Friday, March 22, 2013

My parents don't think I'm smart enough for family medicine - One medical student's story

I'm so excited to join the #FMRevolution and am coming on as an author for the Future of Family Medicine blog. A little bit about me: I'm a 4th year medical student at Stanford University who just matched at the UCLA Family Medicine Residency program for next year. I also have my MS in Health Policy and Management from Harvard School of Public Health

The day before Match Day, I wrote a guest post to Stanford's Scope Blog about my decision to pursue Family Medicine, and I'm reposting it below as my introductory post. I've been amazed by the reception in all honesty, with already 2500+ shares and growing. I think it's an indication that change is in the air. I look forward to posting more about the future of Family Medicine here. Follow me on twitter at @RayCTsai or on my personal blog where I document my personal journey towards healthy living (though I stopped posting for residency applications, but will start back up soon). Thanks! 

I’m not sure why my parents were surprised when I told them that I was applying to go into family medicine. It seemed like a logical transition after spending six years working in public health and primary care before medical school, but from the perspective of Taiwanese immigrant parents, I couldn’t have made a more absurd career choice. I was confronted with comments such as, “Most people choose careers to make money – why aren’t you?” Even more jolting was when they asked, “Why are you throwing away years of hard work and accomplishments?” I was flabbergasted by the line of questioning, but they’re my parents, so I had to answer the fundamental question – why family medicine?

For me, the answer is simple: I went into medicine to improve the health of my community and our society, and when I think about the most pressing health issues facing our nation, it’s preventable lifestyle disease. According to the Centers for Disease Control and Prevention, more than 75 percent of our health-care costs and 7/10 of deaths stem from chronic diseases that are largely preventable.

As a medical profession, we’ve largely been unsuccessful at getting people to engage in healthy behaviors. Luckily that’s where family medicine doctors are uniquely positioned to succeed. For one, the family physician has the breadth of training to serve everyone in a community, and in doing so, can influence community behavior as a whole. This approach is vitally important since lifestyle choices are never made in the clinic; they’re made in communities based on social norms set by families and peers.

Second, as I’ve learned through my own journey of overcoming obesity by losing 40 pounds in the past year, so much of one’s ability to implement healthy lifestyles hinges on one’s sense of self-efficacy. Again, that’s where the family physician comes in. A family physician has the benefit of deep interpersonal relationships developed through continuity of care to more effectively cheerlead and coach a patient to success. If executed correctly, family medicine has the potential to succeed in promoting healthy lifestyles, improving community health, and actually preventing disease in ways we haven’t been able to before.

The potential for primary care to fix our society’s biggest health-care problem and to have a real impact on overall population health is why I’m choosing to go into this field. Increasingly, policy makers are turning towards primary care to fix a health-care system that’s becoming more expensive than we as a society can afford. As that happens, I want to be at the front lines leading the charge and developing impactful solutions.

When I told my parents this, their response was, “There are already a lot of smart people who are trying to fix this problem and unable to find an answer – so what makes you think you can?” In essence, they don’t think I’m smart enough for family medicine. The problem that primary care has been charged to solve is so big that my parents don’t think I can do it.

Maybe my parents are right, but that won’t stop me from trying. Ignoring the issue doesn’t make it any less urgent. To communicate this to my parents, I responded with a Chinese proverb they taught me long ago, “Plugging up your ears so you don’t hear the fire alarm doesn’t mean there isn’t a fire.”

Wednesday, March 20, 2013

Jammin' for Health

There is a palpable need for innovation in health care right now.  We know the traditional, reactive, fee-for-service doctor-centered model that we want to leave behind, and we can imagine the integrated, team-based, patient-centered vision for the future, but it still seems like we need more innovative and concrete ideas for how to get from here to there.  Coming up with these ideas requires insight and creativity, but is innovation just a switch you can turn on?  A group of our students and faculty recently decided that you could practice innovation, and do it better.  Believe it or not, one place to start is jazz music.

Years and years before I came to medicine, I practiced innovation.  I've played the trumpet since I was eight years old, and when I was in high school, I learned to play jazz.  I remember the first time I was asked to improvise a solo with my jazz combo I was terrified.  Some of my band mates were older and I respected them.  I was afraid I didn't have the "right" musical ideas to impress the group.  And improvising seemed so disorganized!  But I learned from my teachers back then a paradox of jazz music: through discipline and practice, creativity can flourish.

John Kao thinks innovation is the same in other fields is the same as in music.  Kao is a business consultant who fosters innovation in large organizations, and his idea is that we can't just wait for "innovation" to happen, we have to take a purposeful approach to gather individuals and share ideas in an open, creative, iterative process. 

As the future of Family Medicine, we should be ready to produce the next new ideas.  Some in our local primary care community have decided to do that in an intentional and effective way, by experimenting with this idea and translating it from Kao's business world to ours. 

