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Monday Jan 09, 2017

No, I'm Not 'Settling' for Family Medicine

During a recent internal medicine rotation, a senior resident expressed disappointment that I've chosen a career in family medicine. He was concerned that my talents would be wasted, because -- in his words -- I wouldn't get to care for the "more complex patients" he sees in internal medicine. Although I appreciated his confidence in my abilities, I felt my heart sink, as it does each time I am faced with misinformed perceptions about family medicine.

I thought back to my last family medicine rotation, and the following patients came to mind:

  • A young woman with a previous diagnosis of idiopathic anaphylaxis was experiencing syncopal episodes of unclear etiology.
  • A man with an extensive history of IV drug use, hepatitis C and multiple other chronic conditions was admitted to our service with a dental abscess, lumbar osteomyelitis and discitis.
  • A woman with end-stage renal disease secondary to lupus nephritis was also struggling with severe depression, multiple chronic conditions (including chronic pain) and debilitating opioid dependence.

These were just a few of the patients I encountered during a two-week family medicine elective, and the complexity of their conditions was comparable to -- if not more complex than -- that of many patients I have seen on other rotations.

There is a fundamental difference in the way in which we view "complexity" in family medicine. We account for all of the biological, psychological and social components that culminate in a person's pathology, recognizing that neglecting any of these factors is neglecting to provide adequate care. This approach sets us apart from many of our subspecialty colleagues.

But, let's face it, constantly explaining this and defending our choice to pursue family medicine can be exhausting.

Meeting fellow medical students who are passionate about family medicine often feels like a breath of fresh air, a meeting of kindred spirits who understand one another's struggles. Although many of us have support from family medicine faculty, mentors or our medical school's family medicine interest group, that support doesn't shield us from the pervasive sentiment that family medicine is somehow inferior to other specialties. We tend to dread questions such as "What do you want to specialize in?" or "Do you know what you want to do after medical school?"

Even though we may feel immensely proud of our career path, most of us have experienced pushback in the form of "advice" that we are "too smart" to "settle" for family medicine, or that we should choose a residency in internal medicine so that we can "keep our options open" in case we eventually decide to narrow our specialty.

Often, the message is less direct. It may be evident in the subtext of conversations or in offhand remarks we overhear during rotations in other specialties. It also may be evident in institutions' disproportionately small amount of time allotted for family medicine rotations -- or total lack thereof. This is all part of a phenomenon known as the "hidden curriculum," which nudges students with high exam scores toward subspecialties. It's important for students and educators to understand that this problem exists and can have toxic downstream effects.

In reality, many students do express an interest in primary care at some point during medical school, likely because the values of primary care align with the reasons that many students chose to pursue careers in medicine. We see this reflected in students ranking family medicine as their top specialty choice in 2016, as well as in the fact that one in four medical students is an AAFP member.

Nevertheless, as students, we are not immune to the disparaging comments of the hidden curriculum. And when issues such as the looming burden of student debt and crippling burnout weigh heavily on us, it can make those higher-paying subspecialties seem appealing.  

It's increasingly crucial that student interest in family medicine translates to students actually choosing careers in family medicine. In the next 20 years, there is a projected shortage of more than 33,000 physicians in the primary care workforce.

This is problematic not only for individual patients, but for our health care system as a whole. As the Health is Primary campaign has shown us, prioritizing primary care leads to better health and better care at lower costs. Areas with more primary care health professionals per person experience lower mortality rates for cancer, heart disease and stroke. An increase of just one primary care physician per 10,000 people can significantly decrease costly and unnecessary care. These are just some of the many benefits of ensuring a robust primary care workforce. We can see that when family medicine is a priority, patients are a priority.

Viewing family medicine as a "backup" career option is not only problematic within the context of medical education, it's a dangerous notion that contradicts patient-centered principles and undermines the optimal functioning of our health care system. Everyone deserves access to high-quality health care and a meaningful relationship with a primary care physician, and now more than ever, we need to work to protect those rights. This means we need the best and brightest medical students committing to provide that high-quality care to patients and enlightening their peers and medical educators about the invaluable role family physicians play in health care.

