Med Students, Schools Must Safeguard Peers' Mental Wellness
My friend was brilliant. He graduated valedictorian of his high-school class and was salutatorian of his undergraduate department. He had other gifts, too, including a phenomenal singing voice that would put Sam Smith to shame.
He also had bipolar disorder, which recently led him to take his own life.
For some students at our medical school, the news of his suicide was shocking. For those closer to him, it was almost understandable.
| Nearly one-fourth of medical students meet depression criteria.
Starting from day one, medical school students are constantly exposed to a host of new and stressful experiences. Support from family and friends can make a big difference, but this type of encouragement may be limited for those who are in a completely new environment far from home. Too often, we try to process these situations in isolation, or we may try to cope in potentially harmful ways, such as through excessive alcohol consumption.
According to a study on mental health in medical students published in JAMA: The Journal of the American Medical Association several years ago, 14 percent of students surveyed at the University of Michigan Medical School had moderate to severe depression, and another study suggested that nearly one-fourth of med students met depression criteria. More shocking, more than one in 10 students (11.2 percent) surveyed in a study assessing burnout reported experiencing suicidal ideation in the previous year. Third- and fourth-year medical students reported higher rates of suicidal ideation than did first- and second-year students.
Although medical students are at particular risk for experiencing mental health issues, we’re unlikely to seek help. One commonly cited reason is stigma. Earlier in our lives, we were somehow molded to react uncomfortably to topics such as depression, schizophrenia, substance use or suicide. Medical school culture then builds high expectations in which weakness is not accepted. Some of us think that disclosing a mental health condition would lead us to be viewed as incompetent.
Even when students decide to seek help, we face additional barriers. Oftentimes, our busy class or clinical rotation schedules prevent us from scheduling needed appointments. And even if we do have free time, getting an appointment with a therapist may take weeks, and it may be a few months before a psychiatrist is available.
Another friend battling depression sought help and found that the institution’s student mental health resources had a three-week wait. She decided to go to the emergency department that day to contract for safety.
Addressing student wellness has become a priority for medical schools. Initially, most schools focused on increasing access to post hoc, therapy-oriented services for individuals who develop mental disorders or significant distress. But in recent years, comprehensive wellness programs are increasingly being implemented to counteract or balance the negative experiences students may face.
My institution established a college advisory program modeled after Vanderbilt University School of Medicine’s wellness program. Students are divided into four colleges (similar to the Hogwarts houses in the Harry Potter books). Within each college, we are further divided into "molecules" of five students with one faculty member who advises us on wellness and provides career counseling throughout medical school.
We meet with our faculty advisers after each clinical rotation to reflect on experiences from the past eight weeks. The most recent discussion focused on personal growth. A third-year student tearfully spoke about the insecurities he faced on his first rotation. He thought he constantly disappointed his team because he hadn’t met clinical expectations. He didn’t realize the expectations of writing complete progress notes on every patient before rounds and providing sign-out to the night team were beyond the scope of a medical student. Furthermore, his team regularly criticized his oral presentations. Hearing fellow third- and fourth-year classmates relate to his experience and offer advice on future rotations seemed to comfort the student, but the fact remains that he should have been supported earlier in his clerkship.
Additional measures taken to improve student wellness have included a dramatic move from assigning grades (honors, high pass, pass, fail) to using a simple pass/fail system. During the preclinical years, most lecture days end by noon. This provides students time to pursue extracurricular activities that range from conducting research to playing intramural sports to visiting family.
Yet even with these changes in place, my classmate struggled with his mental illness. He refused to seek mental health services and attempted to self-medicate. Ultimately, his strongest support was a small group of classmates who, despite his initial resistance, constantly reached out to him during both his highs and his lows. When he first expressed suicidal ideation, our classmates brought him to the emergency department. When he had his first manic episode, those classmates called police for help. They went through so much with him, and now that he has passed, they are the ones left hurting. Their mental health cannot go unaddressed, nor can the mental health of my classmate’s family and loved ones.
This sad experience offers a strong reminder that we future physicians are not invincible. It is acceptable for us to show weakness and to seek help. After all, if we cannot care for ourselves, how can we care for our patients?
Tiffany Ho, M.P.H., is the student member of the AAFP Board of Directors.
Medical Students, We're Only Looking for the Best
For too long, medical students have heard from their mentors that they are "too smart" for primary care. Family medicine, they’re often told, is a solid safety choice, at best, if they fail to match into a residency program in the specialty they really want.
This misguided narrative, combined with the income gap between family physicians and our subspecialty colleagues, has fueled a worsening shortage of primary care physicians.
Photo courtesy of Pennsylvania AFP
Here I am with members of the Penn State University College of Medicine's family medicine interest group. I talked to medical students all over the country in the past year.
In my year as AAFP president-elect, I traveled the country to chapter meetings, media opportunities, Academy conferences and more. Wherever I went, I worked meetings with students into my schedule so I could give them my perspective on family medicine.
About one-fourth of the nation’s medical students are members of the AAFP, but that impressive statistic hasn’t translated into specialty choice often enough. I wanted to help students understand that family medicine is an exciting, viable career choice that will allow them to make a difference for patients and their families.
During a trip to North Carolina, I visited four medical schools in two days. I talked with students during chapter meetings in places like Arkansas, Kansas and Ohio. I would call med school faculty or chapter staff in advance and say, “I’m going to be in your area. Put me to work.”
Some meetings, however, happened on the fly. During the Family Medicine Congressional Conference in Washington, a family medicine interest group leader reached out and asked if I would come to his med school. So I made room in my schedule, he picked me up in his car, and off I went to spend my birthday with 40 medical students.
I was eager to share my insights about our specialty, but as our discussion got started it became clear to me that many of those students were disinterested and were there simply for a free lunch.
So I told them what I thought about using family medicine as a safety choice.
I said that if you aren’t passionate about your patients, we don’t want you in family medicine.
If you’re in medicine for the money, I said, we don’t want you.
If you won’t be an advocate for your patients, we don’t want you.
In short, I took the tale they’ve been told about family medicine and turned it on its ear. We want the best and brightest because family medicine is not a backup plan. This is a specialty for people who are willing to and capable of learning more than one body system and providing comprehensive care to entire families and, in some cases, entire communities. We deliver babies, provide end-of-life care and so much more in between, performing procedures, providing preventive care, managing chronic conditions and doing it all for both genders and all age groups.