The group launched successfully this month and we plan to meet monthly, in the evening, for an hour or two.  There is no "take-away" other than any new insights you pick up.  And there are a few ground rules:
  • After you introduce yourself, you have to offer an idea to add value to the health of your community.
  • No idea is wrong.  In fact in jazz masterclasses, there is a common phrase, "there are no wrong notes, just different choices."
  • We use the Step-up, Step-back principle: If you find you've been talking a lot, step back.  If you find you haven't been talking much, step up.
And then we just go around.  Like in a jazz band, everyone has to solo...

Monday, March 18, 2013

Medical Schools Continue Fraudulent Reports of Primary Care Workforce Production

It is March Madness once again!

Once again, medical schools continue their annual fraudulent and misleading statistics in regards to primary care workforce production.  The Dean's Lie is back and rampant across the country.  It only seems to get worse.  

When will they learn?

USA Today: "Match Day: More medical graduates enter primary care"
About one-quarter (11,762) of the applicants matched to resident positions that train doctors to be on the front line of care — in the areas of internal medicine, pediatrics and family medicine — where serious shortages exist. 
L.A. Times: Match Day 2013 results are good for future internal-medicine patients (apparently not for Family Medicine patients)
.... more med students are headed toward residency programs for internal medicine-primary care and med-peds, which combines internal medicine with pediatrics. Interest in med-peds programs is up 13% from last year, and interest in primary care is up 20% since 2011.
Physician News Digest: "Match Day Results - More primary care doctors than specialists"
More U.S. medical school seniors committed to primary care residencies over specialty positions in the largest Main Residency Match in the history of the program.
The American College of Physicians confused me the most:
Internal Medicine residency match results encouraging for adults needing primary care.... The great majority of current internal medicine residents will ultimately enter a subspecialty of internal medicine, such as cardiology or gastroenterology. Only about 20 to 25 percent of internal medicine residents eventually choose to specialize in general internal medicine, compared with 54 percent in 1998
Compare the title of the article to the content - so what you are saying is: the match is encouraging for primary care, but most of those residents are not going to practice primary care.  It all makes sense to me now!

Before identifying those who play along with the Dean's Lie, it is important to recognize those who finally get it.

Harvard: Always looking to set the example.  
"HMS no longer calculates the number of students going into primary care because it is impossible to determine how many of those who go into internal medicine will eventually go into primary care versus specialty care."
We are also still waiting for that Harvard Family Medicine Department.  Bueller?......  Bueller?.......  My best friend's sister's boyfriend's brother's girlfriend heard from this guy who knows this kid who's going with the girl who remembered when Harvard's Family Medicine Department existed. I guess it's pretty serious. 

Dr. Mintz' Blog: "Residency Match Results Bad For Primary Care (again)"
Musing's of a Dinosaur: Argues that OB/GYN should not be included as primary care

It is also of utmost importance to recognize those graduating medical students that stuck to their personal statement and joined the Family Medicine Revolution.  It is also very important to recognize all those matching in primary care residencies who plan to join the primary care workforce.  The Family Medicine and primary care community is counting on you to prove the following data wrong!  How often is it that an author asks to prove their data wrong?  Please, prove my data wrong.

As per the previous Dean's Lie Post, let us assume a 80-90% sub-specialization rate in internal medicine and a 50-66% sub-specialization rate in pediatrics (and some rounding, because I can).  Also, let us keep in mind the objective specialization rates: JAMA December 2012 20-25%; another JAMA article publishing results of a survey showed 98% plan to sub-specialize within internal medicine.  

Here is your list of examples of all medical schools misleading the public (additions will be ongoing as erroneous data continues to be publicized for misinterpretation by its readers):

It's extremely unfortunate that the Dean of a brand new medical school at FIU is not immune to the Dean's Lie
Dean of the medical school John Rock said more than half of this year’s graduates will be going into primary care, and about a third landed residencies in Florida. Those two numbers are key, as increasing the supply of primary-care physicians — and making sure a good number stay in Florida — were two of the main justifications for state leaders’ decision to grant FIU a medical school in 2006. FIU’s College of Medicine officially opened its doors three years later.
62% of Meharry graduates headed into primary care (not quite).

Guess what?  Indiana University to fill primary care need!  They only mention a few out of their class of 304.  No other stats mentioned.  They were probably watching basketball at the time.

55% of Marshall graduates enter "fields defined as primary care in West Virginia: family medicine, internal medicine, OB/GYN (?), IM/Peds, and pediatrics."  Why, Marshall, why?

Some 42% of UAB graduates will enter primary care residencies.  It's unfortunate that not all 42% will remain in primary care.  It's also unfortunate that the general reader does not know this fact.

