Building the Family Medicine Pipeline
When I was running for AAFP President-elect, I said during a question-and-answer session at the Congress of Delegates that I would try to say yes to every opportunity that came my way. This can be daunting because there are so many opportunities to represent the Academy each week.
However, being president truly is a once-in-a-lifetime experience, and I have tried hard to follow through on my promise. I do everything I can to jump at invitations from state chapters, to medical student functions and other opportunities to meet with AAFP members all over the map.
|Family Medicine Interest Group advisers discuss ways to increase student interest in our specialty during a recent meeting in Nashville, Tenn.|
I recently had one such opportunity on my way back from the Nevada AFP meeting. I was invited to stop in Nashville, Tenn., to be a part of a dynamic workshop for Family Medicine Interest Groups (FMIG) faculty advisers. This leadership summit was an opportunity to bring together medical school and residency faculty and staff from all over the country who serve in adviser or support roles to the student-run FMIGs at their own or an affiliated medical school. One of the most important reasons for doing so is to develop relationships and create a sense of family in this group.
There is a significant turnover in this group because the role of student group adviser often falls to the newest faculty member in a department. In fact, many of the folks present had been involved with their FMIG's for less than a year. This makes it important for us to bring people together so we have an exchange of information as well as support systems for this incredibly important work.
FMIG's are remarkable. There is a great deal of direct student leadership involved for each medical school's group, with a select group of medical students elected or appointed to serve in roles to connect and coordinate between FMIGs. The AAFP recently selected its 2014 FMIG Network Regional Coordinators, who hail from Arizona, Illinois, Missouri, Pennsylvania, and Washington, D.C. These dedicated students work tirelessly to share information with FMIG student leaders at each institution and to provide opportunities for those leaders to connect and share best practices, much like what was done at the FMIG Faculty Adviser Summit.
The advisers all play different roles in this process, depending on their institution, environment and engagement of leaders. They have the responsibility for finding ways of sharing the excitement and passion for family medicine with students during their first two years of medical school, through the FMIG and other department efforts.
Most FMIG's are mainly made up of, and led by, first- and second-year students. Third-year students are on their clinical rotations and have less free time, and fourth-year students have often already committed to specialties. The group of advisers focused some of its discussion on how to keep third- and fourth-year students engaged in FMIGs to help support a family medicine specialty choice among the third-years and to use the fourth-years as mentors for the junior students.
This is a huge and critical aspect of addressing our pipeline challenge. The more we can tell medical students about the joys of family medicine, the more we may maintain their interest as they begin choosing specialties. In these challenging times, the message that our country truly needs primary care physicians is one that medical students need to hear, alongside the message of what's in it for them, which is the opportunity to have the greatest impact on population health and a specialty that provides variety, excitement and deep patient relationships.
This meeting allowed us to discuss the frustrations and the opportunities of a rapidly changing health care system and environment. I promised to take what I heard from the advisers back to the AAFP Board of Directors to help inform our deliberations related to developing our workforce pipeline.
I hope all of our active members work with medical students when given the opportunity. When students are early in their training, they are eager to see true patient encounters. At the same time, we have to recognize how impressionable students are. We need to make sure that our love of our patients and our thankfulness for the opportunities to answer our calling is what comes through. The more we do this, the more students will see that no other specialty creates the opportunities to get to know patients, make a difference and to truly impact families the way family medicine can.
Active AAFP members who would like to be connected with an FMIG faculty adviser at a medical school in their area may contact student interest strategist Ashley Bentley. Thanks for being a part of the learning process.
Reid Blackwelder, M.D., is President of the AAFP.
Support for GME Reform Exists; Agreement on How is Lacking
The Council of Academic Family Medicine (CAFM) recently released a report outlining its four pillars -- pipeline, process of medical education, practice transformation and payment reform -- for advancing primary care physician workforce reform. The article also emphasizes the importance of advocacy moving forward.
In an interview with AAFP News Now, AAFP Vice President for Education Perry Pugno, M.D., M.P.H., the Academy's liaison to CAFM, said the biggest barriers to implementation of these concepts are "the tremendous need for change in how U.S. graduate medical education (GME) is financed" and resistance to reform by people who benefit financially from the flawed system already in place.
Although there is widespread recognition of our nation's need for more primary care physicians, there is not agreement in Washington on how to meet that goal. Two bills have potential to greatly enhance efforts to increase the family physician pipeline, but the lack of progress in moving either bill forward illustrates how difficult -- and frustrating -- the political environment in Washington can be.
In 2011, Reps. Cathy McMorris Rodgers, R-Wash., and Mike Thompson, D-Calif., introduced a bill that would establish a pilot project allowing a portion of GME payments to go directly to non-hospital, community-based primary care residency programs. McMorris Rodgers and Thompson reintroduced the bill, which has support from the AAFP and other physician organizations, in the current session of Congress, but no companion bill has been introduced in the Senate. AAFP staff members are working with Senate staff members to try to find a sponsor for the bill in the Senate.
Meanwhile, Sen. Bernie Sanders, I-Vt., has introduced legislation to reauthorize the teaching health center program, which is set to expire in 2015. Republicans historically have been supportive of community health centers (federal funding for the program doubled under President George W. Bush), but thus far, Senate Republicans have been reluctant to put their names on a bill that specifically supports teaching health centers, a concept initiated as part of the Patient Protection and Affordable Care Act. To date, Sanders' bill has nine other co-sponsors -- all Democrats.
Family physicians might not give GME a second thought once they leave residency, but the way GME is funded affects the types of physicians we produce. Funding an outpatient residency through an inpatient facility doesn't work. And the proof that the existing system doesn't work can be seen in decades of failing to adequately increase the primary care workforce.
Providing GME funds directly to residencies would be a more efficient and more logical process. For example, CMS pays resident salaries in my program based on how much time the residents spend at our local hospital. Thus, residents have to work enough hours in the hospital to get paid, regardless of whether the training they need is hospital-based. Does that make sense for a specialty where the majority of physicians are more likely to practice in an outpatient setting?
In the teaching health center model, residencies are funded directly, and an education committee -- not a hospital -- dictates how residents are trained.
