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Monday Mar 13, 2017

Help Students Cut Through the Bull: FPs Are in Demand

"My attendings tell me there is no future in family medicine," said my medical student. "They said that if I went into family medicine, I would be wasting my education. They told me that I am too smart for family medicine, and that primary care would be taken over by APNs and PAs."

She looked worried, but I'm afraid I laughed at her comments because they were the same warnings I heard as a medical student 25 years ago. You would think the subspecialists' arguments would have changed at least a little in a quarter century, especially in light of the rapid change in technology and medicine.

I explained to the student that this was an example of "bulshytt," a term coined by author Neal Stephenson in his book Anathem. Stephenson offers a couple of definitions of the term, the most relevant of which appears to be "a derogatory term for false speech in general, esp. knowing and deliberate falsehood or obfuscation." 

It is true that medical technology is changing rapidly, and there are forces at work within our society that will stress and change our profession. IBM's Watson (and other expert- and crowd-based systems), genomics and telemedicine are just a few of the emerging technologies that we will be contending with in the next 25 years. However, there will always be a central place in health care for family medicine.

Frankly, I would be much more concerned about going into radiology, oncology or other subspecialties. Watson is effective at algorithmic medicine based on the latest research, and it apparently reads X-rays nearly as well as a radiologist. Surgical robots such as da Vinci and STAR represent a maturing technology that continues to improve. It is hard to imagine an autonomous surgical robot, but autonomous cars were science fiction just a short time ago.

What will remain fundamental are the relationships we have with our patients, the healing power of touch, the reassurance and wisdom of a trusted adviser backed up by all this amazing technology. And this is where it gets really cool.

As technology improves, the price drops and it is easier to use. Look at ultrasound, for example, and CLIA-waived tests that we can perform in our clinics. We will be able to do more and more in our offices or even in our patients' homes at a fraction of the cost of hospital-based care. More and more, hospital systems will need us, but we will not need them. In the long term, I think this is where medicine is going, and it will be family physicians doing the work.

In the short term, there is a tremendous need for well-trained, full-spectrum family physicians in rural and inner-city populations. Infant mortality rates in both of these populations are much higher than in the general population and are frankly appalling. We desperately need well-trained generalist physicians in both these areas who are capable of providing the full continuum of family medicine -- from maternity care and well-child checks to end-of-life care and emergency medicine. Backed up by technology such as telemedicine, care can be provided in a critical-access hospital that is on par with offered in tertiary-care hospitals.

This touches on the social determinants of health, which are likely more important than much of what we do with medicine. With advances in population health and data management, family physicians are uniquely qualified to work at the intersection of primary care and public health. Imagine the impact that a clinic that harnesses individual patient encounters with a truly effective and integrative medical record could have on community health, especially when coupled with strong and effective advocacy. These are areas that will require a family physician's depth and breadth of knowledge.

I've recently attended lectures by people who considered physicians to be superfluous and anachronistic. Smart devices, hologram projections and big data will remove the physician from the equation, according to these speakers. I heard the same argument about how the Internet would make doctors obsolete 20 years ago. I didn't believe it then, and I don't believe it now. Algorithmic medicine works best when the problem is defined. Patients who present to primary care are unselected, complicated and often in need of emotional support. Despite our recent technologic development, we are social animals. Technology provides little comfort. It cannot touch. It has no wisdom.

A wise man once said, "Predictions are difficult, especially about the future."

There may come a time when physicians are no longer needed, but one thing I know is that family physicians will be the last doctors standing. And if a large meteor ever hits Earth or there is a zombie apocalypse, family medicine will be the specialty most in demand. Given those two boundary conditions, and the growth of technology that will benefit primary care, there is a definite future in family medicine, and we will continue to need our best and brightest students to go into it.

I'm sorry I laughed at my student. I'm not usually so socially inept. But really, the arguments haven't changed in more than 20 years.

A bigger question remains. How do we address the same old bulshytt that continues to be perpetuated in medical schools?

John Cullen, M.D., is a member of the AAFP Board of Directors.


The answer to all the above is the totally family practice experience – the local FMExperience. This is all about the experiences, learning, training, interactions, and more across preparation, admission, medical education, graduate medical education, and the first 7 years of practice without interruption from being local, community, relevant, integrated, and basic to health access.

Preparation is about working as teens and young adults to facilitate better health, education, economic, and other local outcomes on various projects guided by the community, schools, and health care leaders.

Those who pursue the family practice total experience level up in requirements while integrating what to learn in clinic, public health, school, and community settings. Working in homes and neighborhoods and schools to best impact outcomes earliest and most efficiently is the key focus of FPEx and also trains the future educators, and leaders of these communities and neighborhoods.

