Taking the Plunge or Taking Off? Advice for Starting as a Family Medicine Resident

Have you ever seen a B-52 Bomber flying in mid-air?  If you haven't - just humor me and imagine a big 'ol plane soaring at about 10,000 feet :)

How do you think it gets up there?  Well, we know it certainly doesn't just pop up in mid-flight, ready to rock and roll.

There is a lot of work that goes into getting one of these 500,000 pound planes off the ground.  First - original design plans are drafted, followed, tested, and reviewed.  Sounds a bit like college, huh?  I'd like to think of it that way - a college student is a blank slate, looking at all the different models they can choose to build of themselves.  Whether one strives to be a lawyer, a doctor, or even an elementary school teacher - the first step is to start by sitting down and drafting plans.

From here, I like to think that medical school is the period of assembling the plane.  Parts and pieces are gathered from all over and combined to build this perfect machine with a directed purpose.  While the pilot is reading the instruction manual, the fuel tanks are being filled (with knowledge! Sorry, I couldn't help but throw in a little cheese).  Medical school is all about making sure the plane is ready for that first flight.

Residency is like take off.

As a new intern in family medicine this year, I have spent the greater part of the last year trying to gather advice from my predecessors.  Over and over I have heard comparisons of residency to "taking a big plunge" or "stepping into fire" or worst of all - "being pushed off a cliff".  Wow. 

This is why I like to think of my first two months of residency as the start of my "Take Off".  My plane is built, I have all the equipment ready to fly, and I've got the manual down (mostly).  I just need a short period of going down the runway, building up speed, and checking all the instrument panels, before I'm ready to take flight.

So my plan in writing this post isn't to rehash any of the same recommendations that you've likely read before, i.e. - "be nice to the nurses", "be on time" etc.  I'm writing this to invite you to consider residency from a different perspective, one opposed to the pessimistic downtrodden black hole that many of us have been trained to believe it will be.  Rather, think about it this way - if you were fully prepared to be a practicing physician on the day of medical school graduation, then why would we need a residency period?  These three years are a time to grow, a time to test your limits, and most importantly - a time for you to build up speed for your big take-off.

Certainly, the hours and days will be long.  But you can do much to prepare yourself for that.  Dedication to sleep, nutrition, and exercise will go far in combating the evils of prolonged and straining work requirements and environments.  My previous post on advice for first year medical student, still holds very true.  After all, this is a building process, and we cannot neglect our foundations.

At the risk of reaching hyperbole, I'll stop just there.  But allow me one more indulgence on the analogy.  While I like to think of myself as a B-52 bomber -sturdy, reliable, and loaded with firepower :) Maybe you are a different sort of plane - an F-15, or stealth bomber, or even a Zeppelin! Ha.  The great news is that in the world of family medicine, there is a residency (or runway) perfectly built for each of us.

Primary Care, Subspecialist Physician Payment Gap Narrowing - Are you listening?

The Family Medicine Revolution is happening before our eyes.  The payment gap between primary care and specialties is shrinking - is anybody listening?

According to a recent Medscape article titled "CMS Proposes Primary Care Raises Funded with Specialist Cuts," Family Medicine is set to get the highest raise of all specialties with a 7% jump.  This is great news when considering Medical Group Management Association (MGMA) recently reported that, when considering 2011 statistics, primary care docs saw a 5% increase in pay compared to the previous year.

CMS administrator Marilyn B. Tavenner states that "helping primary care doctors will help improve patient care and lower health care costs long term."  The Vermont Medical Society produced an article that explains the proposed rule by CMS in a bit more depth.  In an AAFP News Now article published today, 11JULY2012, states that the proposed rule would pay for non face-to-face care as well as care-coordination.

An article by MedPage Today discusses the potential investment in primary care-coordination during the 30 days after a patient is discharged from a hospital stay as an investment worth making - getting patients appropriate follow-up to prevent bounce-backs, readmission rates, and other costly inefficiencies that go along with inadequate primary care follow-up, specifically with a family doctor.  I say specifically a family doctor because this is also a statistically significant data point in recent studies by the Graham Center, not just because it is a biased opinion.

One of the main driving forces for medical student interest for primary care and Family Medicine as a specialty is the gap between reimbursement for services provided and salary achieved for specialists compared to primary care.  This of course was carefully outlined in the Council on Graduate Medical Education's 20th Report, "Advancing Primary Care."   Of course, it does not take a formal report to understand that a difference in pay that averages about $3.5 million over a lifetime can be quite influential to a medical student set to graduate with greater than $200,000 in student loans.  This is not anecdotal, it has been extensively researched by COGME, the Graham Center, and a number of other studies.

