Monday, April 11, 2011

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!


  1. All third-year medical students--or any medical students for that matter--who think they "can already do" family medicine, I encourage you to take Step 3 and the family practice specialty boards now. Then, after you realize you're not a doctor yet, return to school and plan for residency.

  2. Agree with Dr. Bayne. I think you make any profession as complex or simple as you'd like. If your skills are on par with a third year student, you might not appreciate how amazingly complex each different patient is. Simple people see things in simple terms. Some practices have no alcoholic patients. LOL!

  3. If you want to appeal to people who would want to do family medicine you should make a much more intelligent posting. Using sooooooooo is fairly childish and it is iceberg not iceburg to name just a few of your mistakes. Also, very few family medicine doctors see peds/geriatrics/ob-gyn/sports medicine. There simply is not enough time to do all varieties of medicine and make enough money to keep the lights on and pay the support staff. There is also not enough time to stay up to date on all of the current literature required to adequately treat all of these varieties of patients and problems. So you would basically be inadequately treating the majority of your patients except for the bread and butter patients that "SS" speaks about in her post. This is a very poorly written article and reflects negatively on your blog. You really should think things through more before posting especially when it is a ridiculous rant.

  4. Thank you for your comments.

    In response to anonymous - it seems like your post came from either Pittsburgh or Hershey. These are two areas in PA, along with Philadelphia, that make up the most tertiary/specialist-saturated locations in the entire state. In these locations, it is true that family medicine does not traditionally cover a majority of OB. However, family doctors in these locations do take care of a lot of geriatrics and some pediatrics.

    In regards to sports medicine, there are primary care-trained family doctors who pursue fellowships in sports medicine to gain a CAQ. There are team doctors for professional and college sports teams in all three cities that are family medicine trained with a CAQ (I rotated with several personally).

    Thank you for pointing out the mistakes in the post. We try to do our best when editing but sometimes human error gets the best of us. We appreciate the time taken out to ensure that our content is of high quality.

    Although this post may be a bit of a rant (a majority of our posts on this blog are not rants - we invite you to read all of our material) and we respect your opinion, we do not believe the material on this site reflects poorly on the overall intent of this blog. I am sorry that we did not meet your expectations and we will strive to meet those expectations in the future.

  5. A quick note from the author.

    The majority of this blog post was simply copy and pasted from an email I sent back to the committee I sit on. While it may not be as well thought out and polished as a New York Times article or even a post on Kevin MD, I did feel that the topic was good food for thought. If you go to Kevin MD today you will find a post by another medical student on the same topic (so I guess I was on to something).

    Over the course of the two 4-week rotations I did in family medicine I did see and do pediatrics/adult medicine/geriatrics/and some gynecology. I was also exposed to family docs that do procedures, cover high school football teams, work in a county prison, and participate in organized medicine. All while staying very up to date on the latest evidence based treatment options and providing the best care possible for their patients.

    Frankly it is the attitude that no family doctor could possibly see all of those types of patients and do it well that has lead to the negative view of the specialty, when this simply is not the case.

  6. I respect and appreciate the blogger's observations - this is an opinion page after all. And he's right; the challenge in teaching and exposing med students who aren't looking for FM is that you can't easily define the specialty; it doesn't fit into a little box or brief elevator speech, nor should it. Debate is welcome, and everyone has the opportunity to comment, constructively or otherwise.

    A conference like NC does a great job bringing the many varied aspects of FM to the audience, and connects students with the diverse areas of FM that pique their unique clinical interests and sense of social justice and with FM residents, attendings, and national leaders who all share the same passion for FM in all its glorious complexity.

    FM isn't easy. If it were easy, everyone would do it. It's disappointing to FM advocates to see how med schools systematically rob students of the opportunity to have a meaningful primary care experience because of how the curriculum breaks everything up into relatively short block rotations. Many times, only those seeking it out will have a good experience, because they work for it.

    As a fortunate consequence, the med students going into FM, like the contributors to this blog, are passionate, persistent and elequent advocates. Thank you FFM contributors - please keep up the fight & don't minimize your outrage.

  7. "[T]he problem is that [family medicine's] image is so large, when viewed through the tiny view hole of medical school you only see a small part of it."

    Well put. This problem is absolutely the most difficult thing about pitching the field of family medicine to medical students, especially if they aren't familiar with the specialty prior to entering medical school.

    The breadth of different experiences family docs can have is incredible -- I myself have covered high school football games, prescribed suboxone in an opioid addiction program, and worked in urgent care settings performing I&Ds and laceration repair right along side family physicians in locations all over my state. Well child checks, obstetrical evaluations, and pap smears will certainly be an important part of my practice after residency. I also hope to continue to round on my patients in the hospital if my time will allow.

    The beauty of family medicine is that I can tailor my practice to anything my patients need, and be flexible enough to tailor it anew when my patient population changes.

    The best way to get exposed to the variety of ways family docs across the country practice is to come to the AAFP National Conference for Residents & Students in July. You won't regret it, no matter what you end up deciding to do with your medical education.

  8. Stimulating post and comments. Dancing with the wolves is hard to describe, but it's fun. At the confluence of the complexity of family medicine and the simplicity of a communication with a patient or medical student about it is a beautiful human moment. You may quest for it if your mirror anoints you a Family Physician. Others don't see a Family Physician in their mirror, and wisely align with their own career truth.