The FMExperience does not need artificial constructs such as primary care medical homes or translations. How can those outside to FMEx and their communities facilitate or certify what they do not understand? Strained academic and community of need relationships no longer are strained, ignored, or abuse. The leaders of the FMExperience arising from and working with the community and with team members to identify needs and needed changes would work to match needs to resources and change agents.

And those who have demonstrated their abilities as change agents as demonstrated at the preparation and training levels are essential to the FMEx. They are qualified to become team members working at all levels and at all locations across the community.

Addressing the determinants of health requires full dedication to FMEx before, during, and long after training.

What is no longer needed is 90 - 95% of training and 80% of medical student origins arising from the most concentrated of the concentrated. This has a track record of origins and training as well as self preparation, self-training, and practice most irrelevant for what most Americans need and quite the opposite of the FMExperience.

When concentrations in the most concentrated areas can no longer be maintained or formal training breaks down (overall or relevant to most Americans), a vibrant FMExperience preparation, training, and practice will be the firm foundation for health care delivery and best outcomes in health, education, economics, and more - by design.

Most Americans need the FMExperience because the academic and payment designs favoring concentrations of concentrations have failed for generations of trainees.

Given the financial and training design barriers to specialties of greatest need (generalists and general surgical specialties) and given the fastest growing demand and complexity involving the places with most Americans behind by design - The FMExperience PTP is the only true and lasting solution.

And when FMEx grads are all that remains of generalists and those capable of general surgical services and mental health for half of Americans, we will work with these Americans to be certain that they are taken care of and that we arise from them, serve them, live with them, live for them, gain strength from them, give strength to them, and die with them. This also was once the way it was before 100 years of medical education "reforms" helped separate us all from each other.

The current claims about social determinants are actually quite superficial. The health outcomes and the concomitant changes in education, economic, and other dimensions must be addressed by actions, interactions, and investments of time talent and treasure in ways that address behaviors, situations, environments, resources, jobs, housing, public security, public health, primary care, and higher functions in all of these areas. The local FMEx preparation, training, and practice experience is basic, middle, advanced, graduate, professional, most experienced, and most relevant.

Posted by Robert C. Bowman, M.D. on March 13, 2017 at 10:21 PM CDT #


Posted by John Cullen on March 14, 2017 at 05:09 PM CDT #

""They said that if I went into family medicine, I would be wasting my education."

Over the years I've seen many tried to do what FP's do... ER's, OBGYN, disease management consortium, big data, marketing, drug reps, politicians, insurance execs (yes, I'd personally witnessed a whole clan trying to play doctors, all involved in a medical experiment doing blood tests and ultrasounds on themselves).

Even within our profession, I'd witnessed many who thinks FP's don't deserve their big paydays for what could be done by ancillary staff and mid-level providers (one higher-level physician told me he had every confident in his NP over another partner).

Now that the 10 years of data on the ACOs are out, and 6 years data are out on the ACA, you can't help but wonder is the "X-factor" here really the old FPs? Were they the silent soldiers who did more in the trenches than what was recognized for, in modern stakeholders' terms - the "value added" and "returns on investments" (we didn't measure much back in the days)? Did they held the profession to the highest rung of professionalism (it wasn't all about pay in those days)?

This was still fresh in my mind. I just finished a rural rotation elective in my 4th year of medical school. The next rotation was another elective - occupational medicine. We had a chance to do field visits with the manufacturers. I met up with a semi-retired MD now working solely as Catepillar's onsite doc. He was bitter and hypocritical of the previous rural doc, saying that "John" was on his own out there and didn't know what he was doing... Years later, sadly, "John" also decided to become an employee at the hospital ER as he was near retirement.

The old soldier can only go so far. Not only there is a shortage, it's much tougher nowadays... All I can tell you is that many have tried to walk in our shoes and have not succeeded. As I revisited some of these old folks, they are actually scared. At the meetings, they just say defensively "I'm just a nurse, ask the doctor" kind of statements. The patients, aka markets, know that... From a business angle, patient satisfaction scores are still a selling point, because the trust is still there between FP patient-doctor relationships. Trust is something you can't just manufacture and easily duplicate.

That's the X-factor...

Posted by Michael N., MD on March 15, 2017 at 12:08 PM CDT #

This was great to read and has lifted my spirits after a challenging week. Thank you for this perspective and words of encouragement.

Posted by Andrea DeSantis DO on March 15, 2017 at 06:11 PM CDT #

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