Help Students Cut Through the Bull: FPs Are in Demand
Subspecialists in academia have tried to steer students away from primary care for decades. John Cullen, M.D., writes that physician educators need new material because the demand for family medicine isn't going away.[Read More]
Attention, Students: Six Thoughts Before Submitting Your Rank Order List
Rank order lists are due soon for those participating in the National Resident Matching Program. Stewart Decker, M.D., offers a few tips for students still pondering their options.[Read More]
Holy Toledo! As Bad Ideas Go, Closing Residency Is a Whopper
Gary LeRoy, M.D., writes that one health care system's decision to shutter a family medicine residency program in his state doesn't make sense for the business or its community.[Read More]
Time to Lift 16-Hour Limit on First-year Residents
The AAFP is supporting a proposal that would increase the number of consecutive hours first-year residents can work from 16 hours to 24 (plus the possibility of four additional hours for the completion of care of an individual patient).[Read More]
Lead by Example: Train Students to Report Medical Errors
Ninety percent of medical students reported observing adverse events in a recent study, but only 51 percent reported them. This conundrum is not new; more than a decade ago, a case study concluded that medical students' value in ensuring patient safety is often overlooked. Gary LeRoy, M.D., writes that this has to change.[Read More]
Don't Let Implicit Bias Shape Physician Workforce -- or Patient Care
A study at Ohio State University College of Medicine revealed implicit white preference by the admissions committee. This is significant because black, Hispanic and American
Indians and Alaska Natives are underrepresented among
medical students. However, AAFP student Board member Lauren Abdul-Majeed writes that many admissions committee members were mindful of their
individual results when interviewing medical school applicants the
following year. Consequently, that class was the school's most diverse ever.
Meeting With Mentor Underscores Importance of Relationships
A meeting with the mentor who introduced her to family medicine nearly 40 years ago highlighted a week that left Wanda Filer, M.D., M.B.A., feeling like she had been "immunized against burnout."
Try PROBE Tool to Help Stave Off Burnout
When a friend of a friend of mine committed suicide recently, it hit me harder than I would have imagined. I didn't know the man and knew little about him other than that he was an emergency medicine resident and a member of the gay, lesbian, bisexual and transgender community.
When I learned of his tragic passing, I went back and read something he had posted on social media a couple of years ago that stood out as particularly poignant: He wished he could be more proud to be a gay physician and support others who struggle with self-doubt.
| Roughly twice as many physicians experience emotional exhaustion as do adults in the general working population.
The pressures of our profession can be stifling, especially for folks who are hesitant to be open about who they really are. Although each of us faces our own set of circumstances and personal needs, the rate of emotional exhaustion among physicians is about twice that of the general working population. Some theorize that too much empathy can induce compassion fatigue, leading to irritability and uncompassionate treatment of those closest to us. Unfortunately, the consequences of burnout are steep. We lose a doctor a day to suicide. But with proper tools and vigilance, we can help foster wellness and prevent medical student and resident burnout, depression and suicide.
Simultaneously, we can't ignore the many systemic failures that contribute to burnout, including disrespectful behavior that erodes empathy, curricula that don't emphasize social responsibility and engagement, and the unwieldy demands of electronic and paper nuisances.
As our vernacular shifts from a mutually exclusive "work-life balance" to a more holistic "work-life harmony," future physicians can find ways to mediate and integrate multiple commitments while bolstering our resolve. One of the paradigms I came up with recently is the acronym PROBE, which stands for Prioritization, Reflection, Organization, Burnout prevention/mitigation and Expectations. The elements of PROBE may help physicians recognize mild to moderate burnout and do better for themselves, their colleagues, and their patients by exploring some of the suggested tools. However, I would implore anyone who is experiencing severe burnout to set aside any perception of the condition as "a weakness" and to promptly seek the help of other professionals.
- Prioritization -- Pamela Vaccaro, M.A., outlined the idea of the 80/20 rule, which states that 20 percent of your efforts provide 80 percent of the results, in a 2000 Family Practice Management article. She recommended engaging in activities that advance your overall purpose in life. I would suggest this includes developing a shared vision of the future with those closest to you.
- Reflection -- Simply by checking in, you can bring awareness to a difficult moment. Apps such as Headspace may help with increasing the regularity of this process, and the MySelfCare.org quiz might help you gauge compassion fatigue. My fellow AAFP Board member Lynne Lillie, M.D., wrote an excellent post on mindfulness meditation a few weeks ago. Progress can be made by monitoring and measuring what you're doing. Debriefing with fellow residents, a partner and/or faculty are great ways to decompress after tough situations. My residency holds monthly sessions (based on Balint group structure) during which residents share patient stories and tips for dealing with stressful situations. Surgical residents at Stanford University developed a comprehensive Balance in Life program that includes faculty mentors, healthy food, stress management and social events.