Indirect medical education payments also are an issue because CMS leaves distribution of those funds to the discretion of hospitals. Hospitals have legitimate claim to some of that money -- which is roughly $40,000 per resident -- because they provide residents with meals, sleep rooms and more when they are working at the hospital. Although some hospitals are good about sharing those funds, others are not. In my case, our residency receives no money from indirect payments. With 20 family medicine residents (including our first-year residents pictured with me above), imagine what we could do with a fraction of the $800,000 going to the hospital.
The federal government invests $13 billion a year on GME, but those funds need to be used appropriately to produce the workforce the nation needs. The family physician pipeline once again will be one of the key topics during the annual Family Medicine Congressional Conference, scheduled for April 7-8. I hope to see you in Washington.
Daniel Spogen, M.D., is a member of the AAFP Board of Directors.
Chemical Spill Puts Resident, Hospital to Test
Jan. 9 was like any other Thursday. I worked a full, busy and ordinary day as a family medicine resident at my hospital in Huntington, W.Va. Then I drove 30 minutes home to Culloden, W.Va.
It's worth noting that A) Huntington and Culloden are served by two different water treatment plants, and B) I didn't listen to news radio in the car.
On the way home, I stopped to buy groceries for the coming weekend. Although busy grocery stores are nothing unexpected, what I saw on this night was different. It was a new level of frenzy. Still, I didn’t think much of it. Many people in my community had been without power for a few days because of a recent storm. I thought maybe they were restocking their freezers and refrigerators.
I finished my shopping and went to the check-out line. That's when another shopper said to me, "You don't have any water. Why don't you have any water?"
I'm not accustomed to having my shopping cart critiqued, but I was willing to play along.
"Why do I need water?" I asked.
That is how I found out that an estimated 7,500-gallon spill of 4-methylcyclohexane methanol -- a chemical used to treat coal -- had been detected in the Elk River, less than two miles upstream from our area's water treatment plant.
At that point, I was too late. There was no bottled water left on the shelves in that store or any other store in town. I went home to a weekend without water -- me and 300,000 other people.
A state of emergency was declared for a nine-county area that includes Charleston, the state capital and West Virginia's largest city. We were told not to use tap water for any reason, which meant no consumption, no bathing and no cleaning anything.
Schools and businesses closed. The West Virginia National Guard was activated to distribute drinking water and assist residents affected by a chemical spill. Volunteers, like the Poca High School students in the photo above, handed out cases of bottled water to people in need.
Fortunately for me, my hospital and residency program weren't affected. I was able to shower at the hospital and fill water bottles to take home. My fellow residents were wonderful, watching my 6-year-old during his unplanned vacation while I was on call, and they also allowed my husband and son to shower or bathe at their homes.
In the bigger picture, it was fortunate for others in the area that the hospital was unaffected because without water, other health care facilities in the nine-county area were unable to care for their patients.
To transfer patients from one facility to another, you have to have an accepting physician on the receiving end. Although other academic and private admitting services at my hospital declined to accept transfers from the affected facilities in Charleston, our family medicine service did. If we hadn't taken these patients, they would have been sent to facilities in Ohio or Kentucky, and we didn't want that to happen to them.
And although I feel good about the care we were able to give, we were quickly overwhelmed. In addition to patients transferred from other hospitals (after being admitted for reasons unrelated to the spill) we also treated numerous patients who were exposed to the tainted water and were suffering with nausea, rash, headache, diarrhea and vomiting.
We also experienced a surge in patients suffering from influenza. Without access to water, people couldn't wash their hands, and the flu spread rapidly within a few days.
Soon, our hospital was full. People were admitted with no bed to go to, so gurneys were set up in the hallways with makeshift bed numbers taped to the walls.
People pitched in and helped out because in a crisis situation you have to adapt and be flexible. Residents who weren't on call offered to help. We stepped up and took care of patients who needed help.
Finally, on Jan. 15, patients from Charleston started going back to the facilities they came from.
This past weekend, people in my community were allowed to flush their pipes -- running faucets and showers, dishwasher and washing machines -- to clear the tainted water from the system. The process made the house smell, and the stuff coming out of the pipes was awful. But it's progress and a step closer to getting back to normal.
Would you be ready if a crisis affected your community? The AAFP has resources available to help families, medical practices and communities prepare for disasters.
Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.
Editor's Note: Photo is courtesy of Staff Sgt. De-Juan Haley via Wikimedia Commons.
Student Audience at Vanderbilt Gives Hope for Primary Care
As I have often said, one of the great joys of being an AAFP Board member is the opportunity to attend chapter meetings and talk to members from across the country. Every now and then, however, I receive an even more special invitation.
I recently was asked by the family medicine interest group (FMIG) at Vanderbilt to come speak during the medical school's Primary Care Week. It is nearly impossible for me to turn down a request from students, especially those from one of the 11 target schools that lack a department of family medicine.
Although Vanderbilt does not have a family medicine program, there are a number of family physicians in the region who have worked hard to give its students role models and mentors in our amazing specialty. I was honored to add my name to that list. Some students from Meharry Medical College -- another Nashville, Tenn., school -- also were present, but the majority of students were from Vanderbilt.
This was an outstanding experience. We had almost 100 students (including student leaders Eszter Szentirmai, Josh Hollabaugh, Allison Umfress and Ashlee Hurff, who are pictured here) who were interested in primary care and the role that it will play in the future of health care. I took the opportunity to tell my own story, which began at a time when my own alma mater -- Emory University -- lacked a family medicine department. My path was similar to theirs.
I was able to talk about the excitement of finding family medicine while at Emory and nurturing that experience to become a small town family physician. One of the messages that I gave students was to make sure they keep doors open and consider all possible career choices.
We talked about some of the challenges that stop students from picking primary care. For example, at some schools, students interested in primary care sometimes are told they are too smart for family medicine. That is an interesting comment. If anything, someone choosing family medicine is recognizing his or her ability to see everything broadly and doesn’t feel the need to be limited to a particular organ system, body part or group of diseases.
There is no question that these students made a choice and followed a calling into medicine because they want to help people. No specialty can help people as broadly and as immediately as family medicine.
They also were interested in advocacy. We talked about some components of the Patient Protection and Affordable Care Act and how it has provisions that provide incentives for primary care.
We talked about the need to come up with different payment models to support this transformation. We discussed the real need for hospitals to change their structure to be part of new models of care such as accountable care organizations, instead of focusing on keeping their beds full to maximize profits.