Look no further than the military in regards to how payment disparities, or lack thereof, can lead to the production of more primary care doctors.  Take into consideration the annual incentive pay between the different specialties within medicine.  The largest payment disparity between a military family doctor with the same number years of service, rank and the same number of dependents as a military doctor who hit the ROAD (Radiology, Ophtho, Anesthesia, Dermatology) will usually be about $20,000 per year.  Compare that with the civilian world where the disparity is, on average, about ten times that amount.  It is no wonder why the Uniformed Services University of the Health Sciences continues to rank in the top 10 in matching its students to Family Medicine Residencies.  Is this the way that civilian medicine should go in regards to paying physicians?  Probably not.  However, it is interesting how the military world values a foundation in primary care and how it values all of its doctors appropriately within its single-payer system.  

So, where are we heading?  Are new CMS proposals going to make a difference?  Are medical students listening?  Are current family doctors who persuade medical students away from the specialty changing their message?  Will the American Academy of Family Physicians Task Force on Primary Care Valuation truly influence CMS?  Are the new increases a way in which CMS did actually in fact take the AAFP's recommendations rather than the American Medical Association's Relative Value Update Committee's consistently secretive, non-transparent valuation of specialists services?  Only time will tell.

Something that should be listened to and resonated around the country originates from a recent tweet by the American Academy of Family Physicians Family Medicine Interest Group account states: "A new study shows compensation of primary care docs (>$200,000) grew at a faster rate than specialists in the last 5 years."  Now that is something worth talking about.  

Instant Review - Get Family Medicine Out of the Shadows

I must say, it has been a while since I was geared up enough to write a post so quickly after an article has been published.  This immediately changed about 10 minutes ago when I read the following article on Huffington Post by Ranit Mishori, MD, MHS in collaboration with a good friend of Family Medicine, Larry Bauer of the Family Medicine Education Consortium.

"Time for Total Family Medicine -- Get Family Medicine Out of the Shadows"

Contained in this piece is a wonderful assortment of problems Family Medicine continues to face as our country's failed system has evolved over time, specifically within the past 20 years.  In fact, this is probably one of the best overall summaries I have seen in quite some time, really taking everything and putting it into one article.  Many of these ideas have been highlighted by a number of our authors and we really do appreciate the time Dr. Mishori and Larry Bauer put into creating this masterpiece.

Similar to a post I wrote back in December 2010 titled "What is Family Medicine," Dr. Mishori describes the frustration Family Docs face when explaining the specialty.  Many people still do not understand why we run from the pediatric floor, to deliver a baby, and then back to the clinic to see our panel of patients ranging from newborns to the elderly.

Me: "I'm a family physician."
Woman: "Oh, you're an internist." 
Me: "No, not really. I am a family doc. I also see children." 
Another woman: "So, you are a pediatrician"? 
Me: "No, I am a family physician. I also deliver babies." 
First Woman: "Ah, so you are an Ob-Gyn!"

Other major points landed in this article deal with NIH funding - 10 cents per $10 of NIH funding goes to family doctor research, much of what is being done in the communities, where >90% of the USA is actually receiving their care and expecting good outcomes.

The author talks about having a seat at the table for valuation of physician services.  As many already know, we have mentioned the RUC (I will say AMA's RUC no matter how much they deny to have an official hand in it - how much do they make on those coding books again?).  As the RUC is currently sub-specialist dominated, I am still convinced that no major changes will be made to go along with COGME's 20th Report - Advancing Primary Care to get the gap in pay for primary care decreased to 70% of sub-specialists.  To be fair, I will say that family doctors do have A seat at the table.  It is interesting how primary care makes up about half the pie of Medicare services but barely has representation at the table valuating said services.

Dr. Mishori also incorporates the "Too Smart for Family Medicine" routine that we so frequently hear about.  Over here, we say that Family Medicine is a waste of your talent.

Much like the initial calling for the Family Medicine Revolution by Jay Lee, MD, Dr. Mishori ends the piece, calling on all of us to rise up to the occasion and change the current culture:

Some of this needed change requires those of us in the field to step up. Maybe we've bought into our own misconstrued image, as the crunchy granola docs, and don't like to rock the boat. Enough. Total docs, let's rock. Let's demand a place at the table of decision makers. It is fine to be the "sensitive" M.D.s -- we believe in that value -- but we need to wise up when it comes to getting our message out.

Let's wise up and get that message out!  Hoping that this can bring some energy to the upcoming AAFP National Conference of Family Medicine Residents and Medical Students in July as well as the AAFP Congress of Delegates this upcoming fall in Philadelphia.