spent the entire fall on the road, including a four-week rotation on the psychosis floor at Western Psychiatric Institute and Clinic in Pittsburgh and another at St. Vincent de Paul's Family Health Center, a medical clinic for the homeless in San Diego. (Here I am spending a day with residents from that center and its mobile medical clinic.)
In addition to those "auditions," I had 13 interviews in places such as Anchorage, Cincinnati, Denver and Seattle.
I want to work with homeless populations with coexisting physical and mental illness, so I interviewed with four of the five combined family medicine and psychiatry programs in the country. Each of these combined programs offers only two spots, and they each interview nearly two dozen candidates. No pressure.
And on top of that, I have primary care policy and advocacy interests. Sorting out how these family medicine and psychiatry programs compare to categorical family medicine and combined family medicine/preventive medicine programs was a challenge.
But it has been a great experience. Some of my interviews were spread over two days. That gave me time to feel out the programs, meet the residents, faculty and staff. It also gave me time to think about some more important questions, such as "Do I fit in?" and "Does this program fit me?"
That's really what it comes down to. My advice to younger medical students is to spend as much time as you can with residents outside the interview setting. Can you see yourself working and learning alongside these people?
Take time to evaluate where you belong. Reconnect with your mentors when you return to school and analyze what you saw. Who and what do you hope to be, and which program gives you the best chance to reach those goals?
Comparing residency programs isn't like comparing apples to apples. It's more like comparing apples to oranges AND bananas. There are so many innovations and training opportunities, it is an interesting time to pick your ideal residency program.
For example, a combined family medicine and psychiatry residency program I visited had its continuity clinic in a homeless shelter.
A P4 (Preparing the Personal Physician for Practice) family medicine residency provided time for interns to learn necessary skills and bond during month-long "chautauquas" and allowed second- and third-year residents a half a day a week to focus on their areas of interest.
Another P4 program, which has a combined family medicine/preventive medicine residency, had a focus on health policy and practice management, and some graduates move on to become medical directors at federally qualified health centers while others are involved in state and federal policy.
It was energizing to see innovative family medicine residency departments as well as so many impressive applicants excited to make a difference for patients and our healthcare system.
What other advice do I have for students who will go through this process next year and beyond? Enjoy it. Plan in extra time, if possible, and experience the cities you visit.
There were only four hours of daylight when I was visiting Alaska's Family Medicine Residency, but I managed to cram in some cross country skiing and a dog mushing excursion.
I was towed out of a snow bank by a farmer with a tractor while leaving Iowa City. (I couldn't pass up buying cheese curds in Kalona the day after a blizzard.)
I went sight-seeing in San Diego, including a trip to the Cabrillo National Monument (pictured here). I also stumbled upon -- completely by accident, I swear -- a game of nude beach volleyball.
You never know what you might find if you don't get out and look. Here's hoping you find what you're looking for in the Match.
Aaron Meyer is the student member of the AAFP Board of Directors.
Dedicated Medical Students Drawing Peers to Family Medicine
Each year, seven student leaders chosen from our network of Family Medicine Interest Groups (FMIGs) come to the AAFP's offices in Leawood, Kan., for orientation before beginning their new roles.
When our five FMIG regional coordinators, national FMIG coordinator and Student National Medical Association liaison to the AAFP met with Academy leaders and staff in January 2012, AAFP EVP Doug Henley, M.D., challenged them to boost student membership to 20,000. They delivered, helping boost our student membership by 3,500.
Dr. Henley raised the bar to 21,000 when seven new student leaders recently met in Leawood. The task of increasing student membership will become more difficult because a growing percentage of students already are members. To date, 20 percent of medical students have joined our ranks.
So how do the FMIGs grow student interest in family medicine? Each regional coordinator is responsible for keeping in touch with the more than two dozen medical schools in his or her region, as well as with FMIG student leaders on those campuses. They find out what those groups need help with and make sure they are aware of various opportunities, such as funding sources, scholarships and AAFP programs.
It's no coincidence that student attendance at the National Conference of Family Medicine Residents and Medical Students increased by 10 percent in 2012.
The work of the student leaders broadens the AAFP's scope and complements the work of staff members in the Academy's Medical Education Division, who work with FMIG faculty advisers on those same campuses.
A recent survey of those faculty advisers showed that interest in family medicine is increasing among students in 41 percent of FMIGs and is steady in 44 percent. Less than 4 percent reported declining interest.
There are at least 147 FMIGs at our nation's allopathic medical schools, up from 113 just five years ago. Also encouraging is that 10 of the AAFP's 11 target schools (those without a department of family medicine or those that have had a department of family medicine for less than three years) now have an FMIG.
I personally work with our local FMIG every year in Colorado by teaching students how to present Tar Wars, the AAFP's tobacco-free education program for fourth- and fifth-graders. Tar Wars is popular with med students and strengthens their interest in community health and family medicine.