We talked about the role of physician-led teams in taking care of all patients and meeting the depth of their needs in this changing time, especially as patients with multiple chronic diseases become more complicated to manage. More patients than ever are presenting with comorbidities. As family physicians, we are at the front lines of managing this care, and we have the ability to make the greatest impact in patients' lives by managing their health at the earliest stage possible.
This also was a great opportunity to talk with students, many of whom are graduating in 2016 and 2017, about the disparity between the number of U.S. medical students who will be graduating and the number of residency positions that will be available. There was no question that reality is starting to sink in, and these students were interested in how they could advocate for change.
I told them that as medical students, it is critically important for legislators to hear their voices, and I assured them that representatives with medical schools in their districts will want to hear from them. I challenged them to reach out to their legislators, whether by email or a personal visit to their offices.
I am confident that Tennessee's representatives in Congress will be hearing from some of these students.
Having students from both Meharry and Vanderbilt created an interesting point of comparison. Here I was talking about primary care in a target school that ranked at the bottom of medical schools in an Annals of Internal Medicine article that evaluated schools in terms of addressing the social mission of meeting a community's needs. On the other hand, Meharry ranked second in that report, which considered the percentage of graduates who practice primary care, work in health professional shortage areas and are underrepresented minorities.
Based on the AAFP's annual study of family medicine residency matriculation rates, Meharry ranked 23rd in 2013 with 13.8 percent of students matriculating to family medicine residencies, and Vanderbilt ranked 126th (last) with 0.3 percent of students matriculating to family medicine residencies. These figures are based on a three-year rolling average calculated annually by the Academy.
The fact that we had students from both ends of the spectrum expressing an interest in primary care gives me hope that we can continue to open doors and make inroads. Family medicine is all about relationships with patients, but it also should also be about relationships between students in different schools sharing a culture and philosophy, and between students and those of us who are in regular practice. The more we can create and nurture these relationships, the more likely our students will recognize the path to family medicine is truly the one that allows them to follow their heart and fulfill their dream of helping people and changing the world.
Family physicians interested in reaching out to their local FMIGs to see how they can support those groups may contact AAFP student interest strategist Ashley Bentley.
Reid Blackwelder, M.D., is President of the AAFP.
Residents Can Attest to Demand for FPs
I recently served as a panelist during National Primary Care Week activities at my alma mater, Marshall University's Joan C. Edwards School of Medicine. During our session, one of the medical school students asked me how family medicine might change in light of more mid-levels providing primary care. Specifically, the student wanted to know if demand for family physicians might fizzle.
Family physicians are in demand more than any other
specialty and have been for seven years running, according to Merritt Hawkins. The health care search and consulting firm
said in a report last month that the growing demand for family physicians stems
from the need for employed FPs in hospitals and health care systems.
The number of medical students choosing family medicine increased for the fourth straight year in the 2013 National Resident Matching Program, and more U.S. seniors matched to family medicine than in any year since 2002.
Despite those positive signs, the supply of family physicians is nowhere near balanced with the demand. Researchers estimate that the country needs 52,000 more primary care physicians by 2025.
The fact that family physicians are in demand should come as no surprise to family medicine residents. I receive solicitations daily from recruiters, despite the fact that I'm not looking for a job. I signed a contract more than a year ago for a position that will start in August 2014. Most residents don't sign that early, but I found exactly the kind of practice I wanted to join. The federally qualified health center is a patient-centered medical home with a physician friendly electronic health record. Its reimbursement model includes per-member, per-month fees.
The practice is continually pursuing, and receiving, innovation grants and trying new things, so I'm happy with my choice. I'm not circulating my resume. I don't even have a LinkedIn account. And yet, the calls, e-mails and snail mail keep coming at home and at work every day.
One of my fellow third-year residents -- who is looking for a family medicine job -- said she receives more than a dozen e-mails a day from recruiters.
So what did I tell that student during our panel discussion?
I said that nurse practitioners often specialize, so they can't necessarily improve access to primary care in areas of need.
I said family physicians should work to appropriately incorporate mid-levels into our practices because they can play a vital role on our health care teams.
And, I pointed out that many patients prefer to see a physician, and some will switch practices if they don't think they have proper access to their doctor.
We are in demand by patients and employers, and that isn't likely to change.
Kimberly Becher, M.D., is the resident member of the AAFP Board of Directors.
National Event Can Open Students' Eyes to What Primary Care Is Really About
I came to medical school knowing that I would become a family physician. That goal was driven, in part, by the diversity and complexity of the work family physicians do, caring for patients from birth to end of life. I want to take that comprehensive approach back to rural Alabama, where I'm from, and family medicine is the specialty that allows me to do that.
The choice isn't as clear for many medical students, who often aren't exposed to primary care in their first two years because family medicine and other primary care faculty are underrepresented in most medical schools during the preclinical years.
So, how do we get students more -- and earlier -- exposure to primary care and family medicine?
Next week offers one opportunity to
do just that. National Primary Care Week will be
celebrated at medical school campuses around the country Oct. 7-11, giving
students an opportunity to learn about, and experience, primary care. It's also an opportunity to highlight primary care physicians in leadership positions. For example, family physician and State Health Commissioner Cynthia Romero, M.D. -- pictured here with family medicine interest group leader Penelope Carter -- was the keynote speaker at the University of Virginia School of Medicine's Primary Care Week last month. (UVA celebrated a bit early).
During my second year at the University of Alabama, Birmingham, I was responsible for planning National Primary Care Week activities on our campus. Each day, we brought in a speaker from a different primary care specialty -- family medicine, internal medicine, OB/Gyn and pediatrics -- who talked about why primary care is the foundation of patient-centered care and how each specialty plays an important role.
There is a myth perpetuated in some academic settings that family physicians treat coughs and colds and refer everything else, but family physicians do so much more than most students realize. It's a powerful experience to have a physician from the community come to campus and describe a typical day in practice, which could include seeing patients in clinic, making hospital rounds, doing procedures, delivering babies and practicing broad-scope primary care.
Although I knew about that extensive scope of practice early on, I had numerous students come to me throughout the week, saying, "I didn't know this about family medicine," or, "I didn't know that about internal medicine."
The upcoming nationwide event has the potential to open students' eyes to what primary care really is about and what it looks like outside of an academic medical center.