We talked about the many opportunities in family medicine, highlighting that our members work not only in traditional family medicine practices but also in sports medicine, geriatrics, urgent care facilities, hospitals, academia and more.
I told them about my former resident Bruce Vanderhoff, M.D., a family physician who is a chief medical officer of OhioHealth, a system with more than a dozen hospitals, nine urgent cares, 30 rehabilitation centers and more than two dozen imaging centers.
I told them about family physicians like Richard Wender, M.D., the chief cancer control officer for the American Cancer Society, and about former Surgeon General Regina Benjamin, M.D.
Their stories resonate, and these students had never heard them before. We had a robust question-and-answer session, and by the end, even the students who had initially showed up only for the free food were engaged and asking questions.
In my trips to medical schools this year, I heard from students who thought family physicians earned less -- far less -- than $100,000 a year. They were pleasantly surprised when I directed them to a physician survey that showed family physicians earn, on average, more than $220,000 year. And family physician income is increasing at a faster rate than that of our subspecialty colleagues. We’re slowly closing the gap.
As the Health is Primary campaign is making clear, family physicians are the solution for what ails American health care. And we need many more of us.
Unfortunately, family physicians have a tendency to not toot our own horns -- even though we do much of the heavy lifting in our health care system. I appreciate humility, but it’s now my job to toot that horn -- or perhaps blare that horn -- not only to students but also to payers, legislators and federal agencies. People, students included, need to know what we do and why it’s important.
Wanda Filer, M.D., M.B.A., is president of the AAFP. Her term begins today.
Former 'Orphan' School Embraces Family Medicine to Drive Progress
When I was a student at Emory University School of Medicine, it was a so-called orphan school, meaning it did not have a family medicine department. In fact, I was one of the few students in my class who chose family medicine after graduation, but that is a story unto itself.
It was special, more than 30 years later, to be invited back to my alma mater recently to see what is happening in family medicine there and to be a part of the Atlanta school's new direction.
© 2015 Wilford Harewood/Emory UniversityAn Emory University medical student asks a question during a panel discussion about primary care. Emory launched its chapter of Primary Care Progress this month.
Emory recently launched a chapter of Primary Care Progress, an organization that seeks to not only promote primary care but also develop a new generation of leaders. My invitation to participate in a launch event came about, in part, because of the Academy's efforts to build student interest in family medicine. For example, during the recent AAFP National Conference of Family Medicine Residents and Medical Students, AAFP President-elect Wanda Filer, M.D., M.B.A., led a session about leadership in primary care with Andrew Morris-Singer, M.D., the president and founder of Primary Care Progress.
Reaching out to our students and residents and fostering relationships is vital to building our workforce pipeline. During National Conference, I happened to walk up to a group of students who turned out to be the contingency from Emory. These extremely passionate and engaging students were thrilled to be at the event and told me they were strongly considering family medicine residency.
It's also worth noting that Ambar Kulshreshtha, M.D., Ph.D. -- the resident representative to the AAFP's Commission on Quality and Practice -- was a chief resident at Emory last year and is now a member of the school's faculty. Our specialty is truly about family and relationships.
During my visit to Emory, I met many incredible folks dedicated to moving family medicine forward at this storied institution. I was introduced to an invigorated Department of Family and Preventive Medicine, and I spent a great deal of time with many in leadership who are involved with medical student and resident education. I gave a presentation about the patient-centered medical home that drew residents, faculty and staff, as well as some medical students. I was impressed by their energy and even more so by the demonstration of team-based care that was going on there. We had a chance to talk about steps for the future and finding practical approaches to tap into that energy.
I also participated in a panel discussion with primary care leaders from Emory. That event attracted more than 80 students. Immediately after the panel, I was able to give my "Practical Approach to Patient-Centered Medicine" talk. This was a fun and interactive opportunity to engage students about some things that they had not necessarily considered when they began their medical school path. The energy I felt afterward was inspiring.
Many students signed up immediately to receive more information about Primary Care Progress, and they already were talking to faculty about their interest in family medicine and what we do.
Overall, this was an awesome opportunity to talk about the opportunities that exist at Emory. I was able to emphasize team-based education within a large system that has many resources and ways of better integrating family medicine and primary care into the Emory health system. The school has everything in place to be an outstanding leader.
Perhaps one of the most important messages I tried to deliver is the power of cheerful persistence. Even though it was almost an aberrancy to find oneself in family medicine when I started at Emory, it has become an option that students are asking about proactively as they begin their training. I was excited and proud to see what was happening there.
In fact, my medical school classmate Chris Larsen, M.D., D.Phil., is now the school's dean. He attended the Primary Care Progress launch along with another classmate, Rick Agel, M.D. We reminisced about that special time we had together more than three decades ago when we each started on our journeys, and we reflected on where we find ourselves today, working to transform the health care system in this country.
It’s done one school at a time, one system at a time and one community at a time.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Students, Residents Show Their Passion for Family Medicine
You have to admire the passion and dedication that students and residents showed last week during the AAFP's National Conference of Family Medicine Residents and Medical Students.
That passion was evident in the debates about public health, education and other issues heard during the student and resident congresses. And it was evident in the expo hall where students, looking for the next stop in their training, met family medicine residency program representatives who made the case for why their programs stood out from the hundreds of other programs represented in that same expo hall.
But you also could see the passion and dedication simply in the lengths that some attendees made in getting to -- or trying to get to -- Kansas City, Mo.
Photo courtesy of Warren Yamashita
Warren Yamashita, a student at the University of Southern
California's Keck School of Medicine, presents his research poster at Los
Angeles International Airport after his flight was delayed. Yamashita was
bumped from three other flights and could not make it to the AAFP's National
Conference of Family Medicine Residents and Medical Students.
Take, for example, Courtney Hudson, D.O., M.B.A., a second-year resident at the Crozer-Keystone Family Medicine Residency Program in my home state of Pennsylvania. Courtney was participating in the new Family Medicine Leads Emerging Leader Institute, so she had to be in Kansas City early Wednesday morning. Her work schedule was jammed in the days before leaving. On Monday, she worked a cardiac outpatient clinic in the morning before moving on to the primary care outpatient clinic in the afternoon. She then worked the overnight shift -- with five admissions -- at the hospital before attending lectures Tuesday morning. Her 30-hour shift finally ended with a trek to the airport, and she made it into Kansas City late Tuesday night.
