Future of Family Medicine Blog Celebrates One Year of Blogging

Kevin Bernstein, MD,MMS
Co-Founder
Future of Family Medicine Blog

Just about one year ago, Sebastian and I decided to start the Future of Family Medicine Blog. During this time, the blog has been featured in local, state, regional, and national presentations as a successful example of social media use by medical students and residents. We were also nominated for best new health weblog for 2010, only 3 months after starting up! We have been cross-posted on KevinMD on numerous occasions and received international attention from the International Conference on Residency Education. Several of our authors have held key positions in the AAFP, STFM, AMA as well as within medical schools, family medicine residency programs, and state chapters of national organizations.

Although the frequency of postings has decreased recently since many of the authors have started internship and application/interviewing for family medicine residencies, we want to thank all of our dedicated readers, followers, and individuals who have shared our message with your communities, medical associations, patients, and most importantly, the future of our great specialty, family medicine.

This past week I released a video that I have worked on for a number of months to promote the Family Medicine Revolution (#FMRevolution).  I did not know when would be a great time to release it publicly and if it would actually make an impact.  Being as this is the first year anniversary of the blog, I figured it would be a great gift to our readers and loyal followers.  I also realized that this is a very interesting time for the future of our specialty:

• Many fourth year medical students are beginning to interview and may still be on the fence in regards to choice of specialty.
• This is the time where many third year medical students are beginning their time on the wards - learning about different specialties and encountering persuasive physicians and residents that either embrace their decision to choose family medicine, or contribute to the myths and misconceptions of our specialty.
• First year medical students are beginning to attend meetings with various interest groups and may be interested in the current hype surrounding family medicine.
• The AAFP is currently putting on a full-court press in regards to SGR, GME funding, the RUC, and medical student interest across the various regions of the country.

So far, the video has received social media attention around the world, including the AFMRD and STFM list-servs, and by the current AAFP President, Dr. Stream.

It really is amazing how much the Family Medicine Revolution has progressed and how much momentum family medicine has gained within the past year.  I am hopeful that this blog has helped in the process and that it will continue to provide fresh perspectives for the future of family medicine - the only true primary care specialty.

An Appetite for Authority: Psychological Subtleties of Choosing a Specialty

I recently had an interesting conversation with three fellow medical students over a jar of nutella. Two were MS IVs training at a major academic medical center (one budding peds oncologist, one future family physician), and the third was a canadian medical student. I am an osteopathic medical student comitted to pursuing primary care. The conversation started with romantic pursuits, Harry Potter, what to dip into the nutella, but soon evolved into a dynamic discussion about medical specialization, and why we do choose to do it.

Many people believe that the temptation to super-specialize is driven solely by salary…specialties pay more than primary care; they get you out of debt quicker and may allow for a cushier lifestyle. These are undoubtedly key factors for many students choosing a career path in medicine. However, money is an easy scapegoat. When salary is taken out of the equation, much more complex issues of personal investment, ego, and authority begin to surface.

The Canadian medical student in my nutella conversation was quick to remind us that our neighbors to the north don’t pay specialists much more than primary care physicians. Yet, in her view, young Canadian doctors still overwhelmingly prefer to specialize. People want to be experts. It's human nature. The pride that comes with knowing you could be the leading authority on something, and that people would come from all over the world (or all over the hospital) to hear your opinon is incredibly enticing to students. The high salary that specialists get in America is icing on a cake that already looks deliciously prestigious.

As we overdosed on chocolate hazelnut and the jar became pretty unappetizing, our conversation shifted from what’s enticing about specialties to the other side of the coin – what psychological factors turn students off of primary care. The future pediatric oncologist hit the nail on the head. She was telling us about her current sub-internship, working under general pediatricians on complex cases. Each of her patients saw a minimum of seven consults, sometimes up to nine or ten. In most cases, her attending knew exactly what the endocrine guy or the genetics department was going to say. Even as a medical student, she could predict how these consults were going to go, and yet, the culture of a medical center with limitless resources is to cover all bases, gather as many cooks into the kitchen as possible. It made the generalist’s job seem a less important. Even though he was supposed to have the final say on the treatment plan, my friend described a shifted power dynamic that made her attending the low man on the totem pole, a triaging traffic cop. “This is why I’m glad I want to specialize,” she explained. She didn’t work this hard to not be the authority on anything.