So what's on tap for this year's National Primary Care Week? We've heard from family medicine interest groups around the country, and some obvious themes stand out. Students want more information about health care reform, and several schools are featuring speakers or panels that will look at how the Patient Protection and Affordable Care Act will affect primary care. Academy resources available for National Primary Care Week include a PowerPoint presentation with facts and analysis of the Affordable Care Act.
The AAFP also has presentation materials designed to educate students about the patient-centered medical home, which is another common topic for National Primary Care Week activities.
Team-based care and interdisciplinary panels also appear to be popular choices. Other intriguing offerings include residency fairs, flu-shot clinics and clinical skills workshops.
I encourage my fellow medical students to seek out activities on your campus during National Primary Care Week (and bring a friend) and throughout the year. Your colleagues have worked hard to design programming that will give you key insights and understanding you will need to make an informed specialty choice within the next few years. Regardless of whether you choose family medicine like me, we're all going to be working together in an evolving health care system characterized by an increasing demand for family physicians to carry us to better patient health outcomes, better patient experience of care and lower health care costs.
So, what is your medical school doing?
COGME Report Puts Family Medicine on Priority List
In family medicine, we've known for years that the United States isn't getting the proper return for its $13 billion annual investment in graduate medical education. Federal funds paid to hospitals for training purposes too often result in the expansion of the subspecialty residencies hospitals need to maximize their own bottom lines -- cardiologists, radiologists and a slew of other "ologists" -- instead of producing the balanced workforce our health care system actually needs.
If legislators haven't already heard this message from the AAFP, the Council on Graduate Medical Education (COGME) -- which was created by Congress to provide assessments of physician workforce trends and training issues -- has recently spelled it out for them again.
Three years ago, COGME released a report that highlighted the worsening shortage of primary care physicians and recommended addressing the shortage by narrowing the gap in incomes between primary care physicians and subspecialists and reforming medical education.
In a new report released last month, the physician-led panel continued its call for more primary care physicians. In doing so, COGME was critical of Congress for underinvesting in GME. It also took aim at teaching hospitals for not emphasizing primary care and offering curriculum that was inadequate in related areas, including population health, care coordination and team-based care. COGME also questioned why national accrediting organizations have not taken the lead in bringing about these necessary changes.
There are numerous recommendations in the 28-page report, and we will have a more detailed report this week in AAFP News Now. But here are a few highlights:
- COGME recommends that Congress should continue funding existing GME positions and increase funding to support 3,000 more graduates per year.
- The report recommends that overall GME funding be prioritized based on workforce needs, specifically calling for family medicine and other "high priority specialties" and for programs whose graduates go on to practice in underserved areas.
- The report also recommends that any increases in GME funding should be directed toward training programs that produce a high proportion of physicians who continue in one of the prioritized specialties, which also include geriatrics, general internal medicine, general surgery, pediatric subspecialists and psychiatry.
COGME's recommendations are well timed. The Institute of Medicine is expected to release a review of the governance and financing of GME early next year. That report, which was requested by Congress, should prompt legislative reform.
The need is clear. Despite the fact that more than half of patient visits are for primary care, only 7 percent of U.S. medical school graduates are choosing careers in primary care. A study published last year in the Annals of Family Medicine stated that the United States will need more than 50,000 additional primary care physicians by 2025 -- 33,000 to account for population growth, 10,000 to accommodate an aging population and more than 8,000 just to care for people who will be newly insured because of health care reform.
Additional residency positions also are needed to keep pace with number of new medical schools and expanding medical school class sizes. In fact, by 2016, the United States likely will have more medical school graduates than residency slots!
Tax payers are investing billions of dollars each year in physician training as a public good. For this level of investment, shouldn't we expect a physician workforce that meets our country's needs?
Jeff Cain, M.D., is President of the AAFP.
Medical Students Need Washington to Do More
As a recent medical school grad, I spend a great deal of time thinking about my educational debt. I owe $234,000 (and the total is increasing even as I write this). There are many ways I can pay off this debt: National Health Service Corps (NHSC), Public Service Loan Forgiveness, arrangements with future employers, escaping to Mexico, etc.
what about those who are unable to secure a NHSC slot or a job that qualifies for
loan forgiveness? For many students considering careers in medicine, the high
cost will be a burden or even a barrier.
The Student Loan Certainty Act cleared the House and Senate last month, and President Obama signed it into law Aug. 9. The Academy supported the legislation because interest rates on federally subsidized student loans had doubled from 3.4 percent to 6.8 percent on July 1. The new legislation ties undergraduate and graduate loan rates to U.S. Treasury notes and retroactively lowers them -- for now -- to 3.86 percent and 5.4 percent, respectively.
The new law, however, isn't perfect, which is why the AAFP is continuing to advocate for related measures. Specifically, the Academy is asking lawmakers to
- expand funding for federal loan programs targeted to support family medicine and primary care,
- allow deferment of interest and principal payments on medical student loans until after completion of postgraduate training, and
- grant tax-deductibility for interest on principal payment for such loans.
The potential problem with the law is that federally subsidized student loans now will be tied to 10-year U.S. Treasury notes. If bond rates rise, so will the interest rates on this type of loan, which accounts for roughly one-fourth of federal student loans.
The rates are capped at 8.25 percent and 9.5 percent for undergraduates and graduates, respectively, but those potential rates would be significantly higher than current rates and could make education more expensive and more unattainable for some low- and middle-income students.
That scenario could present a problem for our already unbalanced workforce because we know that students with lower income expectations are more likely to choose family medicine as a specialty. Today, our workforce stands at roughly 70 percent subspecialists and 30 percent primary care physicians. What will the workforce ratio be in the future if interest rates approach double figures, making the cost of education an even bigger hurdle?
Three-fourths of medical students come from the top two quintiles of parental income.
Without scholarships, low- and middle-income families disproportionately feel the hit of tuition. A 2002 study from the U.S. Department of Education found that high-achieving, low-income students were five times less likely than high-achieving, wealthy students to enter college in their first two years after high school.
I was fortunate enough to earn a full-tuition scholarship to Saint Louis University as an undergraduate. Without that scholarship, there is no way I could have afforded the $36,000 annual tuition. My parents did not earn the "big bucks." My mom is a speech pathologist and my dad is an economics professor at a community college. The scholarship award was much needed.