In addition to the Emerging Leader program, Courtney worked her residency program's booth in the expo hall and served as an alternate delegate in the National Congress of Family Medicine Residents. She made it home late Sunday night -- just hours before heading back to work on Monday.
I asked Courtney if the trip was worth the effort, and she said she wouldn't have traded it for anything. She also said that immersing yourself in the event is the best way to get the most out of it.
Poor Warren Yamashita wasn't as lucky. Warren, a student at the University of Southern California's Keck School of Medicine scheduled to present his research poster in the expo hall at the conference, saw his flight from Los Angeles delayed. He was subsequently bumped from three alternative flights and could not make it to Kansas City. Waiting overnight at the airport for the city's buses to resume running, Warren engaged in a long conversation with some airline employees and others about families, economics and health care.
Although Warren was unable to present his poster at National Conference, that didn't stop him from presenting it at 2 a.m. in the terminal at the Los Angeles airport. During the past two years at USC, Warren has worked to increase health care access by training interdisciplinary health professional students to act as insurance educators who provide consultations regarding Medi-Cal, Covered California and My Health LA to consumers at community health fairs. His poster chronicled those efforts.
Warren, who won a scholarship from the California AFP to attend the conference, asked AAFP staff to post an email about his experience and photos of his impromptu airport poster presentation because he wanted to contribute "to the spirit of the conference" even if he couldn't be there in person.
These are just two stories out of the thousands that could be told by students and residents who worked National Conference into their hectic clinic and lecture schedules. Total attendance last week was more than 4,200, and the event continues to grow each year.
I came to my first National Conference four years ago. I had just finished my first year of medical school, and although I was pretty sure family medicine was what I wanted to do, I told myself I was going to keep an open mind. Then I arrived at the convention center, and I was blown away by the atmosphere and inspired by the speakers. I felt connected, like I had found my people.
I keep coming back because the passion for family medicine that the students, residents and faculty share at this event is inspiring and energizing. Every year I take home something new because the conference's workshops -- and the issues debated in the congresses -- change to reflect the issues that are important to students and residents.
Warren said he hopes to make it to National Conference next summer.
Kristina Zimmerman, M.D., is the student member of the AAFP Board of Directors.
Helping Hands: Count on Colleagues' Support During Transitions
Summer marks some major transitions for medical students and residents. Medical school graduates take on the mantle of physicians as they transition to interns. Interns become upper-year residents. Residency graduates move on to practice or fellowship training. With each stage, we gain more knowledge and responsibility.
| Here are a dozen reasons I feel confident about making it through my first year of residency -- my co-interns.
This summer, I am facing the transition from medical student to doctor, while also making some other big life changes with my spouse. He is changing jobs, and we are moving, buying our first home and navigating our basset hound’s newfound separation anxiety. It is a lot to juggle.
It’s also a little scary, but more than that, it’s exciting. Although trading my short student white coat for a longer physician coat is a huge step -- and one not taken lightly -- I am ready.
Even before starting residency orientation, I knew a few things that have made me ready:
- I have been training to become a physician for nearly a decade.
- I can admit when I do not know something and need to learn more.
- I am passionate about my patients and family medicine.
- My mentors and family will help me when I need it, with both medical and personal wisdom.
Now that I have been in orientation for more than a week and have had opportunities to bond with my co-interns and some faculty members, I have found more things -- at least 39 more -- to help me survive my first year as a physician. These 39 include my residency team/family -- 12 co-interns and 27 upper-years.
I have already seen firsthand how my new residency family members help each other both inside and outside of work. At work, we have been there to aid our team members struggling with advance cardiac life support medication doses, and we worked together to solve complicated scenarios. At home, we have lent helping hands moving furniture and shared remedies for homesickness (for both humans and dogs).
I will start caring for my own patients on July 1, but I realize that even though I am taking on new roles and greater responsibility, I am not doing it all on my own. I have a great team and family to support me.
So if you are making a transition this summer, remember to stop and look around -- because none of us is alone.
Kristina Zimmerman, M.D., is the student member of the AAFP Board of Directors.
Fellowships Aim to Enhance FPs' Training, Not Limit Our Scope
In just a few short weeks, I will reach the end of my residency, a milestone seven years in the making. Around the country, thousands of newly minted family doctors will be entering the workforce. I, however, will not be one of them. Instead, I plan to further my training with a fellowship in obstetrics. And I am not alone. Each year, roughly 15 percent of graduating family medicine residents enter a fellowship.
Most family medicine residencies offer well-balanced training that will allow graduates to deliver comprehensive care. But some individuals, like me, want to build on that training based on our individual passions. Others may seek to fill perceived gaps in their training. Of course, fellowships are just one avenue to expand our training. Others include focused use of elective time and, in some cases, developing formal areas of concentration.
In recent years, however, I have heard some physicians raise concerns about the growing number of fellowships -- in behavioral health, geriatrics, obstetrics, rural medicine, sports medicine and more -- and the growing number of residents applying for those positions. Specifically, some wonder whether these fellowships pose a threat to the generalist aspect that makes family medicine the vital specialty that it is.
In fact, a recent study in the Annals of Family Medicine found that increasing a family physician's comprehensiveness of care was associated with decreased costs and fewer hospitalizations.
It's true that for specialties such as internal medicine and pediatrics, a fellowship in cardiology or endocrinology will narrow a physician's scope of practice to the specialty that physician chooses. It's also true that a decreasing number of family physicians are providing maternity care and caring for patients in hospitals.
We're told as medical students that family medicine will allow us to care for the whole individual, at every age, and for entire families from cradle to grave. That's my calling. I plan to practice full-scope family medicine and teach after fellowship.
In this way, family medicine fellowships are designed to enhance our training and broaden our scope, rather than limit it. Increased fellowship opportunities give graduating residents the extra training to feel comfortable practicing in the hospital or providing maternity care (as well as satisfying requirements of hospital credentialing committees). And although there are opportunities out there for family physicians who want to focus solely on sports medicine or geriatrics, the vast majority of those completing fellowships will continue to practice broad-scope family medicine. My practice won't be focused on maternity care, but I'll have a deeper knowledge and stronger skillset regarding that subject.
Fellowships themselves aren't the issue. It's how we use that education. Fellowships offer family medicine graduates the flexibility to further our education, augment training in areas of interest and shape our future practices. So although a significant number of family medicine graduates plan to pursue advanced education, most of us will continue to practice general family medicine, albeit with some degree of focus. And learning more can only be a good thing for our patients and our practices.
