First, consider the structure of the academic course itself. The systems-based approach to medical education remains the predominant curricular modality. Under this structure, organ systems are taught by specialists who are invited to profess the proceedings of their specialty. This leaves students with cardiologists teaching cardiology, pulmonologists teaching pulmonology, and family doctors, often, on the sidelines. Certainly, every school employs faculty to a differing degree. In fact, my medical school chooses to bring in primary care providers to approach a 1-2 hour discussion on the broad implications of each system. However, these brief family medicine lectures are all ultimately followed with 2-3 weeks of intensive specialist-driven lecture. This leaves the overwhelming prevalence of educators to be drawn from the specialty fields.
I understand and appreciate the necessity of this approach, but one cannot deny the potential effect on students. How does specialty-driven, systems-based curriculum effect student perception of medicine? Does this leave a dearth of primary care role models at the frontlines of our classrooms?
Next, consider the content and focus of standardized examinations, such as “shelf” exams and USMLE step exams. Exam passages often tell a story, starting with something along the lines of,
“Mr. Smith is a 76 year old male who was referred by his family doctor for difficulty swallowing. He presents to your office today with…”
In my experience, I have rarely come across questions that highlight the role and duties of the family physician. The implication is reasonable – test-writers hope to hone in on minute details of pathology or physiologic consequences of disease. However, in doing so, is their an unintentional belittling or underplay on the value of the family doctor? Does this continued focus on the details and complexities of disease have the effect of placing an unintentional bias towards specialty care in medicine?
Further, consider a medical student’s experience in clinical rotations. Take myself for example – I am now a full ten months into my third year of medical school. Meanwhile, I have spent approximately nine of those months working on inpatient wards or in the operating room. Like most of my colleagues, I have reached the point in academic career in which I must make a decision on my residency path. Yet, is it reasonable for me to do so with 4-6 weeks of total outpatient family medicine exposure? Certainly, I would never argue with the necessity for medical student exposure to the fullest array of clinical experiences. However, does a built-in bias towards inpatient, hospital, and specialty medicine exist within this process?
Certainly, in my experience, specialists do not necessarily paint the best picture of family physicians. Far too often, I hear comments such as, “Oh boy, would you look at what their PCP did? I guess we’ll have to clean up the mess”. These sort of comments are rarely balanced by accolades or praise for general practitioner care or referral. I often found the family physician to be portrayed as a guy on the outside looking in. Ultimately, does the prevailing impression of the inpatient experience in clinical rotations generate a bias towards specialty care?
An article published in the New England Journal of Medicine on February 10th addressed the importance of the involvement of medical schools in the encouragement of primary care selection. The paramount responsibility that was implicated was that the school should place primary care physicians in leadership roles within the administration and deans offices1. This further emphasizes the importance of the medical school curriculum and environment in the process of supporting and advancing the mission of primary care.
I have asked many questions in the preceding paragraphs – this was purposeful. I believe these are all questions that remain to be answered, or questions that could be answered differently depending on the academic institution or environment. Certainly, the modern world of academic medicine provides for limitless variation. I am confident that many medical schools exist that take a balanced approach to exposure and encouragement of residency choice.
The sentiments that I have expressed are drawn from my experience, as well as discussions with my peers. I encourage you to help me answer some of these questions and contribute to a robust discussion below. At the very least, keep these considerations in your mind as you move through your training, or think about the training of others. Does this underlying bias towards specialty training exist in academic medicine?
1. Smith, Stephen R. “A Recipe for Medical Schools to Produce Primary Care Physicians”. New England Journal of Medicine, Feb. 10 2011. Vol. 364;pg 496-497.