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.
Social Justice Inspires Passion in Students, Residents at National Conference
What do you call it when more than 900 students and nearly 950 residents gather for three days of workshops, policymaking sessions, and exhibits? It's the National Conference of Family Medicine Residents and Medical Students, which convened recently in Kansas City, Mo., and proved to be one of the most successful conferences in recent years.
The event is the nation’s largest conference of medical students dedicated to a single specialty, and it featured the nation's largest residency fair.
The theme for the conference was social justice, which is a particularly meaningful topic to family medicine. We know that the care physicians and other providers deliver accounts for only 10 percent of health outcomes. The other 90 percent of health is affected by genetics, behaviors and environmental factors.
The social determinants of health -- such as safe housing, economic security and education -- are our most powerful tools to make lasting improvements in the health of our communities. We know how often patients bring these concerns into our exam rooms, even when the stated reason for a visit is back pain, a sports physical or a new cough. The World Health Organization defines health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
Gloria Wilder, M.D., M.P.H., our inspiring opening keynote speaker at National Conference, challenged AAFP members to bring a broad-based definition of health to the conversation on health care. In championing health care reform, the easy advocacy target is incremental change to our disease-based delivery system. The more difficult objectives are those that affect the social determinants of health, but these are the very changes that will have the largest impact on the health of our communities at the lowest cost. As family physicians, we are ideally positioned to take the lead in this conversation. By knowing our patients and their communities, we can advocate for all of their health needs, not only those in the health care arena.
Many of us came to medicine because we recognized social injustice and believed medicine was a profession that could effect change in people’s lives. Students and residents are particularly close to this predisposition, and their work at the National Conference reflects intense optimism for the future of family medicine. At the business sessions, we heard 65 resolutions, the most of any National Conference I’ve attended in the past five years. Passionate debate was heard on topics such as Medicaid expansion, free clinics and pharmacy assistance programs.
Richard Roberts, M.D., J.D., another champion of our profession, was the perfect bookend to Dr. Wilder’s talk. A past president of the World Organization of Family Doctors, or Wonca, he led us on a journey around the world to show the importance of nonhealth-care-based interventions to affect the public's health. Invoking Barbara Starfield, M.D., M.P.H., he asked "Why family medicine?"
There is clear data that communities with more primary care providers have better health outcomes, and communities with more family physicians have even better outcomes than communities with equivalent numbers of primary care physicians. Although the media frequently highlight the importance of primary care, we have reason to proudly support the unique qualifications of our specialty.
The AAFP has had amazing success with national advocacy efforts in the last few years, and a recognition that primary care matters appears to be growing exponentially. Much time has been spent on abbreviations affecting our system, such as SGR, RUC, and CMS. As the election season intensifies and budget talks resume later this year, we naturally fall into a dialogue that can resemble alphabet soup.
Stepping back to reflect on social justice reminds us why we're fighting these battles: better health care -- and health -- for all.
It also empowers us all to strive for purposeful, lasting changes in our own communities. So take a minute to reflect. Take a cue from Dr. Wilder -- how do you define health, and how are you championing social justice in your community? How can our discipline intensify efforts in this area?
Please share your comments with us below, or take some time to be inspired by those who do.
Jessica Johnson, M.D., M.P.H., is the student member of the AAFP Board of Directors.
National Conference Offers Something for Everyone
The National Conference of Family Medicine Residents and Medical Students is underway in Kansas City, Mo. Watch the video below to hear what's in store during the next three days at the nation's largest medical student conference.
Check back next week for more coverage of this inspiring event.
Changing Training Standards for Maternity Care
As we enter a pivotal time for family medicine to be the basis of the health care infrastructure in the United States, family medicine residencies are questioning what the practice environment of the future will look like and how to train their residents.
are emerging trends for family medicine scope of practice which vary regionally
and by patient and community need. One particular ongoing challenge for many
family medicine residencies is how to provide adequate maternity care training.