Andrew Lutzkanin, M.D., is the resident member of the AAFP Board of Directors.
Team-based Training Key to Providing Team-based Care
One of the core components in transforming a practice is team-based care, and this concept is a focus of many conversations when I visit our chapters across the country.
My employer, the Quillen College of Medicine at East Tennessee State University (ETSU), also has embraced this concept. And the outstanding group of interprofessional educators I work with are constantly looking for ways to enhance not only the way we provide team-based care, but also how we address the all-important process of teaching team-based care. Truly, to embrace, understand and implement team-based care, we have to have team-based education.
Photo courtesy American Pharmacists Association
Here I am speaking at the American Pharmacists Association's annual meeting. I gave a presentation about team-based care with Brian Cross, Pharm.D., who is vice chair of the Department of Pharmacy Practice in the Bill Gatton College of Pharmacy at East Tennessee State University.
During my time as an AAFP officer, I have been honored to speak to the boards of several organizations that represent our colleagues who play critical roles in providing team-based care, including the Association of Family Practice Physician Assistants, the American Academy of Physician Assistants, the American Association of Nurse Practitioners and the American Pharmacists Association (APhA). At each of these meetings, I have had a chance to thank each group for helping improve the care of our patients, and to consider ways to work through challenges to find creative ways of providing education.
There are many others who play important roles in team-based care, including social workers, behavioral health specialists and our county health departments, but today I want to focus on how we work -- and train -- with pharmacists.
Recently, I had the opportunity to work with my friend and colleague, Brian Cross, Pharm.D., who is vice chair of the Department of Pharmacy Practice in the Bill Gatton College of Pharmacy at ETSU, on a presentation about team-based care (login required) during the APhA's annual meeting.
We also co-teach several sessions with our medical students, pharmacy students and residents at ETSU. We start with a patient case that relates to considering and implementing evidence-based approaches to caring for patients with cardiovascular disease. We break our audience into small groups of junior medical students and second-year pharmacy students who then work through questions about patients to seek the best evidence about possible treatments and put them into practice. Then the groups defend their decisions in our discussions.
This particular educational activity is critical because during the same rotation, students, family medicine residents and the pharmacy team work together to coordinate post-hospitalization care in our transitions clinic. Students and residents take what they have learned from this and other sessions and apply it to patient care, and the results have led to dramatic improvements. For example, this clinic has helped reduce our readmission rate from 25 percent to 13 percent.
Almost every patient seen in this clinic has benefited from the true medication reconciliation that can occur when these students review the clinic medication list, the hospital list, the pharmacy list and what the patient brings into the appointment.
In addition, we have other opportunities in which our pharmacists and their team see our patients in the anticoagulation clinic. They don't work in isolation. Instead, they work directly with our residents and medical students. In addition, our social worker leads a group of medical students, pharmacy students and sometimes a resident to make home visits with our patients.
These examples demonstrate ways that learners from different professions are able to put theoretical educational processes from the classroom into direct actions that impact care.
Even if a school or community isn't blessed with a college of pharmacy, those of us in education still can reach out to our local pharmacies and find ways to involve some of their learners or employees in our educational process, which will help create better relationships. One of the keys to team-based care is having this kind of relationship-building at every level. And it is not just between health care professional and patient. It also is between each member of the team.
If you are not involved in academics, there is value in having discussions with the team members who work not only under your roof, but also with local pharmacists or health departments. Each member of this community-based team can talk about the kinds of patient care issues they see and how each might be able to contribute to improving care. Much of this can be done without specific contracts or organizational memos. The core principle is improving the care of our patients by working together.
It's worth noting that the Patient-Centered Primary Care Collaborative (PCPCC) published a report in December that looks at how seven different programs use interprofessional health training to deliver patient-centered care. The PCPCC also is offering a five-part podcast series on this concept.
Meanwhile, the Robert Wood Johnson Foundation offers a free resource related to improving care through team work. And the National Center for Interprofessional Practice and Education offers articles, presentations and other tools in its resource exchange.
Finally, the Academy will be offering a session Sept. 29 and Sept. 30 at the 2015 AAFP Family Medicine Experience (FMX) in Denver titled "Capitalizing on Team-Based Care to Improve Quality and Office Efficiency." Thomas Bodenheimer, M.D., and Berdi Safford, M.D., will be among the FMX panelists.
I am hopeful that some of these ideas resonate with you. None of us takes care of patients in isolation, so the first question to ask and answer is, "Who are the members of our teams?" The second step is to get everyone together and think about how we can impact education and patient care. Thanks for being a part of this critical process.
Reid Blackwelder, M.D., is Board chair of the AAFP.
Mismatch: Why the Disconnect Between Student Interest and Student Choice?
I matched into family medicine. The number of students matching into family medicine increased for the sixth year in a row. Now it's time to celebrate.
Or is it?
|My husband, Rob, helps me find the paper lantern containing my Match information. More than 3,000 students matched into family medicine last week as part of the 2015 National Resident Matching Program.|
Although the number of students matching into family medicine through the National Resident Matching Program increased again this year, the uptick was small, especially among U.S. medical school graduates.
This leaves many -- students and physicians alike -- asking, "What gives?" Everything we have been hearing points to increasing student interest in family medicine, so why aren't more students matching into the specialty?
First, it's true that student interest in family medicine is increasing. The AAFP has reached out to students in many ways, and student membership in the Academy has grown from 14,833 in 2010 to 26,900 today. Student attendance at AAFP's National Conference of Family Medicine Residents and Medical Students has increased substantially each of the past four years. And family medicine interest groups (FMIGs) also are reporting growth, with new groups being formed and interest in existing groups increasing. We even have FMIGs at schools that lack departments of family medicine.
And second, it's not a question of lack of demand. For eight consecutive years, family medicine has been the highest recruited medical specialty for physician employment.
So again we are left wondering, 'Why the disconnect?' The interest and the demand are there, so why doesn't the increase in our match rate reflect this?
Unfortunately, there's no single easy answer. Instead, we see interwoven barriers preventing a smooth translation from student interest into student choice of family medicine. The AAFP has for years investigated these barriers and worked to develop and execute plans to overcome them. That work continues, and there are ways you can help.
The issue of student debt has two components: the debt itself and overall physician payment, which affects students' ability to repay their debt. Many fourth-year medical students recently completed their exit loan counseling, and, after years of trying not to worry about the amount of debt they were accruing, they finally had to face it.