So what's the bottom line for family medicine? A 2009 study by the Robert Graham Center evaluated what influences specialty choices and found that as long as debt did not exceed $250,000, students were not deterred from a family medicine career. What we don't know, however, is how many students who are interested in primary care careers are deterred from even entering medical school because of the high cost.
Exposure to the NHSC was one of the strongest predictors of careers in family medicine in the Graham Center study. I know several students who have no medical student debt because of the NHSC's Students to Service Loan Repayment Program, which provides assistance to fourth-year medical students dedicated to working in areas with physician shortages.
It's worth noting that the Academy has a Web page devoted to debt management. As for me, I will enroll in the Public Service Loan Forgiveness program. As long as I work at a nonprofit organization, my loans will be forgiven after I make 10 years of qualifying monthly payments -- if the program is not discontinued, that is. Signed into law in 2007, this program soon will start to see its first wave of enrollees apply for loan forgiveness. My fear is that the program could be discontinued before I have the chance to apply, and then, since I was able to enroll in a discounted payment plan, I will have significantly more interest to pay. I feel very uncertain going forward.
And if I'm feeling uncertain, what are students from low-income families experiencing? When parents discuss undergraduate and medical school debt burden with their children, what are the results of those dinner table conversations?
Lowering the interest rates on student loans, at least temporarily, was a first step, but more work is needed to create a physician workforce that is diversified and represents the population. The time is now to let your voice be heard. Talk to your House and Senate representatives about the importance of a strong primary care workforce. Talk to them about how education should be valued just as much as a home purchase. I encourage you to act.
Aaron Meyer, M.D., is the student member of the AAFP Board of Directors.
From Classroom to Med School and Back: Why I Love Teaching
I recently started a job that combines two things that I love: teaching and medicine. Although I've known for a long time what I wanted to do, it took me a while to get here.
More than 13 years ago, I decided to leave graduate
school at the University of North Carolina to pursue admission to medical
school. At the time, I was three months into a master's degree in linguistics
when I realized pursuing my doctorate in the field just wasn't for me. Although
I needed the opportunity that graduate school had afforded me to be analytical
and thoughtful, I didn’t see myself sitting in an office pouring over
transcriptions of computer-mediated communication (i.e., Internet chat -- the
topic of my master's thesis) for the rest of my life.
I was ready to turn around and head back to Kentucky when my mother, in that way that parents do, mentioned that medical schools might be less likely to admit a student who already bailed out of graduate school.
Best advice ever. Not because I loved linguistics, which I did, but because it made me stay at UNC. During my second year there, I became a teacher, and it changed my perspective completely.
The first time I stood in a class of my own, in front of 22 college freshmen, I sweated bullets. I felt insanely underqualified and unprepared despite hundreds of hours of education pedagogy and at least three weeks of completed lesson plans. Considering that I was teaching English composition, one of the classically hated requirements of college, the great triumph of that first day was capturing the attention of every student by correctly identifying that the Nigerian student in my class spoke Yoruba.
I loved spending that first semester learning to disseminate information, but also being a part of the development of my students' lives.
After realizing that my teaching style really could include me sitting on a desk in the front of the room, answering students' cell phones that rang during my lecture and confiscating anything that didn't explicitly pertain to that day's subject matter, I never questioned that teaching is where I belong.
But I did question what I should be teaching.
I started medical school, four years after finishing that master's degree, knowing that I would graduate looking to return to education. So, this past year, when the job search was finally upon me, I looked exclusively for academic jobs.
I had been bombarded by countless job solicitations beginning in my first year of residency promising no call, no weekends, no OB, no inpatient, exotic parts of the country, the possibility of loan repayment. And, believe me, a future of no late-night awakenings and uninterrupted Saturdays had a certain appeal, but by the end of residency, I loved the hospital, labor and delivery, late nights, early mornings and the satisfaction of the breadth of what I can do.
The search began late for me; it was November before I started looking and March before I interviewed anywhere in person. I know many residents who did substantially more interviews than I did, who cultivated contacts for years, keeping up with hometown doctors who might be their ticket to a perfect job. I went to three in-person interviews, having done a few more phone interviews, but I knew I was not the right match for those places. I found two really wonderful job possibilities in interesting places, both very different from Milwaukee where I had been living.
I'm excited to start anew, finished with medical school and residency (and any other degree programs for a while!) as an assistant professor in the Department of Family Medicine at the University of Kansas School of Medicine. I’m excited to be able to continue in as full a spectrum of practice as I can and to teach and learn from medical students and residents.
Sometime close to the end of my intern year, I was contacted through Facebook by a young man who had been in one of the last English classes I taught. He wanted to tell me that he had decided to become an English teacher based, at least in some part, on his experience in my course. He added that he was still in contact with many of those classmates and that during a number of years of discussion, they all felt that my classroom had become a community. That conversation, and the hope that someday I might be honored with another like it, is why I continue to teach, to help students find that community, whether in medicine, linguistics, or life.
Tully Marks, M.D., is the resident member of the AAFP
Board of Directors.
First-year Residents Set Expectations for Themselves
A new academic year started this month at family medicine residencies across the country. The new year means a new crop of first-year residents, who bring with them a great deal of energy, excitement and -- of course -- nervousness about their new roles.
As chair of the Department of Family and Community Medicine at the University of Nevada School of Medicine, Reno, I recently sat down with our new residents and asked them how they are adjusting.
It's worth noting that four of our seven interns are from Caribbean medical schools. I asked them if they felt any disadvantage compared to our American medical school graduates. They all said no and added that their rotations in U.S. hospitals had more than adequately prepared them.
Here is what they all had to say.
Q: Do you feel confident? Are you appropriately prepared for internship?
A: Meghan Ward, M.D.
I just feel pretty ready to start. I wouldn’t say that I'm overconfident, however, and I know that I have a lot to learn. I do feel that my training has prepared me well. I am sure there will be times when I feel inadequate, but I realize that this is a learning environment and there is a lot of support to make sure I am successful. I am up for the challenge.
Q: As you become an intern, it can be nerve racking. How would you rank your level of nervousness being an intern? Do you think this is a lot of responsibility to take on, or do you feel ready for it?
A: J. Kevin Daniels, M.D.