- Organization -- One's (digital) house is a reflection of one's inner mind, so working to relieve a cluttered inbox, keeping a repository of readings (e.g, on Google Drive, Dropbox, or using the free AAFP app for podcasts and FP Essentials issues), and learning time-saving tricks to use in your electronic health record system can all help you to be more efficient in your day-to-day tasks. This, in turn, may have the egosyntonic effect of giving you more time to enjoy the pleasures in your life.
- Burnout prevention and mitigation -- The Resident Doctors of Canada recently released a Mental Health Continuum pocket card for personal burnout awareness and mitigation that details a spectrum -- healthy > reacting > injured > ill -- with each category listing actions to take and coping skills (e.g., visualization, goal setting, positive self-talk, tactical breathing) to use. The AMA's STEPS Forward collection has an online module highlighting six key aspects for resident wellbeing and the AAFP maintains a list of burnout resources. Finding what works for you in the moment is crucial to avoiding pent-up frustrations that can inevitably release in very unhealthy ways.
- Expectations -- These can be set unreasonably high, leading to unattainable goals. Talking with those with experience in this area may help in setting reasonable expectations, and you may uncover some wise advice for how to avoid pitfalls. It's also important to guide expectations of family members and friends so you don't disappoint them. Whether it's a new job, a new rotation or a new project, setting your own goals can help you come away with a sense of self-growth.
Hopefully, this acronym will help you PROBE the issue of wellness in a systematic way and lead you to contentment in this healing profession. We have a long way to go to prevent the devastation of burnout in our profession; let's work together and take care of our own.
Richard Bruno, M.D., M.P.H., is the resident member of the AAFP Board of Directors.
Breaking Point Offers Med Students Chance to Grow
Saying goodbye to people you care about is rarely, if ever, an easy task. "See you soon" didn't really work on our last day of medical school because we had no idea when -- or if -- we might be reunited. Although we celebrated our graduation, we said our farewells slowly. As the night progressed, each goodbye hug seemed to last just a little bit longer than the previous one.
The past five years in medical school (I spent an extra year to get a master's degree in public health) taught me not only about my future profession, but also a lot about myself. As I transition to the next chapter of my life, I often think about how the people around me have impacted my personal growth.
| Johns Hopkins University School of Medicine students, including me, celebrate our graduation May 16 in Baltimore.
The most distinct memories that come to mind are of the happiest, most lighthearted moments of medical school. My classmates and I have numerous memories we all look back on and laugh at: the awkward times we practiced physical examination on each other while trying to maintain personal space, the random food adventures we managed to pull off at the last minute or the study sessions filled with ridiculous mnemonics.
But medical school was not all joyful times. I grew more during the times of stress, during the times I allowed myself to be vulnerable. Instead of associating these memories with shame, failure or rejection, I have learned to embrace them as wonderful learning opportunities.
The clearest defining moment of growth occurred on my medicine rotation during third year, but I never thanked the classmate who helped me through it for being so supportive during my lowest point in school. As my medicine attending was providing me with feedback on my morning patient presentation one day, she called me insensitive. I was shocked. I racked my brain for reasons, but I couldn't figure out why. My attending said I labeled the patient as a drug addict by overemphasizing the patient's heroin use, which she thought wasn't relevant to the patient's chief complaint. But actually the patient's drug use was the root cause for her presentation. My failing was that I had not made a strong enough case to clarify the connection. Tired, stressed and frustrated that I had not explained that it took me hours to get the patient to open up and confide in me, I surprised even myself when I broke down and cried in front of my attending and classmate.
As medical students, we constantly had to prove that we were worthy of becoming physicians. Residents and attendings constantly evaluated our performance on each rotation. We continually felt stress and the need to shine during morning rounds, and we mentally prepared for a series of followup questions. Simultaneously, we needed to learn the particular style each attending had while digesting the most up-to-date, evidenced-based guidelines or research studies relevant for the field. The pressure on medical students quickly builds. Ultimately, most of us reach a tipping point and we learn how much we can handle before we shut down.