Loan amounts vary from student to student. I consider myself fortunate to be the recipient of a National Health Service Corps (NHSC) scholarship for part of my medical education. Yet even with the scholarship, my student loan debt is $172,000. This is a scary number for me, but not as scary as the mountain of debt some face. One of my colleagues, who also is going into family medicine, owes $410,000.
He applied for an NHSC scholarship during medical school, but there simply was not enough funding for all the students who applied. So yes, we still need to take a look at student debt and how to alleviate more of it, including through more scholarships and loan repayment programs, lower loan interest rates, ensuring public loan forgiveness programs remains intact, and more.
Equally important is physician payment reform. Students are worried their income will not cover their debt and the cost of living, let alone the expense of starting a practice. With a 21 percent Medicare payment cut set to go into effect on April 1 if Congress doesn't act to repeal the sustainable growth rate (SGR) formula, this topic has been center stage for practicing physicians and the AAFP in recent weeks. I urge you to reach out to your legislators and tell them to repeal the SGR.
Despite all the great work going into finding solutions for student debt and payment reform, students still worry these two massive issues are a long way from getting solved. These concerns can make them hesitant to choose family medicine, and this is where practicing family physicians can make an immediate and direct impact through mentoring.
For example, family physician Mark Goedecker, M.D., of York, Pa., has visited many medical schools, including mine, to share his family's story of overcoming substantial student debt. His main message is "You can afford to be a family physician." Of all our FMIG events in the past four years, Dr. Goedecker’s talk was the most well attended and the most inspirational.
But financial topics are not the only issues medical students want to hear about from residents and physicians. We want and need more family physician role models! We need to see your enthusiasm and passion for family medicine; we need to see family medicine's broad scope and its diversity of patients; we need to see you combating burnout; we need you to show us the way.
We can get some of this insight from conferences and meetings, especially National Conference, but you can help build and maintain student enthusiasm and passion for family medicine all year round. We want to see family doctors caring for kids; performing vasectomies; and doing prenatal care, palliative care, sports medicine and more. Show us, talk to us and teach us.
Showing us your passion for family medicine through mentorship also helps us understand the strength, value and importance of family medicine. Show us how primary care is delivered in teams, and that all members of the health care team, including our nurse practitioner and physician assistant colleagues, have a unique and valuable role in patient care. Help dispel the many myths and misperceptions about family medicine that students hear.
Imagine what would happen if some of these barriers to student choice were removed, and more students who would make phenomenal family doctors followed their passion to family medicine. It's what needs to happen to eliminate the primary care shortage and achieve our quadruple aim of better care, better health, lower costs and happier physicians.
Kristina Zimmerman is the student member of the AAFP Board of Directors.
The Envelope, Please: Waiting for Match Results
We are almost there, mere months from realizing a dream we have poured our hearts and souls into for years. Although thoughts of graduation are in the backs of our minds, something else remains at the forefront: the National Resident Matching Program (NRMP).
Match week activities start March 16 when we fourth-year allopathic medical students find out whether we have matched to a residency, and programs find out whether they have filled their positions. We won't know our specific results until March 20.
It's been a long and sometimes grueling process since Match registration opened six months ago. We have fretted over letters of recommendation, decisions about which residencies to apply to, travel and other expenses, interviews, and ranking our residency choices.
All this led up to officially submitting our rank order lists on Feb. 25.
Whew. Take a breath. That was a lot. So now what?
Now, we wait.
My husband also is waiting -- somewhat patiently -- to see where I land so he can figure out where we will be living and, thus, where he will be working. He's a Pennsylvania state employee, so the majority of my 14 interviews were with in-state programs.
I have faith that wherever we end up will be the right spot for us. I feel confident that I'll be able to fit in anywhere because of the passion family physicians share for primary care, our patients and our communities.
I also think residents get out of a program what they put into it. We not only have a lot to learn but a lot to give, so my plan is to give my new program everything I can and become the best doctor I can be. If that happens, I'll be happy with the final result.
Since I submitted my program rankings, I've completed an obstetrics rotation and started another in emergency medicine. The good news is that I'm too busy during work hours to think about the magnitude of the letter I'll be opening soon.
There are 23 days from the time we submitted our rank order lists until Match day. As I post this, I am keenly aware that there are only 10 days left -- but who’s counting? (Well, actually, many fourth-year medical students likely have it calculated down to the second.)
As the anticipation grows, and the Match draws closer, find solace, my fellow fourth-year students. We are ready. We have done everything we can. I'm happy and excited to take the next step in my training, and the wait is almost over.
Come back to the AAFP website on Match Day for NRMP results and AAFP News coverage of those results.
Kristina Zimmerman is the student member of the AAFP Board of Directors.
Under Attack: We Can All Join the Fight for GME Funding
For thousands of U.S. medical school seniors, the end is drawing near. In less than five months, they will be completing their fourth year of undergraduate medical training and gaining those two highly prized letters at the end of their name: M.D. But their work is far from complete.
Throughout the fall, they traveled the country interviewing for residency spots at programs large and small. Now, with the National Resident Matching Program -- better known as the Match -- only six weeks away, their anxiety is starting to grow.
Getting into medical school was difficult. According to the Association of American Medical Colleges, more than 40 percent of those who apply are turned away. Getting through medical school was difficult, too. Hours of classes, tests, clinical clerkships and overnight call. Next stop, residency. Getting in the door there is no easy task, either, and now it looks like the process could get even harder.
At a time when a shortage of primary care physicians is getting worse, hundreds of family medicine residency positions are in jeopardy.
The Patient Protection and Affordable Care Act created the Teaching Health Center Graduate Medical Education (THCGME) program to increase the number of primary care physicians. Unfortunately, the federal government's $230 million investment in that innovative program -- and other critical primary care programs -- is set to expire this year. In a survey last year, two-thirds of THCGME program directors said they likely would be unable to continue supporting current residency positions without continued federal funding.
Some aren't waiting to see whether or not Congress will act, and it's hard to blame them for being cautious.
The Fresno Bee reported Jan. 31 that the Sierra Vista Family Medicine Residency program in Fresno, Calif., already has decided not to take on a third class of residents in anticipation of a funding shortfall.
That program had received nearly 800 applications for four residency slots, but the program needs $2.4 million over three years to train each class of four residents.
