What's wrong with the way I look!?

Several weeks ago, one of the docs on a committee that I serve on sent out a link to the group to an article titled "Primary care's image problem," which you can find by clicking here.

The question to the group: tell me what you think? First let me give you some background. The article's author came across another blog by medical student SS (oddly enough by a friend of mine who attends Columbia) that was cross posted on KevinMD. In her blog, SS describes her experience working in an outpatient VA clinic. Rather than paraphrase, here is what she said:

It was awesome because I was the “doctor.” I essentially had full responsibility for each patient. From calling him in from the waiting room to deciding what medications he needed and at what dose, and everything in between, he was my responsibility. After I saw the patient, I’d present the case to my attending for a few minutes, we’d discuss and he’d teach for a minute and modify my plan a little if necessary, then the real doctor would go in and say hello and sign the orders I had suggested. I was my patient’s health care provider – a phenomenal feeling and an awesome transition in that I now think of myself as a capable clinician-in-training.

But that’s why I found primary care to be boring. I could do it. As a 3rd-year medical student. The cases I saw were by and large obesity, hypertension, diabetes and hyperlipidemia. A little tweaking of drug doses here and there, lots of education about lifestyle changes, plenty of questioning to assess for target organ damage, referrals for specialist followups… and far too much of “staying the course.” And if this is what most of family medicine/primary care is like… I don’t want to do it for the rest of my life.

The blog's author uses this rather short excerpt to make her point that we in primary care have an "image problem." To quote the article's author:

If you spend much time reading blogs and online discussions among medical students, however, the attitude that primary care is unexciting is far from unusual. And it’s not clear how much of this is based on reality and how much is perception.

She continues later:

But the article also hits on another factor: the high expectations of many medical students for a career that’s both intellectually and financially rewarding. These students, after all, are quite elite – very bright, very hard-working, competitive and achievement-oriented, with high aspirations for their future – and this sometimes leads to feelings of entitlement. When this is the mindset, primary care often simply can’t compete, especially if students perceive (mistakenly) that it’s easy enough for any rookie to do.

So, then the question to our small group of 2 family docs, 1 resident, 1 student (me!), and 1 chapter executive: Tell me what you think and what we can do to fix this at National Conference?

Well, here is what I think:

You have to start by looking at the background of how SS came to form her opinion. She was doing a 5 week, outpatient internal medicine rotation at a VA clinic. This tells me a lot about her experience. First, since its IM and not Family, that means no kids. No kids in my office alone would make it very boring for me. Beyond that, she's working at a VA clinic, which at least in my experience is predominately older men. So few women if any and certainly no OB or GYN. Last, and also because of it being a VA clinic, I would argue that all she saw in 5 weeks there were chronic care follow ups and med checks. Again, speaking from my experience, most of the older vets that use the VA system go there once or twice a year to have lab work and get their prescriptions at a lower cost, but then see their own physician for more acute problems.

To sum all of that up, she spent 5 weeks outpatient seeing virtually only older men with chronic problems who needed their blood pressure checked and their medicines refilled. And when you put it like that - hell yes is that boring. The problem is that Family Medicine is so much more than that. Acute problems mixed with chronic follow up mixed with procedures mixed with starting people on their chronic meds mixed with babies, kids, young adults, older folks, and for those in a rural practice the occasional pet or two. But did she see any of that in her five weeks. No. Do most students see even half of that? No. With not every school requiring a family medicine rotation and some not even an outpatient general medicine rotation, how could you expect any student to get exposed to all that family medicine has to offer by simply going through their rotations?

The author of the article says that we have an "image problem." I would say that the problem is that our image is so large, when viewed through the tiny view hole of medical school you only see a small part of it. And unfortunately far too often all students see is that boring little corner of chronic care follow ups or viral sinusitis. I dont think there is anything we have to do differently at NC to help fix this. The great thing about NC is how diverse the programming is - all the different realms of family medicine that are put on display through workshops, seminars, and even the diversity of the residency programs. We just need to get people to COME AND SEE THAT. (see below)

And for those that can't, we need to make sure that we are reaching out to departments and sharing resources so that they can reach out to their own students (one on one if they have to) to show them all that family medicine has to offer them. We need to make sure that schools have good preceptors available to them for rotations in all practice settings so that they aren't stuck sending drones of people to clinics like the VA (not to say that the VA isnt a valuable experience). And lastly, we need to reach out to those students that are even marginally interested in what we do and be sure to fill in the missing pieces of the bigger FM image so that they can walk away from their rotations saying "gee that was the tip of the iceberg" rather than "gee, if that's all there is, I sure dont want to do it"

For all you students out there reading this: COME TO NATIONAL CONFERENCE!

www.aafp.org/nc