I was able to meet with our national FMIG leaders, via Skype during their recent meeting n Leawood, and I was impressed by their energy, enthusiasm and commitment. They are (left to right in the photo above) Simon Tesfamariam, of Duke University School of Medicine, Student National Medical Association Liaison to the AAFP; Kristina Zimmerman, of The Commonwealth Medical College, FMIG Network Region 3 Coordinator; Catherine Louw, of the University of Washington School of Medicine, FMIG Network Region 1 Coordinator; Kenetra Hix, of the University of Tennessee Health Science Center, FMIG Network Region 5 Coordinator; Lauren Kendall, of the University of Illinois at Chicago, FMIG Network National Coordinator; Mustafa Alavi, also of the University of Illinois at Chicago, FMIG Network Region 2 Coordinator; and Mark Prats, of the Uniformed Services University of the Health Sciences, FMIG Network Region 4 Coordinator.
FMIGs are on the front line of our family medicine revolution. Good luck to you all.
Jeff Cain, M.D., is president of the AAFP.
Youth Need Minority Physicians to be Role Models, Mentors
“You can’t be what you can’t see.” -- Marie Wilson of the White House Project.
Wilson was speaking of women in leadership and our need for successful role models, but the statement holds true for young people of all races and both genders. In my years as a family physician and mentor, I have learned that minority children don't often see physicians who look like them.
Although African Americans account for more than 12 percent of the U.S. population, only 4 percent of our nation's doctors are black, according to the AMA. The numbers are similar for Hispanics, who account for 16.3 percent of the population and 5 percent of physicians.
The numbers are unlikely to change significantly any time soon. According to the Association of American Medical Colleges, African Americans and Hispanics accounted for 7 and 8 percent, respectively, of medical school applications last year.
For youth in underserved communities, including here in Chicago, exposure to the world of opportunities is critical to their future success. They need to know they have a broader range of career options that can include -- but not be limited to -- sports or media. They actually need to see the role models and mentors in the health professions who look like them and are providing services in our communities, particularly where there is such a great need.
At the University of Illinois at Chicago College of Medicine, our Urban Health Program offers a comprehensive program designed to expose local students to the medical profession. This program aims to attract historically underrepresented minority students to medical careers and encourage them to work in underserved areas as we strive to reduce health disparities in our state.
Health Career Opportunity Programs, funded by the Health Resources and Services Administration, have been established at high schools throughout Chicago to highlight professions in health and biomedical sciences.
The University of Illinois Early Outreach Program brings hundreds of junior high and high school students to campus on Saturdays. They are exposed to all of the health professional college programs (medicine, dentistry, nursing, pharmacy, public health and allied health), and those young people have opportunities to interact with medical students and residents and other health professional students.
The UIC College of Medicine Urban Health Program also co-hosts a medical career day each year for high school students with an interest in health sciences. This event includes labs, demonstrations, workshops and panel discussions with medical students.
Of course, that's just one example at one college/institution.
Last year in Sacramento, Calif., Sutter Health
Family Medicine Residency Program and the University of California-Davis Health
System Family Medicine Residency teamed up with the California AFP to produce
the Future Faces of Family Medicine
project, which brought family medicine residents together with 20 Sacramento
High School students -- many from socioeconomically disadvantaged backgrounds
-- who are interested in medical careers.
A four-month course on primary care included CPR certification, visiting a simulation lab, attending an obstetric delivery workshop, learning how to perform a physical exam and more.
The program is returning for a second year in Sacramento, and the CAFP plans to roll out the program to two additional cities this year. The CAFP hopes to have resources available for residency programs, including those in other states, available by the end of the year.
Meanwhile, a mentoring opportunity might come to you. The Tour for Diversity in Medicine recently made six stops at colleges in the South and Midwest. The tour, which is supported by the AAFP and others, is designed to promote medicine and dentistry to undergraduate students from underrepresented minority groups. Organizers recruited physicians from the local communities to serve on panels so that students could hear their stories, get their perspectives and be inspired by their achievements and the obstacles they have overcome.
But being a role model in any of our communities doesn't have to be as complicated as replicating a residency program initiative or joining a bus tour. Being a role model can be as simple as visiting our local schools, talking to students about what we do, the importance of academic success and what it takes to be a doctor, and letting them shadow us for a day.
Yes, it costs time. However, the return on investment is tremendous. We can and must do more.
The AMA has developed a program that encourages physicians to talk to children about careers in medicine. Doctors Back to School provides physicians with resources, including instructions on giving a presentation.
The AAFP, with the AMA's approval, is in the process of developing a similar program and resources specifically for primary care physicians.
Our communities need family physicians to be active role models. Tell your story. Make a difference!
Javette Orgain, M.D., M.P.H., is the vice speaker of the AAFP's Congress of Delegates.