I'm pretty nervous about it just because being responsible for all these patients is a big deal, and you are doing it for real the first time. It will make you kind of nervous. I think that I'm ready for it because I feel that I'm well supported on the rotation. The senior residents and faculty are here and seem very willing to help and make sure I succeed. I'm not just out there by myself, so that makes me feel a little more confident.
Q: What have you learned so far that has taken you by surprise in the first two weeks of your internship?
A: Benjamin Hansen, M.D.
I think the most profound thing to me is that we understand that family medicine's emphasis is on treating the whole patient. Treating the social aspect of the disease -- not just the diseases themselves -- is important, but I never realized just how important that really is in terms of promoting wellness. People have a real desire to just have a conversation with you, to interact with you on a personal level. If you can get to understand people in that regard, they are little bit more passionate about taking care of themselves, a little more passionate about getting well. And I think that it promotes wellness a little more than antibiotics can do alone or whatever you are treating with.
Q: Internship takes a lot of time, and a lot of interns have trouble with time management and getting into their personal life with this year of heavy study. How do you plan on managing your time?
A: Umar Nasir, M.D.
First year is a huge transition from medical school to being a doctor, so it's basically a huge learning curve. The first priority should be learning new stuff and getting more comfortable with practicing family medicine. It can get difficult to manage your own personal life along with working; however, I think our first focus should be just learning medicine and becoming better. I think that you can have time for personal life; however, it all depends on individuals and how they manage time between their work and how efficient they are. I think it is different with everyone.
Q: When you start a new training program and you are thrown into a hospital where a lot of people are accustomed working together and you're the new kid on the block, sometimes people don't get treated the best. How do you feel like you're being treated?
A: Kyle Baron, M.D.
I think that I've been very fortunate since I've only so far been working on the pediatric floor. All the staff up there -- from the nurses, MAs (medical assistants) to the techs -- have been very helpful and incredibly friendly. There are times when you get ignored a little bit. What I found is a lot of times when they do not know who you are, they don't make the effort to figure out who you are. Sometimes they think you are just a medical student and were given a task, so they don't need to help you or talk to you or it might be some other similar situation. As soon as you make yourself known, introduce yourself to everyone and be polite with everybody, they will get to know who you are. What I have experienced so far is that everyone is very friendly and helpful, and they know we are all there for the same reason. Even though I wouldn't say they go out of their way, I have found that if you ask for help, they will give it. I have not experienced any situation where someone wasn't willing to give help.
Q: Why did you choose family medicine? Also, how do you balance internship and personal life?
A: Stephanie Reinhardt, M.D.
I chose family medicine mostly because of my experience at medical school. I just loved being able to see an adult patient with multiple chronic diseases, then pediatric kids that weren’t well and then going in and seeing a pregnant patient. I just loved the variety and being able to be good at a lot of little things. It's kind of what I envisioned doctors being when I was growing up, so it is kind of neat to have all the variety that we get in family medicine and all the prevention that we get to work with. I'm pretty passionate about preventing the long-term diseases that we treat, and I think that family medicine definitely does the best job with that over all the fields that I have seen. The first week is a little hard because we are working so much, but I've managed to always have dinners together at home every night. It is just something we do. My husband and I decided to make dinner together every night so we just have time together, and then we take the dogs for a walk. I think it's just making priorities. For me, my priority is medicine and my husband, so when I have free time, it's just where it goes. You have to have balance in your life.
Q: Are you happy you chose family medicine? How do you see that evolving during the next four years?
A: Satu Salonen, M.D.
I am happy that I chose family medicine. Well, I started on family medicine wards so I'm actually getting to see what family medicine really is. I like the fact that we see newborns, then we see pediatric patients, the obstetrical patients and then adults, so you really do get the whole scope of medicine, which is what I wanted. Hopefully, I will become more confident and comfortable. As you know, just as you're starting out, it can be a bit overwhelming trying to tackle all the different patients from newborns to adults and multiple different situations. I feel pretty good now. I have a great senior resident, who is helping me out a lot, and I see myself growing as I go along.
Daniel Spogen, M.D. , is a member of the AAFP Board of Directors.
Sharing My Dream -- and a Bathroom, a Kitchen and a Living Room
I recently had laser eye surgery, which means I no longer need glasses. Finally! It also should mean no more jokes comparing me to Harry Potter -- unless people visit my apartment.
Although J.K. Rowling's bespectacled boy wizard had a bed in a tiny room under the stairs, my new bedroom is in a tiny room above the stairs. To be exact, it's 6-by-10. The ceiling is so low, I can't stand up. But there is just enough room to lie down.
What about my room downstairs? That space features a desk and, well, that's it -- unless you count the closet.
Of course, there is more to my new home than just a bed and a desk. There also is a shared kitchen, shared living area and shared bathroom. If you're in the market for an apartment, my housemate -- a 60-year-old retired limo driver -- and I are looking for a third person to share our limited space.
Why would a young, single physician willingly pick
such a Spartan place?
Welcome to my life as a resident, complete with medical school debt. I plan to save as much money as possible during the next five years because that's how long it will take me to complete the combined family medicine and psychiatry residency at St. Vincent de Paul's Family Health Center, a medical clinic in a homeless shelter that is affiliated with the University of California, San Diego.
My new apartment will cost me only $600 a month -- less than half the price of a decent one-bedroom apartment in this coastal city.
As for the space under the stairs, that's where my bicycle will be stored when I'm not using it for the five-mile ride to work. The bike figures to get plenty of work since it's in better shape than my 1997 Honda Civic and costs a lot less to operate. The car -- following the 1,800-mile, six-state drive from St. Louis -- now has more than 114,000 miles on it.
The four-day trek -- interrupted by a family vacation in Denver -- just about finished off the Civic. The car overheated in the Nevada desert and had to be serviced before I could complete my journey.
After that, the Civic's temperature gauge stayed in the normal range. But, just to be safe, I was on the road each morning by 4 a.m. and stopped during the hottest part of the day. My modest goal was for the Civic to make it to San Diego.
Luckily, it held together, which allowed me to experience the joys of California traffic. (I already found out that driving in San Diego is nothing compared to driving in Los Angeles, though.)
So, why am I here? Last fall, I completed a four-week rotation at St. Vincent de Paul's. Although I interviewed with more than a dozen residency programs, I knew I wanted to return to San Diego. When I matched into St. Vincent de Paul's -- my first choice of residencies -- in March, I was thrilled.