This is a hotly debated issue that academic family medicine has been struggling with for years. In areas with a paucity of family physicians providing maternity care, many educators have favored lowering the minimum curricular requirements. Others, however, have stood firm and called for maintaining the full scope of training within family medicine.
During the past year, a proposal was finally agreed upon by the Association of Family Medicine Residency Directors, the Review Committee for Family Medicine (RC-FM), and the Review Committee for Obstetrics and Gynecology (RC-OB-GYN). The proposal created a two-track system. The first track would cover a minimum of two rotations, or blocks, in maternity care for all family medicine residents with no requirements for continuity deliveries. Providing this track, which was for those not intending to deliver in practice, would have been required for all family medicine residencies.
A second, optional advanced track would have required at least four months of rotational work as well as 80 deliveries and continuity deliveries. This track was meant for family medicine residents who want to deliver in practice.
In June, the world of academic family medicine was waiting for the final vote from the board of directors of the Accreditation Council for Graduate Medical Education (ACGME). With all the key players on board, the big question was when (not if) to implement the new plan -- for the incoming class of 2012 or for the class of 2013?
As program directors were making curricular plans for this system, however, the ACGME denied the proposal on the grounds that it does not allow optional requirements. By default, residency programs have to continue the current requirements of 40 total deliveries per resident, including 10 continuity deliveries.
The RC-FM now has been asked to revise the proposal as a clear, minimum standard. The new question is what should that standard be? Should we set a floor for maternity care exposure? The original priorities were to reduce citations for programs unable to provide 40 deliveries for each resident while providing structure for residents who desire a more robust training environment.
The RC-FM has its work cut out. This a critical decision for maternity care within family medicine because it will determine what all family physicians will learn in order to care for pregnant patients. In addition, this issue is demonstrative of the widening diversity of family physicians and our training needs. We have reached a critical time for our specialty. We must produce family physicians that can respond and adapt to the needs of our communities. Let's send our residents out to practice fully trained.
AAFP Board member Daniel Spogen, M.D., wrote about the growing concern regarding shrinking scope of practice in his March blog, which asked compelling questions about the issue. We received some interesting and helpful answers. To further the discussion, I'll leave you with these questions: Should we continue to advocate for full scope of training as an Academy? How do we define ourselves as a specialty now and in the future?
Julie Wood, M.D., of Lee's Summit, Mo., is a first-year member of the AAFP Board of Directors.
Physicians Have Calling Not Only to Heal, But to Lead
As a medical student at the University of Mississippi, it often seemed as though the hardest part of my day was learning the acronyms, like AAA, COPD, CHF, WPW and HELLP.
As time progressed and I gained more experience, the secret language of acronyms made sense to me and made my work easier. At the end of a long day, it is more efficient to write or say "NSTEMI" than "non-ST segment elevation myocardial infarction." Learning the acronyms is not nearly as important as learning the medicine behind them, of course, but mastering them makes life easier.
Fast forward four years. I soon will graduate from the family medicine residency program at the University of Mississippi Medical Center. At the same time, I'm struggling with the thought of dealing with an entirely new alphabet. The realization that terms like CMS, CME, RUC, BC/BS and SGR will make the difference between a successful career in the modern medical world and becoming burned out and disillusioned with it fills me with trepidation.
Residency training is evolving to meet the educational challenges necessitated by advances in medical knowledge and capabilities, but our residency programs often fail to train physicians to advocate the changes that need to be made in the health care system itself.
The AAFP can help. The annual National Conference of Family Medicine Residents and Medical Students, which is scheduled this year for July 26-28 in in Kansas City, Mo., is an excellent way to get started on making our future as family physicians what we want it to be. National Conference presents three priorities of the AAFP in one meeting: engagement, education and advocacy.
As a student and resident, I've served on a handful of AAFP subcommittees and commissions, been a delegate and alternate delegate to the Congress of Delegates, and now am the resident member of the Board of Directors. I'm often asked why I chose to get involved in advocacy, and I answer with five good reasons:
- Josiah Bartlett,
- Lyman Hall,
- Benjamin Rush,
- Matthew Thornton and
- Oliver Wolcott.