Nationally, there are 60 teaching health center programs with a total of more than 500 family medicine residency slots. If Congress fails to reauthorize and adequately fund the THCGME program, how long will it be until we hear of more residencies pulling the plug on residency positions?
You've invested considerable time and money and likely amassed a daunting level of debt to pursue your goal -- your dream -- of becoming a physician. But if you're medical student, you might be wondering how this funding crisis could affect your spot in the Match. And if you're a resident at a teaching health center, you might be worried -- justifiably so -- about whether or not you get to keep yours.
So what is the AAFP doing about it?
- Last fall, the Academy released a proposal that built on recommendations for GME made by the Institute of Medicine earlier in the year. The AAFP's plan would, among other things, significantly change the way GME is financed.
- Two months later, AAFP leaders were on Capitol Hill to discuss several key issues -- including funding for teaching health centers -- with legislators and congressional staff.
- GME likely will be one of the topics on the agenda when the AAFP Board of Directors spends another day lobbying on Capitol Hill later this month.
- The AAFP and the Council of Academic Family Medicine recently responded to the House Energy and Commerce Committee's request for comments on GME reform with a letter that reinforced the concepts in the proposal released last fall, including support for community-based training programs and the need for accountability for the roughly $9 billion in federal GME funds that are funneled through academic health centers.
- That letter is just one of many the Academy has sent to Congress regarding GME reform in recent months.
Health care faces a "primary care cliff" in 2015. In addition to GME, funding for the National Health Service Corps and community health centers also is set to expire this year. We students and residents can do our part by getting directly involved in the advocacy efforts of the Academy and our state chapters. For example, efforts by students and residents last year helped the Pennsylvania AFP secure state funds for nine new family medicine residency positions and a development program for residents interested in practicing in underserved areas.
Students and residents also should be aware of scholarship opportunities to attend the Academy's Family Medicine Congressional Conference (FMCC). The May 12-13 event in Washington trains family physicians (and students) to advocate for patients and family medicine and concludes with a day of lobbying on Capitol Hill. The deadline for scholarship applications is March 6.
Whether you attend FMCC or not, your legislators need to know how funding cuts to primary care programs affect medical training and health care in their states.
Andrew Lutzkanin, M.D., is the resident member of the AAFP Board of Directors.
When Opportunities Arise, You Have to Jump
"OK, it's time to jump.
I have jumped into many challenges during my professional career -- from being an assistant residency director to practicing full-scope family medicine in the small town where I grew up to leadership positions in the AAFP -- but I had never done anything like this.
The U.S. Army recently invited Academy leaders to tour Fort Sam Houston and Brooke Army Medical Center in San Antonio, and I made the trip along with Andrew Lutzkanin, M.D., the resident member of the Board of Directors. The tour provided insights into the world of military medicine as we visited the facility's level-one trauma center, a burn treatment unit and the ICU.
We also toured the Center for the Intrepid, a world-class rehabilitation and prosthesis center. We heard inspiring stories from soldiers who had the will and personal stamina to rehabilitate themselves with the goal of returning to their units. The bond they feel with their comrades is truly hard to describe. In many ways, I thought of family physicians and the common bond we share to help our patients.
We also visited Camp Bullis, a military training site near San Antonio that includes a replica of a forward hospital medical treatment facility. The Army can construct one of these 84-bed facilities -- complete with operating rooms and ICUs -- in as little as three days. Medics and physicians train in this mock up "tent hospital" that could be run off of a generator.
But what about the jump? As part of our three-day visit to San Antonio, we also had the opportunity to make tandem parachute jumps with the elite Army Golden Knights Parachute Team. It was quite an adrenalin rush to leap out of an airplane at 14,000 feet and free fall for about a minute before feeling the chute open with a jolt and then simply floating. I had no experience with parachutes, but when given the chance, I jumped.
© 2014 Ashley Bentley/AAFPHere I am meeting with our student leaders via Google Hangout. Our family medicine interest group network leaders work to help promote family medicine at campuses across the country.
With our hectic schedules, it's sometimes difficult for family physicians to make the most of every opportunity that comes along. But I also had been asked to meet -- online -- with new family medicine interest group (FMIG) leaders. Their orientation meeting at AAFP headquarters in Leawood, Kan., was taking place at the same time Andrew and I were attending the Army's All-American Bowl, which features 90 of the nation's best high-school football players.
When it comes to speaking with medical students, you find a way to make it happen. Although an Alamo Dome filled with thousands of cheering fans and a marching band might not seem like the ideal place to hold a video chat, Andrew and I managed to find a quiet stairwell in the stadium and met the students via Google Hangout.
Each FMIG leader asked me a question related to the big issues -- such as scope of practice, student debt and new models of care -- that are affecting their peers' specialty choices. I addressed these questions, and I pledged to them that the AAFP will continue to work on issues that matter to students because they matter to the future of our specialty. I also reinforced the importance of the work these students will do this year to increase student interest in family medicine by working to strengthen FMIGs at medical schools across the country.
Before we returned to the game, Andrew -- who is a former FMIG network leader himself -- shared his experience with the students and also discussed how our young leaders will work together in the year ahead. Kristina Zimmerman, the student member of the AAFP Board; Richard Bruno, M.D., M.P.H., resident chair of the AAFP National Conference of Family Medicine Residents and Medical Students; and Brian Blank, student chair of the conference, also participated in the call.
During our visit in San Antonio, we met with several military officers. At one meeting, I pointed out to Andrew there were five generals in the room discussing the challenges they face in military medicine. Family medicine, no doubt, faces its own challenges. But meeting with our student and resident leaders, and spending a few days with Andrew, confirmed what I already knew. Our future is in good hands.
Robert Wergin, M.D., is president of the AAFP.
Digital Media: It's Here to Stay, and That's a Good Thing
When I started medical school almost four years ago, I still used paper notes. I printed out lecture slides and scribbled my notes during live lectures. Oftentimes, I had to go back to the recorded, archived lecture to fill in any notes I missed. By the end of the year, my bookshelves were buckling under thick binders full of lecture notes -- notes that I could not readily refer back to because it was too time-consuming to flip through thousands of pages to locate one specific detail. It was faster and easier to search for the information electronically.
This, combined with my desire to be more environmentally conscientious, compelled me to go paperless during my second year in medical school. I downloaded lectures on my laptop and organized them for easy retrieval. I could type my notes more quickly than I could write them, and I could more easily link those notes to specific parts of the lecture. While studying, I used tools on my computer to find keywords and topics within seconds rather than wasting hours leafing through shelves of paper. After making the switch to electronic media, I never looked back.