To medical students who are still pondering their specialty choice, I want to say three things. First, in a profession that has maintained a hierarchy of prestige, I know it's difficult to commit to a medical specialty that doesn't always garner the same level of admiration as medical and surgical subspecialties. Second, I want to assure you that this outdated perception of prestige is changing; it is becoming increasingly evident that family medicine is the backbone of U.S. health care, and health policy and physician payment reform have begun to reflect that.

Finally, I want medical students to know that by choosing family medicine, you are not compromising on the scope or complexity of medical practice. The level of patient complexity and diversity of pathology seen by family physicians matches and often exceeds that of other specialties. Family physicians are on the front lines of health care, providing compassionate, comprehensive, whole-person care to anyone who walks through the clinic door.

AAFP Board Chair Wanda Filer, M.D., M.B.A., tells medical students in no uncertain terms, "If you aren't passionate about your patients, we don't want you in family medicine. If you're in medicine for the money, we don't want you. If you won't be an advocate for your patients, we don't want you."

This is family medicine, and it's not for the weak of mind or faint of heart.

Lauren Abdul-Majeed is the student member of the AAFP Board of Directors.


Students are investing so much more in a decision for family medicine now. They need to know that family medicine leaders are doing everything possible so that they have a better future.

They should have assurance of revenue increasing to family practices at or above the cost of delivery increases. This is the true route to financially viable practices, more and better team members, increased productivity, and increases in the higher primary care functions. It is also the route to more family physicians, higher retention of graduates in family medicine and in primary care, and resolution of the great and growing access barriers. Financial viability has deteriorated steadily.

Where the nation most needs family physicians, there are five degrees of payment discrimination and a sixth (pay for performance) has been added since 2010. Designs that compromise most family physicians and most Americans should not be supported or promoted.

Despite the deteriorations, family medicine has survived based upon the dedication of the medical students choosing family medicine, but they deserve much better dedication regarding family medicine leaders.

Family medicine faces an unprecedented time. All sources of primary care have steadily departed with fewer entering after training and even fewer remaining. This is entirely about the financial design - a design that insures that no training intervention can resolve access woes despite many and increasing failed promises.

Family medicine has not remained unscathed. After an entire generation of 95% of active graduates remaining in family medicine positions, family medicine graduates are pursuing other types of positions, other specialties, and other careers. The erosion has pushed past 12% of FM grads found in emergency medicine and 4% each into urgent and hospitalist care. The levels are likely higher than noted in this Graham Center data. An additional 5 – 10% have faded from active family practice based on training in other specialties, changes in gender, retirement changes, and movements to other careers. It is likely that one-third of family physicians who are active in health care delivery are somewhere else compared to 10 – 15 years ago.

Rural proportions of family physicians have been fading from the initial 30% down to 24% in the 1990s down to 20% for active FM grads. This would actually be lower but the increasing FM components listing themselves as hospital based (ER, hospitalists, some others) has a 26% rural distribution. Family physicians still distribute at levels slightly above the rural population level, but distribution has been declining in rural and urban settings of need. Active FM grads are down to 36% found where 40% of Americans are in most need of care – in 2621 lowest physician concentration counties.

FM leaders should not be supportive of government leaders that have promised much and delivered little. The builders of FM learned not to trust politicians or academic institutions. The restoration of family medicine and the support of the first decade of graduates was about building coalitions – coalitions of the patients and populations most served by family physicians.

have not maintained the important coalitions across the populations most served by family physicians. The efforts of builders of FM

Family medicine must redirect its many priorities to some very basic ones. FM leaders should ask themselves every day and multiple times a day, “What did I do today to deserve the trust of the medical students that are the future of family medicine?”

Whatever piece of property, program, conference, government relationship, foundation relationship, or promotional effort that gets in the way of this priority - needs to be sacrificed for a pure focus on what matters most.

Posted by Robert C. Bowman, M.D. on January 10, 2017 at 01:15 AM CST #

I loved reading your article . When I was a 1st yr resident my program closed in UF and many of my friends went to other fields as internal medicine. I left to another program to continue my residency in family med. I am so glad I did. I live in Florida and enjoy my work every day .

Posted by Glenda Buyo on January 10, 2017 at 08:02 AM CST #

Back when I was in medical school (and the earth was still cooling) I remember being told I was too smart to be a family physician. I cannot tell you how many times a day I don't feel smart enough to be a family physician! (Don't tell your medical students that-ask why they want to settle for one body part when they can have the entire breadth of medicine).