My attending's reaction to my tears caught me off guard. Her stoic exterior immediately melted into a more maternal response as she recognized my distress. She had seen it numerous times in the past, among both students and residents. We spent the next hour discussing the stressors I had encountered on this rotation and clarified expectations. Although the following two weeks did not get easier as our team cared for incredibly sick and complex patients, this became my most memorable rotation because our team grew as a unit. The attending ensured we had a safe learning environment by deconstructing the traditional team hierarchy. Thus, she alleviated several layers of stress and allowed us to focus more on providing quality patient care.
Despite ending inpatient medicine on a positive note, I did not share my powerful experience with anyone until several months after the rotation ended. I still felt embarrassed about crying in front of my entire team. Slowly, my brave friends shared times they, too, broke down on a rotation. Looking back now, we realized how these moments of vulnerability enabled us to gain incredibly valuable experiences for both patient care and personal growth. During these low periods, we grasped and validated our passion for medicine. We had physically and mentally invested in the care of our patients, and we had to understand that we had this safe space to make mistakes and learn from them.
Although I am sad to leave an incredible group of friends, I am also excited to start residency. Instead of constantly feeling the pressure to prove myself, I know I can focus on my personal growth as a family physician. I look forward to the joyous, comical memories I will share with my cointerns. Instead of trying to wish vulnerability goodbye, I hope to embrace it to grow into a stronger, more compassionate family physician.
Tiffany Ho, M.D., M.P.H., is the student member of the AAFP Board of Directors.
Give Back: Making a Plea for Family Medicine Preceptors
"This is so cool!" my medical student says as we run from the clinic to the ER.
I agree. It is only 50 yards or so, but my heart is beating hard -- not because of the distance, but because of the urgency of the nurse's phone call. We were called out of a well-child exam to examine a patient with chest pain and hemodynamic instability.
"I had no idea family docs did so much," the student says.
| My clinic has a rotation for medical students, and we also make time for pre-med students, such as Isaac Mitchell (left) of Northwest Nazarene University.
I hear this from many medical students, who often don't realize the full scope of family medicine, especially as practiced in small communities like mine. When I look at my practice through the eyes of a medical student, it tends to shake me out of my complacency and makes me appreciate the incredible diversity of what we do. It really is cool.
This is a plea for more community preceptor sites. We need medical students to experience family medicine away from academic medical centers. If students don't see what we do and where we do it, how can they possibly choose to become community family physicians themselves?
Bringing medical students into your community and clinic is incredibly rewarding and useful. My practice has been accepting medical students for years, and it has become an integral part of our practice.
After 20 years, my practice fits me like a glove. It is easy to become comfortable and even blasé about the day-to-day care my community needs. Mentoring medical students keeps me on top of my game, especially with a generation of medical students who fact-check most of the things I tell them. Indeed, I use them to stay abreast of the latest in medical research, both by keeping me interested in pursuing the literature and by having them teach me. They question everything, which makes me do the same.
I enjoy seeing them realize the incredible breadth of knowledge required in family medicine, as well as the complexity of an office visit, and I tease them about whether they think they're smart enough to be a family physician.
I also explain that they are only seeing the tip of the iceberg when it comes to a patient's history. I spend a lot of time talking about who is related to whom and what unspoken stressors are present -- the whole backstory of why the patient is in the exam room.
I used to worry that my patients would object to having medical students in the exam room, but I have rarely seen this. Rather, most enjoy being a part of medical education.
I often hear patients ask students why they are doing a rotation in our clinic in Valdez, Alaska, although it often comes out as, "Who did you piss off to get assigned here?"
When students answer that they had to beat out 10 of their peers to get the opportunity, my patients leave with a thoughtful expression. The rotation is competitive because we don't have enough community preceptors.
I get it. Teaching medical students does take time, especially if you do it right. But I see my role as not only teaching about family medicine, but also about work-life balance, good relationships, a good medical team approach, a healthy diet and exercise. We take students on adventures to model the concept of work hard, play harder. I freely admit that my partner, Michelle, is an enormous part of this.
The medical students earn their keep, though, seeing patients when it is busy and being an integral part of the health team. Like all family physicians, I have many patients who are complicated and require more time than I can give. I have found medical students are able to address many of the social determinants of health that complicate care, as well as spend the time that many of my patients need.
Given our isolated location on the Alaskan frontier with limited resources and hours away from a tertiary care center, the students often play a critical role. On one occasion, a school bus carrying teenage skiers hit a semi truck on an icy road. Our medical student became an essential part of a system completely overloaded by a mass casualty event.