Those physicians were five of the 56 members of the Continental Congress who signed the Declaration of Independence in 1776. The fact that such a significant proportion of the men who forged our future as a nation -- roughly 9 percent -- signed such an important document outside their direct knowledge focus tells me that we, as highly trained and motivated individuals, have a calling not only to heal, but to lead.
When it comes down to it, we all have a passion to make things better. The challenge I offer you, my fellow residents and medical students, is to broaden your sense of what's in the realm of "changeable." Think beyond the confines of your future group or practice and imagine how much better we can make our health care system if we have 10,000 residents and 20,000 students engaged and actively advocating for the future of family medicine in the United States.
It's not an easy task to reach and energize so many people, but then, nothing in medicine is easy. When the process is difficult, we tend to focus on the individual steps that matter, and lose sight of the bigger picture.
Simply put, that big picture involves making the system better. Many of us, in deciding to pursue medicine, encountered an older physician full of frustration and burned out by years of hard work. Often, that physician's advice was along the lines of "Do something else -- anything else. It's just not worth it anymore."
I know, and I hope you do, as well, that this is not the case now and does not have to be the case in the future. The truth is that the face of medicine in the next 20 to 30 years will be what our current students and residents make it.
That brings me back to National Conference, where you, students and residents, can advocate change by participating in your respective Congress business sessions. Hone your advocacy skills by writing resolutions, testifying on the floor, serving on a reference committee and running for leadership positions.
In addition to connecting with people who share your passion for family medicine, National Conference offers workshops, procedural skills courses, and clinics that provide hands-on practice experience, as well as an opportunity to meet representatives from more than 300 residency programs, 50 employers, medical missions and fellowships.
Finally, a few words for three specific groups:
- Students, it is never too early to get involved. You determine what your impact will be. Be bold, be passionate and be heard.
- Residents, now is a great time to get involved. The lessons you learn at National Conference can make you a better physician and make your practice more effective.
- Program directors and medical school faculty, support your students and residents. Don't just encourage them to attend and get involved. Send them. Students who attend National Conference are much more likely to become family physicians, and residents who attend are trained to serve as leaders and educators. Ask them about their experiences, and help them spread the message. It's in the halls of medical schools and the lounges of residencies that the passion for family medicine is born and nurtured.
I look forward to seeing you next month in Kansas City and helping you learn the new alphabet of medicine. If there is anything I can do to help you make the most of the experience, please e-mail me or tweet me @pbrentsmith_md.
Brent Smith, M.D., is the resident member of the AAFP Board of Directors.
Editor's Note: Attendees who register for National Conference by June 28 save $50.
Family Medicine Welcomes Mount Sinai Into the Fold
Did you feel the earth move last week? It was because the list of U.S. medical schools lacking a department of family medicine just got a little shorter.
Mount Sinai School of Medicine will open its Department of Family Medicine and Community Health on July 1, leaving just 10 U.S. allopathic medical schools without family medicine departments.
Sinai restarted its Family Medicine Interest Group earlier this year, and
already has 20 active student members. Adding a department of family medicine sends
a message to students, and to our country, that the school values our specialty
and the needs of our health care system. It facilitates the learning process
for students who want to be family physicians and provides invaluable mentors
and role models.
Calman's institute, one of the largest community health centers in the state with more than two dozen locations, will work in collaboration with Mount Sinai. The institute's new Family Health Center of Harlem and Mount Sinai Hospital will meet a critical need in the community, serving two of the poorest areas of New York City: Central and East Harlem. That area has been federally designated as a Medically Underserved Area and a Health Professionals Shortage Area.
The nation as a whole is facing a shortage of primary care physicians. Can one school adding a family medicine program really make a difference?