Not only do electronic files take up less space, but electronic media can be read virtually anywhere and also can be listened to in the car or on the subway.
Now that my medical education has moved beyond the lecture hall into clinics and hospitals where hypothetical scenarios are replaced with real-time patient interactions, easily accessible information is even more important. I cannot bring bookshelves full of notes and clinical pearls from home. And only so much information can fit into a small, white coat-sized notebook. Plus, there's still the issue of quick retrieval. Fortunately, we live in an era when electronic media are readily available. Unlike generations of physicians before me, I only need one information retrieval tool in my white coat pocket -- my smartphone -- and I carry it now more than ever.
From my smartphone, I have quick, easy and unlimited access to the most relevant and up-to-date information I need to verify a diagnosis and/or treatment plan, as well as tools to help me educate patients. Among the electronic resources I use every day are the AAFP website; my medical school library's databases of DynaMed, PubMed and New England Journal of Medicine; and apps such as Epocrates, Micromedex, UpToDate, the American Heart Association's Cardiovascular Risk Calculator, Evernote, and the AAFP journals American Family Physician and Family Practice Management. I can use Dropbox to store my notes and important documents on the Web for retrieval on any of my electronic devices -- my tablet, smartphone or computer.
Some may argue that use of technology in the exam room diminishes meaningful patient interactions and harms the doctor-patient relationship. This has not been my experience. In fact, I would argue that proper use of electronics during a patient visit actually strengthens the interaction and engages patients more fully. For example:
- There are many instances where the computer screen can be shown to patients, such as when reviewing blood work results, growth or vitals. These numbers and trends can, and should, be shared and discussed with patients.
- Using electronic health records, various health trends can often be shown on graphs so patients can see how they are doing over time.
- When documenting/charting patient information, we can let patients see what we are typing and verify with them that the information is correct.
- Photos can be helpful when reviewing items such as rashes, anatomy or plants they are allergic to, etc. We also can clarify which medications a patient is taking by showing them pictures of the medication on the Epocrates app.
- And of course, we can use our electronic devices to quickly find an answer to a patient's question when we don't know the answer.
I have done all of these things, and patients have said that it has made many health topics easier for them to understand and has helped them feel more like a part of their health care team. Many patients appreciate the visuals, especially when they can access them again later at home.
During one patient interaction, I showed a patient two images of the English plantain, which was the source of his allergy symptoms. One image was a pencil drawing in a book from 1946. The second was a color photograph from Google Images. The patient found the photo more helpful and was happy he would be able to find it later if he forgot what it looked like.
Another reason it is important for physicians to become familiar and comfortable with electronic resources is that our patients are using them. Patients are trying to educate themselves by using the Internet and apps to look up health information and symptoms, track their health and fitness activities, etc. We need to keep up. We need to know what tools they are using and where they are getting their information so that we can guide them to valid, useful facts.
Are they using Wikipedia, WebMD, Google Scholar, MyFitnessPal, Apple Health, something else? Why are they using certain resources? These are conversations that are important to have. Many patients want to be more engaged in their health. They want to use electronic health tools to access their personal health information through an online portal, track health and fitness goals, and transmit their health data -- such as daily weights, blood pressures, glucose readings -- directly to their medical homes. As physicians, we have to be ready to navigate these new technologies and make them work to our patients' benefit.
Technology will keep moving forward. As it evolves, we need to be sure our ability to use it effectively with our patients does, too.
Kristina Zimmerman is the student member of the AAFP Board of Directors.
Penny Wise, Pound Foolish: We Can't Afford to Cut Our Investment in Teaching Health Centers
Not that long ago, Pardee Hospital in Hendersonville, N.C., was considering dropping its family medicine residency. Although such a move would have saved the not-for-profit facility roughly $1 million a year, it would have been a severe blow to primary care and the primary care workforce in the area.
Instead, Blue Ridge Community Health Center, a federally qualified health center (FQHC), joined a collaboration last year that already included Pardee and the Mountain Area Health Education Center of Asheville. The move not only preserved a valuable training program, it also gave residents exposure to a second outpatient setting -- an integrated FQHC that offers dental, behavioral health, radiographic and laboratory services; an on-site pharmacy; and interpretive services for a patient panel that includes a large Spanish-speaking population.
| Here I am touring the Hendersonville Family Medicine Residency with program director Geoffrey Jones, M.D., (left) and faculty member Magdalena Hayes, M.D. I visited the program Dec. 3 in Hendersonville, N.C.
The changes didn't stop there. After Pardee ceded control of the residency to the FQHC, the program increased its number of residents from three per class to four with funding from the Teaching Health Center Graduate Medical Education (THCGME) program.
That five-year, $230 million initiative provides funds directly to community-based teaching sites with a goal of producing more primary care physicians. One hundred primary care residents have graduated from teaching health centers in the first three years of the program's existence. That's noteworthy because we know that residents who train in underserved areas are more likely to practice in those settings.
I toured the Hendersonville residency Dec. 3 and saw first-hand what a teaching health center is about. I came away impressed by the residents, the faculty and the facilities.
Unfortunately, the Hendersonville program -- and other teaching health centers in 24 states -- face uncertain futures because of funding. Barring a reauthorization by Congress, funding for the THCGME program will end in 2015. That means first-year residents took a giant leap of faith when they entered these programs this summer. Still, residents I talked with this week were focused on their training and optimistic that a solution will be found.
The AAFP is doing its part. The Academy and more than 100 other medical and social service organizations sent a letter to congressional leaders last month, urging that funding for teaching health centers and other important primary care programs be extended.
The second issue facing teaching health centers is that the Health Resources and Services Administration (HRSA) recently announced that it plans to reduce payments for each resident during the 2015-16 school year. The AAFP has responded with letters to HRSA and Congress urging that full funding be restored.
During a recent trip to Capitol Hill, Academy leaders discussed both the need to restore funding for the 2015-16 academic year and the need to extend funding for the program beyond 2015 with congressional leaders and staff. At a time when our nation already faces a dire shortage of primary care physicians, we cannot afford to abandon a program that shows great promise for producing more family physicians.
Robert Wergin, M.D., is president of the AAFP.