Posted by Cheryl Carter on January 10, 2017 at 10:45 AM CST #

The lack of respect of family medicine is an absolutely *institutionalized* lack of respect and goes far deeper than just medical school. Dr. Bowman in his post alluded to the worst of the disrespect, which comes straight out of the ivory towers of largely non-physician "thought leaders, policy makers, and stakeholders" in Washington, DC and other places where family medicine is essentially unheard of. CMS pays us significantly less for our services than subspecialists on purpose. They lump us in with midlevels and other non-physician personnel with the equivalent of a few weeks of clinical training as "providers." And then they take away any autonomy by dictating exactly how we have to practice medicine, plus saddle us with a bunch of useless computer box-checking that some high school grad level clerical worker could do. THAT'S where the real disrespect comes from.

Posted by MO Family Doc on January 12, 2017 at 12:45 PM CST #

In the midst of the present lack of appreciation for our field, I believe there's still hope down the road for Family Medicine.

Posted by Kalaki Clarke, MD on January 12, 2017 at 03:08 PM CST #

A great way to encourage medical students why to choose Family Medicine is simply, " Family Medicine is a lifetime of learning, applying and perfecting the knowledge of experience. We are the primary purveyors of good health and always our patient's advocate."

Posted by Robert Nicewander on January 15, 2017 at 12:32 AM CST #

Sometimes what helps me is to wax a little philosophical about all of this.

I think that it was Segovia who once said, "The guitar is the easiest instrument to play and the hardest to play well".

We spend years learning the medical equivalent of music theory. We do our mandatory 10,000 hours of practice on notes, chords, and scales to hone our craft to mastery.

We then we enter our patient's room to join in an ancient dance together as music and magic happens as we listen to the spaces between the notes.

Posted by Vondell Clark MD MPH on January 16, 2017 at 01:05 PM CST #

I remember the "talk" that the Dean's office had with me when I declared that I wanted to go into family medicine. "You can go into any specialty you want… Urology". I laughed so hard that I almost fell on the floor. He didn't realize how ludicrous his statement sounded to me. Every day, family medicine challenges me more than any of the so-called "real" specialties.

Posted by William Stueve on January 16, 2017 at 01:26 PM CST #

Family medicine is a very rewarding profession, however the increasing administrative complexities weigh heaviest on those of us in the medical world who practice full scope of care (aka.. we do everything). We need to be paid better and we need the logistics of caring for patients to be simplified, streamlined and relevant. Increasingly many of the medical students who rotate with me claim that they would love to go into Family Medicine, but the pay and the hassles were making them choose otherwise.

Posted by Andrea DeSantis DO on January 16, 2017 at 08:39 PM CST #

In San Jose where I serve as Department t Vice Chief in med staff leadership I currently advocate for preservation of Family Doctors opportunity to maintain their hospital privilege lists to do procedures such as Lumbar Puncture, paracentesis, central line placement, and with back up, thoracocentesis. We can't afford to drink the "coolaide" dogma that somehow these procedures performed bedside by our IR and ER colleagues are suddenly unsafe when done by a Family Doc. I have found Emergency Medicine procedure venues helpful for learning/mastering ultrasound guidance for these procedures. Perhaps our AAFP, CAFP will consider adding refresher courses of this kind in the future. In order to be at the hospital political table it is so important to Be Actively privileged in hospital doing procedures more than clicking buttons and intellectual care. Otherwise Family Doctor privileges will be amputated into a mere stump. I fear we will all too soon replaced by midlevels and at best the Hospital physician will be a captain of army of midlevels. Family doctors, Students, residents Never Give Up! Our diverse specialty enables us to see the patient in 5 dimensions aka multi-levels across specialties, a Most Valuable Physician position in hospital. Last week as hospitalist, I was consulted by OB for hypertension management in a post partum lady who delivered term via C-section. I enjoyed researching meds online to not interfere with breastfeeding. Proud to say ini 36 hrs her milk came in and her hypertension resolved and she and little kiddo doing well!

Posted by Susan Wilturner on May 12, 2017 at 12:14 PM CDT #

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.