Primary care is not for everyone. This friend is going to be a fantastic pediatric specialist, and a caring physician. It would be incredibly short-sighted for me to claim that all students who choose to specialize are motivated by pride and ego. But it would also be naïve to discount these factors in ourselves. Choosing a field of medicine is a complex process that is ideally driven by geunine interest and passion, but often heavily affected by financial and lifestyle concerns, as well as the desire to validate the years of work we have put in to achieve our goals. There is nothing wrong with wanting to practice at a prestigious institution, garner respect from colleagues and be valued as a prominent physician. From time to time, however, it is important to step back and ask ourselves how much the desire to impress others is affecting the choices we make. A primary care physician might never be world’s leading expert on nutella allergies, but family doctors are the authority on their patients. The best ones take ownership of this more subtle authority, even in a kitchen full of cooks.

Bringing It All Back Home

In the scope of history, medicine has a definite tendency towards cyclical trends through generations. Recently, I've been considering the moves to incentivize preventative medicine, as well as those to reduce admissions and lengths of hospital stay. These factors are driving health care out of the hospital, and into the home. But looking though the lens of the past – we've been there before.

For the overwhelming majority of American history, health care delivery was centered around the home. Only recently, with the rise of the hospital system, have we witnessed an explosion of inpatient care. Far from this, the only care done outside the house was in charitable centers for the destitute. Further, physicians rarely maintained private offices. Early American medicine was a diminutive practice, and professional physicians viewed as a whole, were considered inconsistent at best.

Throughout the 18th and 19th centuries, the center of health care delivery was definitively the home. It was considered a familial responsibility to care for the sick of the household, and it was often beyond thought to send an ill family member outside for care. There was great tradition in caring for one's own family and considerable comfort and dignity in dying in one's home. In rare or advanced circumstances, a doctor could be summoned to the house to offer guidance. But, by and large, patients remained in bed and the extent of care was entirely within the confines of the family house.

The rise of the professional hospital system and the association of physician licensing to health facilities did much to initiate the movement of medicine outside of the home. Increased urbanization and longer work hours also limited the ability for families to care for themselves. The final blow was cast by the rise of individual health insurance, and the co-committal necessity to seek professional care. By the 1930s and 1940s, the public perception had shifted and American expectations aligned with hospital and office-based care. Since that time, health care delivery has become overwhelmingly associated with these entities.

Modern medicine is now seeing a rejuvenation in health care in the home, and a movement away from the hospital and office. Equipping patients with home blood pressure cuffs, glucose monitors, and sensitive scales allow regular monitoring of health. Many large health systems have developed integrated patient tracking programs, in which these devices automatically transmit information into the system database for that patient. Red flags are recognized by the system, and a phone call to the patient allows immediate evaluation and intervention. Further, the rise of direct care physicians has seen a sharp return to “house calls”. In the near future, a continued increased emphasis on preventative care will keep patients out of waiting rooms and tele-medicine will allow many to confer with doctors from the comfort of own living rooms.

Looking at the cyclical nature of American health care, I am reminded of the importance of remembering our roots. With the current debates and projections in health reform, perhaps it would be prudent to more fully consider the past as a means of plotting the trajectory of the future?

Another thought, which may be somewhat tangential, is no less important for the future of family medicine. As we move into this increasing technological world of health care delivery, it becomes ever more paramount that we stick tightly to our foundations. We must be resolute in our commitment to our patients and present in our compassion. We must practice a delicate and humanistic bedside manner. For that is the one thing that computers and precision medicine can never replicate – a comforting hand, a warm heart, and the dedication and trust of a life-long family physician.