Exposing Students to Rural Health Key to Producing Rural Docs
Less than half an hour from the U.S.-Mexico border, the tiny town of Patagonia, Ariz., lies nestled between a sprawling state park and a massive national forest. Although I was born and raised in Tucson and started my practice there, I came to Patagonia in the 1990s when I was offered the opportunity to work at the small town's federally qualified health center.
Why would a big-city physician leave home to come to a town that was literally 1,000 times smaller?
I liked the idea of practicing full-scope family medicine. I liked the challenge of doing more with fewer resources, putting pressure on myself to become a better clinician. And I wanted the chance to develop true, close relationships with my patients. I got all that in Patagonia because in a town of less than 1,000 people, it didn't take long to become a vital part of the community. I stayed for 13 years.
Photo courtesy Chandra TontschUniversity of Arizona College of Medicine student Chandra Tontsch, right, completed a family medicine rotation in Lakeside, Ariz., with preceptor Elizabeth Bierer, M.D. The college places medical students in rural settings in hopes that they will later choose to practice in underserved areas.
In 2006, the University of Arizona recruited me to teach rural health in Tucson. Earlier this year, I took on the role of director of the university's Rural Health Professions Program. Although I am no longer providing rural health care as an individual physician, my goal is to show medical students the rewards this area of medicine offers and hopefully draw more of them to this important practice setting.
More than 20 percent of the U.S. population lives in rural areas, but rural physicians account for only about 10 percent of the physician workforce. Compounding the problem is the fact that many of the physicians practicing in these areas are approaching retirement and not enough young physicians are stepping up to take their place. In fact, less than 5 percent of physicians who graduated from medical schools from 2006-08 went on to practice in rural areas.
At the state level, as much as one-third of Arizona's population lives in primary care health professional shortage areas. The state has more than 140 primary care shortage areas (including some inner-city areas), and it has been estimated that Arizona would need more than 300 additional primary care physicians to address the problem.
In our Rural Health Professions Program, 22 students are selected at the end of their first year and placed in rural settings, primarily working with family physicians. During their third year, students are required to complete a clinical rotation in a rural setting in family medicine, internal medicine, pediatrics, obstetrics, or surgery. (Many do more than one rotation in rural areas.) Finally, during their fourth year, students are encouraged to go back to rural settings for a four-week preceptorship, and roughly three-fourths of them do. It's worth noting that the university's Phoenix campus runs its own similar program.
One of the challenges in my new role will be tracking outcomes to see how many of our graduates are practicing in rural areas. In the past few years, we have added a number of new physician preceptors who participated in the Rural Health Professions Program as students. Having been through the program, they can provide good mentorship to new students and encourage them to stay on this path.
Students who have questions about rural health may be interested in an American Medical Student Association webinar that (then) AAFP President-elect Robert Wergin, M.D., of Milford, Neb., participated in last month during National Primary Care Week.
Finally, the AAFP created member interest groups earlier this year as a forum for family physicians to share their mutual interests and address common concerns. One of the six groups that has already been established focuses on rural health. You can learn more on the AAFP website.
Carlos Gonzales, M.D., is a member of the AAFP Board of Directors.
Asking Right Questions Critical to Making Right Match
It may seem like the academic year just started, but for fourth-year medical students, the decision about where to spend the next three or more years is just around the corner. And the fall and winter, also known as "interview season," is when it gets really interesting.
Fall is the time for fourth-years to prepare for the National Resident Matching Program -- better known as the Match -- by visiting and interviewing with potential residency programs. The AAFP offers a tremendous free resource -- Strolling Through the Match -- that can be helpful to students regardless of year or specialty interest. The 80-page PDF covers a wide range of topics:
- residency application timeline and checklist;
- introduction to the Electronic Residency Application Service and the specialties that participate;
- a residency program evaluation guide;
- residency selection steps and interviewing tips;
- examples of how the Match works for applicants;
- new tips on post-interview etiquette; and
- tips on writing a curriculum vitae and a personal statement.
We used Strolling Through the Match widely at the University of Alabama when I was a student, and the information is practical and thorough. Still, some of the most valuable advice I received when preparing for interview season came from those who had been through the process and got their desired Match results, So, I thought it might be helpful to share the tips and takeaways from my experience just last year.
The most important thing to evaluate at each interview is how well you fit in with the faculty and, most importantly, the residents, because you will be working closely with them for the next three years (or more). If you can't get along with them, your life will be miserable.
After that, you have to prioritize the features you desire in a program, such as teaching exposure and the amount and extent of care you will provide to pediatric, obstetric and adult patients, as well as the amount of time you will spend working in inpatient versus outpatient settings. Your residency experiences form the bulk of your medical training, and if you aren't trained on something during residency, it's far more arduous to make that happen after residency.
If you have a spouse or significant other, involve that person in the decision-making process, especially if you are moving somewhere new. You will be extremely busy during residency, and he or she will have to spend a lot of time without you. Your loved one needs to be happy where you are going.
Realize that you aren't likely to find a perfect program, but you will have a gut feeling about where you belong, and that is more important than anything else.
You may already have interviews scheduled, but do you know what questions to ask? Here are some things to consider asking at each of your visits:
- What are the program's board passage rates? This will give you an idea of how good the clinical experience is.
- Where do the program's graduates get jobs? This will tell you whether the graduates are respected and perceived to be well-trained by the local community.
- What are the strengths and weaknesses of the program?
- What kind of interaction do residents and faculty have outside of work?
While you are evaluating the programs you visit, keep in mind that you also are being evaluated at every moment, not just during the formal interviews. Residents will scrutinize you for your "fit" at any moment they interact with you, including meals and tours, so treat every moment seriously and always be on your toes.
Residency representatives will want to know why you are interested in their program and what specific aspects drew you there, so show you have done your research and be prepared to name something about that program other than just its name or reputation.
While fourth-year medical students are planning for the long term, it's not too early for first- through third-year students to start building CVs, learning as much as they can about each specialty, and seeking experiences that can help prepare them to choose their future. Here are some possible scenarios to consider:
- First-year students, you can use your only summer off during medical school to experience family medicine. Find international service opportunities for students, or find a family physician to shadow. Your faculty or state chapter can help you with this.
- Second-year students, build your CV by pursuing leadership opportunities on your campus -- for example, with your school's family medicine interest group.
- Third-year students, get out of the academic health center during your elective rotations and experience primary care where it occurs most often -- in the community. Use the AAFP's clerkship directory to find an elective rotation.
Tate Hinkle, M.D., is the student member of the AAFP Board of Directors.
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