After the long drive west, I finally arrived last Thursday. The first thing I did was head for the ocean, where I soaked my feet in the surf. Standing there in the wet sand, the change in scenery was striking. The beach and palm trees reminded me that I am a long way from home, and things are about to change in a big way.
Orientation at my residency begins next week, and I'll start training on our electronic health records system, receive instruction in emergency management and listen to pearls of wisdom from current residents. Clinical rotations start July 8.
My situation is an odd mix of purgatory and vacation. I am nervous, excited and eager for my new life to start. At the same time, I am trying to take in as much of my new city and have some fun while I can before I am expected to work 60 to 80 hours a week.
I have been to a production of Les Miserables, and I plan to visit Balboa Park soon. There will be opportunities to meet and build rapport with my fellow residents at social events. I already attended a hot yoga class with the outgoing chief resident. Never in my life have I sweated so much -- not even in an overheated car in the Nevada desert.
I've made it this far. I feel like I'm ready for whatever comes next.
Aaron Meyer, M.D., is the student member of the AAFP Board of Directors.
Family Medicine Wins … or Loses?
On the day before graduation at the University of Nevada School of Medicine, where I am Chairman of the Department of Family and Community Medicine, the school recognizes students who have performed well during an awards ceremony. The ceremony also offers an opportunity for students from both our Reno and Las Vegas campuses to recognize the faculty mentors who were important to them during their training through individual and departmental awards.
This year, I was honored to receive the Tow Humanism award and the Clinical Faculty Teacher of the Year award for Reno, while Kate Martin, M.D., assistant professor in family and community medicine, won the clinical teaching award for Las Vegas. Amanda Magrini, M.D., the chief resident in our family medicine residency, received the Resident Teacher of the Year award.
Not one clinical award was presented to a department other than family medicine, which also won Clinical Department of the Year awards for both Reno and Las Vegas.
You might think with this level of recognition that our family medicine program would be well on its way to recruiting more students into our specialty.
Not so fast. Only five of our 64 graduates this year chose family medicine.
Our country has recognized the need for more physicians -- specifically, primary care physicians -- and our medical schools have responded by increasing enrollments. In 2009, there were 15,638 U.S. medical school graduates who participated in the National Resident Matching Program. This year, that number increased by nearly 2,000 to 17,487, an increase of almost 12 percent.
Meanwhile, family medicine residency training programs increased the number of available slots by almost 300 (from 2,764 in 2012 to 3,062 in 2013). The number of U.S. graduates going into family medicine also increased compared with last year's figure, but only by 39.
That slight increase in U.S. graduates filling family medicine positions combined with the much larger increase in the number of U.S. graduates overall means that the percentage of U.S. graduates choosing family medicine actually went down, from 48.4 percent in 2012 to 44.9 percent in 2013.
The bottom line is that we have a need for more family physicians, and we have more available students to match to family medicine. And yet, a lower percentage of U.S. graduates are choosing our specialty.
Five years ago, 20 percent of Nevada graduates chose family medicine. Now we are down to 7 percent.
Obviously, there is a huge disconnect. Our family medicine program is being recognized for excellence in patient care and teaching, so why aren't more of our graduates choosing family medicine?
The Future of Family Medicine project pointed out two main reasons students don't choose family medicine: lifestyle and income.
Students perceive family doctors as always being available for patients, working late hours, taking frequent phone calls and having our personal lives interrupted by patient care issues in the middle of the night, on holidays and weekends. To address this issue, a more patient-centered approach with an emphasis on prevention in the office might improve our lives outside of it.
Income is an even bigger issue. The disparities in income between specialties can be huge, with several hundred thousand dollar differences between the average primary care physician income and that of certain subspecialists. Narrowing that gap is definitely on the Academy's agenda.
We are looking to create primary care-specific evaluation and management codes that support the increased complexity of the family physician encounter. In addition, we are advocating a CPT uplift for primary care physicians. As we move to a value-based system of payment, this should improve payment to primary care by paying for care coordination and population management of chronic disease.
In our department, we take exit surveys from our resident applicants who decide not to match our program. Three factors have emerged that touch on those issues of lifestyle and money: insufficient financial support for family medicine education, lack of an electronic health records (EHR) system and incomplete patient-centered medical home (PCMH) transformation.
The budget to support medical education in family medicine is lacking for both residents' and students' education. This shortfall relates to the income issue because our students see the faculty struggling to increase clinical revenue so they can carry out the mission of education.
We have not yet implemented our EHR, and our PCMH is in its infancy. There are plenty of data that show the practice environment and physician and patient satisfaction improve dramatically when technology is used and a practice transforms into a PCMH. We are working toward that goal.
So, what do we need to do, both at our local level and nationally, to attract more students into family medicine?
- Continue to be great role models and teachers in family medicine.
- Work to protect and increase graduate medical education funding so that students see that family medicine is valued.
- Continue to move forward with information technology and the PCMH, and work to improve practice environments.
- Move forward with the transition to a value-based system of payment. In the meantime, advocate that family physicians' income be increased and that the income gap between our specialty and others be closed.
Family physicians make great role models and teachers, but that isn't enough to encourage a sufficient number of students to go into family medicine. What else do you think could be done to draw more students to our specialty?
Daniel Spogen, M.D., is a member of the AAFP Board of Directors.
Duke Students Show Keen Interest in Family Medicine
I am always impressed with the passion of medical students and family medicine residents, and my recent trip to Duke University was no exception.
Duke's Family Medicine Interest Group (FMIG) invited me to be a speaker at their annual awards meeting in Durham, N.C. This created an opportunity for me to meet with the school's chair of community and family medicine, Lloyd Michener, M.D., (who recently made news for his work on integrating primary care and public health) and to spend some time with family medicine residents.
This trip, however, was primarily about students. There was a great deal of excitement and enthusiasm about this year’s Match and what it may mean for Duke's future. The school had four students match into family medicine residencies, including one who will be staying on at Duke.
Although four may not sound like a big number, it doubled last year's total and matched the school's highest number of students matching into family medicine residencies during the past six years. (For some perspective, Duke produced zero family medicine residents out of a class of 112 students in 2009.)