The Atlanta Journal-Constitution's headline: "More than 50% of Georgia medical students receive a primary care match."  Looking into a crystal ball, the author states that the following schools produced "Primary Care Physicians": Morehouse School of Medicine with 67 percent, Medical College of Georgia with 40 percent, Mercer with 61 percent, Emory with 38.7 percent, and Philadelphia College of Osteopathic Medicine's Georgia Branch Campus with 52 percent - and they did not even start residency yet!  That is power.  Do these schools do a better job than most at producing primary care physicians?  Absolutely.  However, how can anyone state that these schools already produced primary care physicians?  It is a shame that this author was fooled by an entire state worth of medical school deans.  Case in point:  read the following statement from Morehouse School of Medicine's dean:
According to Dr. Valerie Montgomery Rice, dean and executive vice president at Morehouse School of Medicine, 96.3 percent of MSM seniors received a match. Of those, 67 percent matched in primary care and core specialties, a testament, Rice said to “us identifying students who are aligned with our mission, which is to work in under-served areas and have a high affinity for primary care.”   
But, Dr. Rice - 3 of your 52 students that matched are going into Family Medicine = 5.8%, of your 14 graduates matching in pediatrics, maybe 7-9 will practice primary care (15%), and of your 8 that matched in internal medicine, 1-3 will stay in primary care  will practice primary care (a generous 6% of the class.  So, in actuality, maybe 26% of your class is going to practice primary care medicine in 5 years?  To be totally generous, we may get you to 30-35%.  We are still about 50% short of your number.  Where are you hiding your other primary care graduates?  Let us add OB/GYN: if we consider all of them primary care doctors, then we get to 12 more percent.  We are still very short and I am still very confused as to where this data is coming from.

33 of 55 graduates from Texas Tech will practice primary care - we are talking about practice.  Where is Allen Iverson when you need him?

In a rather sobering piece, OnCentral from South Los Angeles reported that only 1 of its 16 graduates from Charles R. Drew University matched into Family Medicine.  The report also makes mention that this program matched 18 out of 24 into Family Medicine in the 1990's.  That is old school.

We do appreciate Tufts for their Maine track - 7 of its 32 students matched into Family Medicine.  They do state that a total of 16 from that track will pursue residencies in primary care fields.  Assuming a good mix of pediatrics, IM, Med/Peds, and assuming that many going for the track are more likely to go into primary care, this may be the closest to the 40% that COGME recommends for primary care workforce.  It is unfortunate that others do not do the same.  It is also unfortunate that Tufts states that 39% of its overall class will pursue potential careers in primary care.  Good job on them to throw in the word "potential."  That is more accurate.  Hopefully the general public will read it the same way as it was intended.  

Eastern Carolina University tells its local NBC news station that 58 percent of their graduates chose primary care.  Hopefully this was also televised so that those who were unable to read this were able to watch it on their evening news.  This is a true testament of their "sense of commitment" with primary care topping their list!

A vague statement, such as "43 percent matched into a primary care residency," is also misleading.  The University of Connecticut knows that this will not accurately translate into primary care doctors.  A majority of its readers will most likely perceive this as a medical school that is pumping out primary care doctors.  A majority of its readers will also not read my comment because they still have not approved it.

Over 55% from Albany Medical College will enter primary care specialties, including family practice.  At least get the name of the specialty correct - that would be Family Medicine.  Thanks.

University of California Health gives us an action-packed story full of inaccurate information from all of its medical schools.  UC-San Diego: 40% , UC-Davis: 48.6%, UC-San Francisco: 48%, 
Lee Jones, associate dean for student affairs, said students in the Class of 2013 matched to “really solid,” high-quality programs throughout the country, including residencies at Harvard University, Stanford University, UCLA, the University of Washington and other top-flight institutions, as well as UC Davis. The percentage of students entering primary care increased once again, reaching a 10-year high, he said.
According to the University of Iowa's publication, Iowa Now, the headline reads: "More than 40 percent of the graduates chose primary care specialties."  Iowa Now must be stuck in the past.

The University of Hawaii tells Hawaii News Now: Typically, more than 60 percent choose the primary care route, one of the highest percentages in the nation.  They do not break it down further in the article.  So, I am assuming that over 65% are going into Family Medicine?  That must be a record. claims that 40% of the University of Michigan graduates will pursue primary care.  The article also states that half of Michigan State's class will pursue primary care specialties.  It is a good thing that the author used "pursue" given that many of them will not end up within the primary care workforce.  

In the Columbus Dispatch, Ohio State claims that about 40% of its seniors are entering primary care... maybe primary care residencies but definitely not the primary care workforce.

Dean Krugman at University of Colorado personally told the Denver Post that 45% of this year's class is focused on primary care.  Many of those will also be focused on pursuing a sub-specialty fellowship in 3 years.

Wright State with 50.5%.  They do not provide any good quotes from deans, etc.  Probably a good strategy.