Another student assisted me in an emergency cesarean delivery of twins during a snowstorm. Students have helped me with severe hypothermia cases and often do a better job than I do on counseling teenagers about health issues.
More than 32,000 medical students are AAFP members, and many of them will gather to learn and share their enthusiasm at the National Conference of Family Medicine Residents and Medical Students, July 28-30 in Kansas City, Mo. They all need our assistance and expertise. There is a shortage of family medicine rotations, made worse by competition with students of nurse practitioner and physician assistant schools, many of which pay clinic sites to precept their students.
These medical students are our future, and they need places to experience the full range of family medicine. I know they won't all go into family medicine as a specialty, but I do expect them to treat family physicians with the same respect as they would members of whatever specialty they ultimately choose. I want them to understand the value of family medicine and how they will work with family physicians if they choose another specialty.
Most importantly, these students remind us who we are as family physicians and why we do what we do.
John Cullen, M.D., is a member of the AAFP Board of Directors.
AAFP Award for Excellence in GME: And the Winners Are …
Native Americans account for just 0.3 percent of U.S. physicians, but Hailey Wilson, M.D., overcame those long odds to achieve her goal and now works at a federally qualified health center that serves a largely Native American population.
David Tran, M.D., the son of refugees, also beat the odds to become a physician, overcoming homelessness and the loss of his father during college.
Jerry Abraham, M.D., M.P.H., has served in leadership roles for his county medical society and state medical association board, and this month was a member of the AAFP delegation to the AMA House of Delegates in Chicago.
I could go on about the winners of the AAFP's Award for Excellence in Graduate Medical Education, but the curricula vitae of the 12 honorees -- along with their personal statements and letters of recommendation -- take up some 166 pages of degrees, honors, volunteering, leadership roles, publications and other accomplishments.
The Academy's commissions are tasked with making selections for several awards the AAFP gives in recognition of exceptional service and commitment to family medicine, and it has been my honor this year to serve as the board liaison to the AAFP Commission on Membership and Member Services. At our recent summer meeting, commission members finalized the selections for the aforementioned award, which is given each year to a dozen second-year family medicine residents. The honor, supported by a grant from Novo Nordisk, recognizes outstanding residents for their leadership, civic involvement, exemplary patient care, and aptitude for and interest in family medicine.
Every member of the Commission on Membership and Member Services reviewed each of the more than 100 applications we received. It was an extraordinary time commitment to be sure, but every reviewer echoed a sense of incredible appreciation of the quality and diversity within our specialty. It was difficult to select 12 winners from the numerous exceptional candidates who applied with the support of their residency program directors.
As I thought about writing this piece, I reflected on how much our Academy and its members have influenced the medical school admission process, the selection process for family medicine residents, and the support for new physicians and emerging medical leaders.
Those medical schools with a strong commitment to family medicine and primary care include family physicians on their admission committees. They look for candidates who have connections to rural communities, an interest in a broad spectrum of practice, premedical experience working with diverse populations and underserved communities, and who have been exposed to family medicine. They seek candidates who demonstrate a breadth of knowledge and experience, as well as a desire for lifelong learning that will prepare them for the incredible variety of interactions that characterizes the practice of family medicine.
The medical students who are part of a family medicine interest group and student members of our Academy have demonstrated an early commitment, and extraordinary pre-doctoral faculty across our country are instrumental in encouraging and facilitating the journey of those students toward a family medicine residency program.
Family medicine residency programs apply similar selection criteria, sifting through the myriad of applicants for each of their residency slots, and extending invitations to those whom they feel will fit well into an established health care team that cares for a broadly diverse population. Many residency programs have a special commitment to a specific underserved population and eagerly seek applicants who have special experience and interests that will better prepare them for a future practice serving those communities.
This year's award applications included extraordinary examples of commitment to underserved populations and research, as well as compassion, communication and knowledge-based decision-making. I applaud the commission members who made the difficult selection process work.
The winners will be recognized at a special breakfast on Sept. 22 during the Family Medicine Experience in Orlando, Fla. At last year's award ceremony, I sat with the parents and residency program directors of two incredibly humble individuals who spoke not of themselves or their accomplishments, but instead described how much the mentorship they experienced from practicing family physicians meant to them.
When I read about the 12 individuals who will receive this year's Award for Excellence in Graduate Medical Education, I appreciated how successfully family physicians have influenced the premedical education of our high school and college students, the pre-doctoral education of our medical students and the training of our family medicine residents. Behind each and every individual who receives this award are the thousands and thousands of family physicians across our country who make a difference every day in caring for our patients, their families and their communities. You make it possible for us to recognize a few exceptional family medicine residents. We all should take pride in the impact each of us has in growing the future of family medicine.