The students asked good questions about ways to stimulate interest in family medicine and invigorate their FMIG. We talked extensively about leadership opportunities at the AAFP's National Conference of Family Medicine Residents and Medical Students, which is scheduled for Aug. 1-3 in Kansas City, Mo., and how this can extend to students regardless of career choice. However, once students come and participate in this event, it is hard not to get excited about family medicine.
We also talked about ways of handling the usual challenges students face in family medicine. Even early in their careers, students are hearing the usual refrain of "You are too smart to go into family medicine" from their faculty and peers. This is a very real issue for our students, and it is difficult to withstand over time.
We talked about one way of reframing the situation, which is to recognize that family medicine is the largest specialty. Second, most folks who go into internal medicine, for example, subspecialize. Another way of looking at that choice would be to talk about becoming a limited practice specialist. This allows an opportunity for students interested in family medicine to say how they truly don't want to limit themselves. They want the excitement and the challenge of doing more than "just" being an orthopedist. And they could praise their peers who recognize that they need to limit their options by subspecializing. It is good to know one’s boundaries.
Most important, however, is a message that we all need to hear -- not just the students. What we have been doing for many years is critical to the creation of a true health care system in this country. It has been, and continues to, be difficult at times. People don't always understand what we do. However, for the first time, people in power are talking about primary care and the patient-centered medical home. Even if they don't fully understand what those terms mean, it is a start.
Winston Churchill once said, "You can always count on Americans to do the right thing -- after they've tried everything else." We are getting to the point where our country has tried everything else to create a health care system instead of a disease-management process.
Ultimately, what family physicians have been doing all along is what our country needs most. Now, people are finally turning to true primary care.
Reid Blackwelder, M.D., is president-elect, of the AAFP.
Primary Care Physician Shortage Requires Bold Action
If we build it, they will come.
For the first time in more than 100 years, a new medical school will open this summer in Indiana. Marian University's College of Osteopathic Medicine has a decided focus on primary care. The dean, the associate dean and two of the trustees -- including me -- are family physicians. We have taken a deliberate approach to screening, looking for students who not only have an interest in primary care but who also are interested in staying in the Hoosier State to practice medicine. We hope the new school will produce more than 90 primary care physicians per year, starting in 2017.
Student interest in the school has been encouraging. For the 150 spots available in Marian's first class, we received more than 3,200 applications.
This effort is an important step in addressing a glaring need. Indiana University's School of Medicine, the state's only med school (until now), boasts the nation's second-largest student body, but the school has not produced enough primary care doctors to meet demand.
That demand is going to increase dramatically in the near future as veteran physicians retire, the Patient Protection and Affordable Care Act expands access to health care and an aging baby boomer population becomes eligible for Medicare. By 2020, the state is expected to face a shortage of 2,000 primary care physicians.
Health care leaders in my state are well aware of the need, and opening a new med school is one strategy to address it.
Indiana isn't alone. The United States is facing a shortage of 45,000 primary care physicians by the year 2020. Marian is one of three osteopathic med schools opening this year, and more than a dozen new allopathic medical schools are in various stages of development.
Of course, it won't do much good to churn out more medical school graduates if we don't also increase the number of residency slots available. Although there are bills under consideration in Congress that would increase the number of Medicare-funded residency positions, there is no guarantee that such legislation will produce more family physicians.
Here in Indiana, we're taking steps to do just that.
Marian -- a small Catholic school in Indianapolis -- won't offer a residency program, but the new medical school has partnered with two hospital systems that do. St. Vincent Health is a network of 20 hospitals, and Community Health Network has eight. (I am the chief medical officer of the latter.)
Community Health Network has two family medicine residencies -- one allopathic and one osteopathic. We recently expanded our allopathic residency from seven slots per class to eight per class.
We also successfully applied and received CMS funding for 22 additional residency positions. We now must decide whether to expand our existing programs or develop a new residency program. Whichever way we decide to go, we need to act quickly before Marian's first class graduates in 2017.
It's becoming increasingly clear that it will take bold action and creative thinking to address the looming physician shortage. What is happening in your state?
Clif Knight, M.D., is a member of the AAFP Board of Directors.
Match Opens Door to New Challenges
It should have been easy, but it wasn't.
On Friday afternoon, I was sitting with my parents, who had driven 100 miles to watch me perform the simple, mundane task of opening an envelope. This, of course, was no ordinary piece of mail. The letter inside was the culmination of eight years of hard work and a lifetime of dreams.
This was The Match.
It took me less than 10 seconds to open that envelope, but it seemed much longer. I knew what I wanted, and I felt confident that I would get the result I had hoped for. But until you pull out that letter, there is uncertainty.
Where was I going? There were plenty of choices.
Last fall, I completed four-week rotations at clinics in Pennsylvania and California and interviewed at a dozen other residency programs in between (as well as another in Alaska).
The letter in the envelope held the answer and would influence my life and career for years to come. The entire day had been one big swell of emotion. I was exhausted, and it was only 2 p.m. when it was over.
I have wanted to be a doctor for as long as I can remember. It's not surprising considering the amount of time I spent around physicians during my childhood. I was born with a heart defect and had open heart surgery when I was 2. That led to annual visits with a cardiologist. I also was fortunate to have a great pediatrician.
So when I headed to Saint Louis University as a college freshman, I already knew I would become a doctor. The question was what kind.
The answer -- family medicine -- came during the year I spent working at the Nativity House, a homeless shelter in Tacoma, Wash. I also developed an interest in psychiatry while working at the U.S. Department of Veterans Affairs during my third year in medical school.
When it was time to look for a residency, my goal was to match into a program that combined family medicine and psychiatry. I found it in November during my rotation at St. Vincent de Paul's Family Health Center, a medical clinic in a homeless shelter that is affiliated with the University of California, San Diego.
It is a challenging, five-year program. And there were only two spots available. By the time Match Day rolled around, San Diego was my first choice.
When I opened my envelope and saw San Diego on the letter inside, it was a huge relief. This is the program that gives me the best opportunity to be the person and physician I hope to become.
I have less than two months of medical school left. I have a three-week rotation in rural family medicine in Illinois and then a two-week primary care course before my residency program starts in San Diego.
I'm excited for the transition. It is thrilling and terrifying at the same time.
Here I come.
Aaron Meyer is the student member of the AAFP Board of Directors.
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