1. For an extensive and enjoyable review on this subject, I would encourage EVERY medical student to read Paul Starr's The Social Transformation of American Medicine. If we understand where we are coming from, we can better be prepared for where we are going.

2. Quality of care and patient satisfaction seem to be hot topics in medicine at present. Certainly, the importance of a bedside manner cannot be underestimated. However, I find it intriguing that we are still striving for perfection in this area in the 21st century. After all, the basics of bedside manner were outlined 2000 years ago in the works of Hippocrates. Nearly 400 years ago, Thomas Sydenham wrote extensively on the details and the art of patient care. Again, with the cyclical nature of health care – before so eagerly looking toward the future and waiting for new solutions to arise, perhaps we should more often delve into the past.

How do international electives fit into medical education?

Last summer, I traveled to Vietnam with a family doctor on faculty in my school's family medicine department. The first thing he taught me when I got there was how to drive a motorcycle. Not exactly what I expected from an international health experience, but undeniably cool!

I then used my newly-founded motorcycle driving abilities (I didn't have a license, but, really, it didn't matter) as we traveled to different health communes in rural Vietnam screening local residents for diabetes and hypertension in the morning and managing more complicated long-term patients of his in the afternoon. I diagnosed and treated my own patients in the morning - dispensing new meds, modulating medication doses and talking to patients about prevention. In the afternoons, I learned about managing complicated rheumatoid arthritis, cleft palate, congenital heart defects and more - all without the help of subspecialists and generally without labs or radiology.

When I returned home later that summer, not only had I developed a solid fund of clinical knowledge but I also had developed a solid relationship with a family doctor who breathes and lives primary care, the commitment to the underserved and compassion for patients.

The AAMC Graduation Survey, which all medical students complete before graduation, found that 38% of students participated in an international experience in 2000. Most of these experiences occurred either in the summer between their 1st and 2nd years of medical school or as an elective during 4th year.

A literature review completed in 2003 of International Health Experiences of Medical Students suggested an association between international experiences and career choices in primary care specialties and in underserved populations. The article and others published suggest that students develop soft skills in empathy, compassion and others while completing an international health elective - skills that are essential for doctors but often not taught in the medical school setting.

Offering more international health electives may draw more medical students to primary care and family medicine - not a silver bullet but one strategy among many in this multifaceted cause-and-effect of student specialty choice.

What can family medicine and primary care departments do? One significant barrier to a student's participation in an international health elective is the financial burden. We need to offer more scholarships and funding for students interested in international experiences - not just our strongest students but students who are on the margin about their interest in primary care and underserved care.

Another barrier is the timing - if students miss out on an international health elective between their first and second year of medical school, they may not have another chance to participate in one until well into their fourth year... beyond when specialty decisions are made. Could medical school curricula be redesigned to allow elective time in 3rd year and the potential of international electives then?

For those interested in an international health elective, the AAFP student website offers resources in finding electives.

I personally will never forget the time I spent in Vietnam and one day I hope to return as a physician to serve there. I hope that other students will have the opportunity to pursue international health electives - not only so that we can serve those abroad but also so that we can develop ourselves into better and more compassionate clinicians.


References:
Thompson MJ et al. "Educational Effects of International Health Electives on U.S. and Canadian Medical Students and Residents: A Literature Review." Academic Medicine 2003;78:342-7.

Godkin M and J Savageau. "The Effect of Medical Students' International Experiences on Attitudes Toward Serving Underserved Multicultural Populations." Fam Med 2003;35:273-8.

Future of Family Medicine Match Day Coverage - The 2011 Family Medicine Match Results

Disclaimer: This post will be an evolving post that will change throughout the course of the week as results and statistics are released for the match in regards to family medicine.

Well, medical students - the day is here!  NRMP Match Day - a day that brings us full circle to US Grads matching into residency programs throughout the country.  It all started back in December with the military match, then continued with early match, the Osteopathic match, and now the NRMP match.

Military match stats this year had family medicine listed along with peds, ob, surg, and ortho as the most competitive for medical students participating in the military match.