Yes, it certainly does any time one of the country's highly regarded medical schools takes this kind of initiative. Mount Sinai's new program is in line with a shift we are seeing to a more patient-centered approach. And more access to primary care means better preventive care, better management of chronic conditions and better outcomes overall.
Dr. Calman has been recognized by numerous health care organizations -- including the AAFP -- for his efforts to improve public health. For the past several months, the AAFP worked with the New York AFP to provide data and support to his staff at the Institute for Family Health as they worked to make this partnership with Mount Sinai a reality.
Now, about those other 10 schools. We're working on it.
The AAFP provides scholarships to medical students at targeted schools to attend the National Conference of Family Medicine Residents and Medical Students. Staff members from the AAFP''s Division of Medical Education also make site visits for faculty and resource development, and the Academy provides funding and support to Family Medicine Interest Groups.
Although real and important change takes time, hard work often pays off, so we look forward to seeing this list of medical schools without family medicine departments dwindle:
- Columbia University College of Physicians and Surgeons;
- George Washington University School of Medicine and Health Sciences;
- Harvard Medical School;
- Johns Hopkins University School of Medicine;
- New York University School of Medicine;
- Stanford University School of Medicine;
- Washington University School of Medicine (St. Louis);
- Vanderbilt University School of Medicine;
- Weill Cornell Medical College; and
School of Medicine.
We're not the only ones who would like to see these 10 schools make changes to recognize the importance of our specialty.
also need academic medicine to further explore the importance of primary care
in your research and underscore it in your training," HHS Secretary
Kathleen Sebelius said in a recent speech at John
Hopkins. "Far too often, especially at our leading teaching hospitals,
primary care has been treated like it was less challenging, less important, and
a less worthy use of a physician's skills. We need to change these attitudes,
and that starts with our medical schools."
Jeffrey Cain, M.D., of Denver, is president-elect of the AAFP.
The Joys -- and Advantages -- of Solo Practice
One weekday afternoon when I was sitting on a bleacher watching my daughter play softball, another parent asked me why I wasn't at my office seeing patients. My answer? She's only going to grow up once. I attended every one of my daughter's high school softball games, but I also made plenty of time for patients.
Many physicians struggle with work/life balance, so being your own boss has distinct advantages. I own my own small practice in suburban Boston, and I love being a solo doc -- again.
I started my career as a family physician back in 1990, and I owned my own practice by 1992. Over time, it grew to include two other physicians and a nurse practitioner. But after Harvard Pilgrim Health Care -- one of our region's biggest health plans -- lost more than $200 million and fell into receivership in 1999, things got tough for me as well.
By 2001, I thought I had no choice but to become an employed physician, and I went to work at a hospital-owned practice. It's a decision I regret. After four years, I'd had enough of being an employee and went back to being my own boss.
This time around, there are no partners. The practice includes me, a nurse practitioner, a medical assistant and a front office worker. I also recently hired an office manager to help us achieve meaningful use and to transform the practice into a patient-centered medical home. I'm a better business person this time, understand contracts better and know what it takes financially to run a practice.
So why do I prefer things this way? For one thing, I'm in control. Not only do I set my own schedule, I can fix problems without interference or going through channels.
More importantly, I have a stronger bond with my patients than I did as an employee in a large practice. When a patient seeks care in a group practice, he or she may not see the same physician every time. As a solo family doc, my patients know I am involved in all aspects of their care, even if they see the nurse practitioner.
I know my patients, their families and their stories. It helps that my practice is in Walpole, Mass., a town of about 22,000 people where I grew up.
It sounds pretty good, right? And yet the number of small and solo family practices is in decline. A recent AAFP survey shows that 63 percent of our active members are employed physicians. The figure is even higher among new physicians.
This trend is troubling to me. We can't forget about the small and solo family practices out there because there still are many areas of the country that cannot support large practices.
Part of the problem is that students and residents often are not exposed to the small and solo practice model, though there are exceptions. How can our students and residents develop an interest in something they've never experienced?