Here are the winners:
- Jerry Abraham, M.D., M.P.H., University of Southern California Family Medicine Residency Program at California Hospital;
- Margot Brown, M.D., Santa Rosa Family Medicine Residency;
- Stewart Decker, M.D., Cascades East Family Medicine Residency;
- Daniel Gordon, M.D., Memorial University Medical Center Family Medicine Residency;
- Christina Kinnevey, M.D., Sutter Health Family Medicine Residency;
- Adam Kowalski, M.D., Carl R. Darnall Army Medical Center Family Medicine Residency Program;
- Catherine Moore, D.O., Mercy Family Medicine Residency;
- Charles, Salmen, M.D., University of Minnesota/North Memorial Family Medicine Residency Program;
- David Tran, M.D., Long Beach Memorial Family Medicine Residency Program;
- Juan Carlos Venis, M.D., M.P.H., Indiana University Health Ball Memorial Hospital Family Medicine Residency;
- Hailey Wilson, M.D., Swedish Cherry Hill Family Medicine Residency; and
- Jason Woloski, M.D., Penn State Milton S. Hershey Medical Center Family Medicine Residency.
Carl Olden, M.D., is a member of the AAFP Board of Directors.
Keeping a Promise to Share What I Know
When we take the Hippocratic Oath we pledge, among other things, to share our knowledge and teach the next generation of physicians. Like a lot of promises, however, this one isn't always fulfilled.
I was a volunteer community preceptor for a decade in my small town, which is near the University of Wisconsin School of Medicine and Public Health. Three afternoons each semester, or six times a year, one first-year medical student and one second-year student would come spend time in my clinic.
|Here I am answering a question from Tyler Grunow, a first-year medical student at the University of Wisconsin School of Medicine and Public Health, between patients. I have been a volunteer community preceptor for more than a decade.|
My role was to help students develop history taking skills (illness, chief complaint, past history, family history, current meds, etc.), practice physical skills (such as listening to the heart and testing reflexes) and understanding the doctor-patient relationship and why it's valuable.
It sounds simple enough, and yet our specialty finds itself in a situation where far too few family medicine practices are willing or able help. I get it. A few years ago I was chair of an AAFP commission while also serving on the local board of health and working full time. Something on my overloaded schedule had to go, so I took a break from precepting.
It was a mistake.
While I was on that break I was asked to talk about precepting during a panel discussion at a family medicine conference. One of the questions, ironically, was how do you find time to help students and meet all your other commitments.
I was reminded of a student named Scott, who came to visit my clinic for the fourth time on a particularly busy day. I told him before we got started that he could shadow me that day but that I wouldn't have time for didactic learning.
I felt guilty because I didn't stick to our usual routine, and at the end of the afternoon I apologized. "I hope you got something out of that," I said.
He looked at me surprised.
"Dr. Schwartzstein," he said, "that was our best session yet. I learned so much from watching you interact with patients. It was wonderful."
Scott had learned by observing. He got a sense of the doctor-patient relationship and how it is at the core of what we do. Family medicine is about relationships, and he saw how I interacted with my patients and the level of comfort they had with me.
As I told that story at the conference, I realized precepting wasn't something I could give up in good faith. And I realized it wasn't something I had to give up to maintain productivity. I can do this.
So the med students are back in my clinic, three afternoons a semester, six times a year. Physicians are pressed for time, and many likely think med students will slow them down, hurt their productivity or force them to work late. The reality is that it shouldn't be that big of a burden. In fact, students can add value to a practice.
I find out what students are studying before they visit. If, for example, it's cardio, I make sure they get to listen to patients' hearts. I start by asking if there something specific they want to get out of a visit, and if there is I try to help them with that particular interest.
I try to answer questions between patients or at the end of the day. I ask, did you learn anything today? And I'm eager to hear their answers. Students have different perspectives about new ways to do things, and their questions keep me on my toes.
In addition to teaching when we have students in our clinics, we are recruiting future family physicians. While they no doubt notice the administrative burdens and imperfect EHRs and ask about that, I am careful in how I address those issues. Despite these challenges, I still love being a family doctor, and I am careful to talk about, and show students, that love as I see patients with them.
A long time ago during med school graduation I pledged that I would share what I learn. Now, and until I retire, I will follow through on that promise.
Alan Schwartzstein, M.D., is the vice speaker of the AAFP Congress of Delegates.
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