Osteopathic match: "Primary care specialties of family (medicine) saw a 15% increase and internal medicine saw a 28% increase. Family (medicine) was the largest matched specialty with 373 positions filled."

Last year's family medicine match results: "more U.S. medical students chose family medicine as their specialty.. resulting in a fill rate of 91.4%, the highest percentage for family medicine ever."

This year, 172 more students chose family medicine - 2,576 family medicine positions were filled out of 2,730: a fill rate of 94.4% - impressive when taking into account that 100 more positions were available for family medicine vs. last year. Of the 2,576 candidates who selected family medicine, 1,317 of them are U.S. medical school graduates - this as a result of 133 more US Grads choosing family medicine this year (7.9% of US students chose family medicine last year vs 8.4% this year).

At 1PM EST, the NRMP released exciting results in regards to primary care!

For the second year in a row, more U.S. medical school seniors will train as family medicine residents, according to new data released today by the National Resident Matching Program (NRMP).  The number of U.S. seniors matched to family medicine positions rose by 11 percent over 2010....
  Among primary care specialties, family medicine programs continued to experience the strongest growth in the number of positions filled by U.S. seniors. In this year’s Match, U.S. seniors filled nearly half of the 2,708 family medicine residency slots. Family medicine also offered 100 more positions this year. 

This link will take you to AAFP's perspective on this year's match data.  Here is a summary of discussion:

Although the Match results are encouraging, student interest, however, is still not at the level it needs to be. Although the match rate in family medicine among US medical school graduates has increased, the majority of positions offered and filled in the NRMP, especially among US graduates, continue to be in non-primary care sub-specialties. In its 20th Annual Report “Advancing Primary Care”, the Council on Graduate Medical Education (COGME) affirms that the US physician workforce needs to be made up of "at least 40% primary care physicians" to ensure the nation's health, health care access, health care expenditures and health outcomes for the future.  
COGME projects that to reach this 40%, 63,000 additional primary care physicians are needed. If health reform succeeds in increasing the number of insured individuals, more than 100,000 additional primary care physicians will be needed. 
The number of students entering family medicine is most reflective of the future physicians who will provide primary care for adults in the future. The vast majority of internal medicine residents sub-specialize; only 2% of students entering an internal medicine residency choose to do general primary care after residency graduation in one study.

AAFP President, Dr. Roland Goertz, comments about this year's match results in AAFP's press release: 2011 Match Results Again Spotlight Family Medicine Gains

“This year’s results mark the second consecutive year of increased interest in family medicine,” Goertz said. “Although several factors likely contribute to the increase, we believe an important element is recognition that primary care medicine is absolutely essential if we are to improve the quality of health care and help control its costs. Of course, sustaining this interest will require continuing changes in the way America pays for and delivers health care to patients.” 

“Primary care has become much more visible as a result of the discussion about improving our health care system,” he said. “More people understand that if we’re to have high quality care at a controllable cost, we need to rebalance our system on a foundation of primary medical care.

Add in the heightened awareness through activities of the Family Medicine Interest Groups, and students began to understand that family physicians will be able to practice the kind of medicine they envisioned when they decided to become a doctor.” 

MedPage Today joins in on the mix and offers their perspective on primary care in an article titled "Primary Care Again a Top Choice on Match Day."

"This is good news for internal medicine and adult patient care in the U.S.," J. Fred Ralston Jr. MD, president of the American College of Physicians (ACP), said in a statement.
The organization appeared guarded, however, adding that the primary care work force still has "a long way to go" to meet the needs of an aging population with various chronic diseases.
"We're cautiously optimistic and hope that the positive trend continues, but the U.S. still has to overcome a generational shift that resulted in decreased numbers of students choosing primary care as a career," Steven Weinberger, MD, executive vice president and CEO of the ACP, said in the statement

While we continue to compile data, we invite you to visit Mike Sevilla, MD's Family Medicine Rocks! Podcast recorded earlier today on BlogTalkRadio - info about this podcast can be found at his new site, http://www.familymedicinerocks.com.