We need to find more ways for students and residents to see this kind of practice, but it isn't always easy for small practices and solo docs because having a student or resident for a rotation can slow you down, which hurts productivity and finances.
Small practices often are located far from medical schools and residency programs. Personally, my practice is an hour from my old med school in Boston. It might not be feasible for some small practices and solo docs to have med students or residents in their practices on a regular basis or for those physicians to be regular visitors in educational settings. But there are things we can do in a less formal matter. I have had medical students shadow me in my practice. I have done grand rounds at my alma mater. And I am working with my state chapter to come up with other connections for small, solo practices and medical students and residents.
So for my fellow small practice and solo docs out there, what are you willing to do to expose our future family physicians to our model of care? Our small towns and rural areas cannot afford to lose it.
Laura Knobel, M.D., of Walpole, Mass., is a third-year member of the AAFP Board of Directors.
Students, Residents: Stand Up and Make a Difference for Family Medicine
Did you know that people in power, including our country's leaders, are talking about family medicine with knowledge and respect? Even more importantly, they are asking for our opinions. I experienced this first-hand during recent meetings with members of Congress and congressional staffers where I advocated for family medicine regarding the sustainable growth rate formula and funding for graduate medical education.
People finally are recognizing that primary care has to be the foundation of an improved health care system in this country, and primary care is family medicine.
Advocating for family medicine, however, is not a role just for the elected leaders of the AAFP. Everyone can play a role, particularly medical students and residents because you are our future. Each of you can take part in the discussion that is developing about the future of health care. The resulting decisions will affect how you practice medicine, regardless of specialty, and how your patients receive care.
Advocacy is not a routine part of medical school or residency training, yet one of the most important duties of a physician is to advocate. You are an advocate for your patients, your practice, your community, and your specialty. It is critical that as an advocate you are informed and active. It's never too early to get involved. Now is the time for you to find a way to be connected on a regular basis. Happily, there are many ways for you to do just that.
I encourage you to come to the National Conference of Family Medicine Residents and Medical Students. This event, scheduled for July 26-28 in Kansas City, Mo., is one of the Academy's three annual leadership events. Contact your chapter for information about representing your state as a delegate to either the student or resident congress. Delegates play an important role in writing resolutions and debating those resolutions during the student and resident congresses. Some resolutions go on to be considered by the AAFP Congress of Delegates, the Board of Directors or the Academy's commissions.
National Conference also is the venue for elections for student and resident leaders. The Academy selects representatives from both groups to serve on all of its commissions (including governmental advocacy) and the Board of Directors. Jessica Johnson, who will graduate this weekend from the University of Connecticut School of Medicine, and Brent Smith, M.D., a third-year resident at the University of Mississippi Medical Center, are your elected Board members.
Students and residents also can make a difference through Speak Out. This resource connects you with your elected representatives in Washington. Draft letters on critical issues -- such as physician payment -- are available for you to review, edit and send to your lawmakers, and it only takes a few minutes.
This blog is another resource that can help you stay connected. Here you can meet your AAFP leaders and learn about the Academy's priorities. Please reach out to us. Family physicians love to connect people. It is something that we do well, beginning with our patients and their families, and extending to our network of providers in our patient-centered medical homes. We know how to share information and coordinate effort. We can tell a good story that captivates an audience. Now that audience includes legislators and Congressional committees.
You can find almost all members of the AAFP Board of Directors on Twitter as a result of our students, residents, and special constituencies asking us to add it to our repertoire. I encourage you to follow AAFP President Glen Steam, M.D., M.B.I., on Twitter @aafpprez or Facebook to keep on top of our advocacy efforts in real time.
This is the best time to be a family physician. Advocating for our patients and principles and connecting through social media will allow us to change the world. Link up, speak up and Speak Out!
Reid Blackwelder, M.D., of Kingsport, Tenn., is a third-year member of the AAFP Board of Directors.
Shrinking Scope of Practice Raises Questions About Future of Family Medicine Training
During the past two years, all 12 of the residents who completed the family medicine program at the University of Nevada School of Medicine started their careers as employed physicians. They're not alone.
According to AAFP
data, more than 60 percent of AAFP members are employed physicians, and more
than 80 percent of new physicians -- those who completed residency within the
past seven years -- are employed. Thirty years ago, employed physicians were a
minority in family medicine, but a slow shift to the employed model during the
past two decades has eroded our collective scope of practice.
That erosion has occurred because some employers dictate scope of practice. Many family physicians have taken jobs with hospital groups who need primary care physicians to coordinate outpatient medicine. They don't necessarily need FPs to provide obstetric or pediatric care.
A recent AAFP member survey indicates that fewer than 20 percent of AAFP members have hospital privileges for routine obstetric delivery, and fewer than 60 percent have privileges for newborn care. Those numbers are down from 25.7 percent and 64.7 percent, respectively, in 1995. According to the American Board of Family Medicine (ABFM), fewer than 10 percent of family docs are providing maternity care, and fewer than 42 percent perform in-office procedures.
These numbers likely will continue to decline as more of us take employed positions.
One of the factors that typically draws students to family medicine is the broad scope of practice. Traditionally, family medicine has offered us opportunities to do a bit of everything. We have treated and cared for entire families -- from cradle to grave. But many new physicians are finding that they can't do that.
Employers are just one factor contributing to the problem. Restrictions on duty hours have reduced residency training and experience, leaving new physicians feeling less prepared for practice than in previous generations.
Although many small towns and rural areas continue to need primary care physicians who can provide a wide range of services, the percentage of family physicians taking those kinds of jobs is small. Fewer than 20 percent of AAFP members practice in rural areas, down from 31.7 percent in 1994.
And even rural areas aren't immune to these changes. According to the ABFM, more than 70 percent of family physicians -- regardless of whether they practiced in urban areas, rural areas or areas with health care professional shortages -- were "attending to the specialized needs of women" in 2003. By 2010, the percentage of physicians in all three categories who offered those serviced had dropped to less than 50 percent.
These are troubling trends. We have advocated against expanding the scope of independent practice for nurse practitioners (NPs), but if family physicians aren't providing pediatric care or maternity care or doing procedures or inpatient care, how do we differentiate ourselves from NPs or any other health care professionals?
As more residents are becoming outpatient docs, we have to ask ourselves:
- Where are we going with training?
- What needs to be done with curriculum design?
I recently attended the Association of Departments of Family Medicine (ADFM) winter meeting. Half of a day of the four-day event was dedicated to scope-of-practice issues. The Council of Academic Family Medicine, which includes the ADFM, is in the process of evaluating training and curriculum. Meanwhile, the ABFM is surveying test takers about what skills are truly needed by family physicians.
The aforementioned reduction in training time coincides with an ever increasing amount of complexity in the specialty. Patients are living longer while coping with more chronic conditions. Meanwhile, physicians are expected to be more tech savvy, implementing electronic health records and transforming practices to the patient-centered medical home model. How do we teach everything in a condensed time frame?
One potential solution is expanding residency programs to four years. The extra year would make up for time lost to work restrictions and give residents a chance to develop an area of concentration. The Accreditation Council for Graduate Medical Education has announced a pilot to examine length of training, and a call for proposals was released March 16. Up to 25 residency programs will be selected for a pilot scheduled to begin in July 2013.
The AAFP needs to be involved in these important discussions, and the Academy needs to know what members think. So I pose these questions to you:
- Is it important to you that your Academy advocate for full scope of practice?
- Should we instead move forward, focusing education and training on outpatient adult medicine and population management issues?
The AAFP Board of Directors is expected to discuss this issue at its May meeting. Your input here could help inform that discussion.
Daniel Spogen, M.D., of
Reno, Nev., is a first-year member of the AAFP Board of Directors. He is a
professor and chairman of the Department of Family and Community Medicine and
director of medical education at the University of Nevada School of Medicine.