The Medical College of Wisconsin believes that primary care attracted 38% of its graduates this year.  It's a tough bullet to swallow with 14% going into internal medicine, 12.5% pediatrics, 9.5% family medicine, and 2% med/peds.  Adjusted for the Dean's Lie, it's closer to about 17-20%.  Ouch.

Florida State School Of Medicine sending 51% of graduates into primary care residencies - also misleading given the dean's lie. Yes "primary care" residency - all practicing primary care in 5 years? False.  Initially reported at over 60% by FSUSoM on twitter, prompting this conversation.

LSU-Shreveport - 49 out of 115 graduated will geaux into primary care fields.  

Most accurate assessment of the day: courtesy of the South Jersey Times.  Apparently, some graduates from UMDNJ are studying to become primary care physicians in the specialties pediatrics and OB/Gyn. That is all.

The University of Washington did not lie.  Thank you.

University of Utah: they are watching primary care production closely, stating that 26 of its 73 matching seniors will enter primary care residencies.  We will be watching closely too.  Please report back in five years.

I understand the love affair with this piece by a Stanford medical student who defied the odds of attending Stanford to match into Family Medicine. It is definitely well-written and should be shared.  I agree and published this piece a while ago - Family Medicine is a Waste of Your Talent!  

Stanford also tripled its usual matches into Family Medicine, with its school usually producing 2-3 grads out of over 90.  This year they matched 8 out of 91, still among the nation's lowest. I did praise Stanford in the past for avoiding the Dean's Lie in my original blog post.  They just could not avoid it this year - courtesy of Dean Charles Prober, MD:
It was also somewhat unique in that almost half matched in an area of general medicine — pediatrics, general surgery, ob/gyn
Wandering back to the state where I received my undergraduate, graduate school, and medical education - Pennsylvania!

Temple made no mention of primary care production.  Primary care was nowhere to be found at UPenn Medicine.  Penn State knew better.  Jefferson did not release any information. It is probably better that way.

University of Pittsburgh - 50 of 142 students matched into primary care fields.  Did they mean Heinz Field or the primary care workforce?  They post on blogger, hopefully my comment will be approved.

Last, but not least, is my alma mater!  How could I forget about you?  My bank account receives monthly reminders.  

Drexel University College of Medicine informs CBS Philly that 39 percent of its 260 graduates matched to residencies in primary care!  I can tell you from those that matched "primary care" two years ago, many are not going to end up in primary care.  They also did not mention how many matched into Family Medicine (not many). 

If there are any schools that need to be added and I have missed, please submit your story in the comments section!

So what does this all boil down to?

According to the AAFP (and logic), it is much more accurate to analyze medical school graduate statistics from at least five years ago.  This takes into account the number of residents that do not enter fellowship training after they complete their three or four year residency program. 

In an effort to properly educate the general public who do not understand the Dean's Lie, I have initiated an effort to reach out to the various media outlets that are publishing false data with this message:

Your story is misleading, false, and contains fraudulent information provided by medical schools. Also known as "the Dean's Lie," only about 20-25% of internal medicine residents remain in primary care (this is from the American College of Physicians, confirmed by JAMA study 2012;308(21):2241-2247, down from over 50% in 1998). Internal medicine residencies should not be considered primary care residencies if an overwhelming majority do not practice primary care. Moreover, for a more accurate measurement of primary care workforce production, the percent reported that match into primary care should be based on looking at match data from 5 years ago (2 years after residency training). When looking at this data, the overall primary care workforce is trending towards and below 30%, much lower than COGME's recommended 40+ percent primary care workforce.  
Is it my personal mission to taint the mirage painted by medical schools?  Perhaps. Are some schools better than others (including those listed) at pumping out primary care doctors?  Absolutely!  

Prime example: University of Minnesota-Deluth 
44.1% of the 59 students who will graduate in May selected Family Medicine as their choice of residency 
From the AAFP 2012 Top 10 for Family Medicine production:

The Brody School of Medicine at East Carolina University: 20.9 %
Oregon Health & Science University School of Medicine: 18.4 %
The University of North Dakota School of Medicine & Health Sciences: 18.1 %
Uniformed Services University of Health Sciences: 17.2 %
The Joan C. Edwards School of Medicine at Marshall University: 16.8 %
The University of New Mexico School of Medicine: 16.2 %
The University of Iowa Roy J. and Lucille A. Carver College of Medicine: 15.9 %
The University of Kansas School of Medicine, with 15.4 %
The University of Washington School of Medicine: 15.3 %
The Sanford School of Medicine at the University of South Dakota: 15.2 %

There are other great primary care, rural, urban, and similar pipeline pathways at medical schools producing primary care physicians at alarming rates.  These are the success stories that need to be shared and recognized as best practices for contributing to our primary care workforce.

In summary:

At some point the truth must come forward.  Hopefully a major media outlet (NYT, WSJ, etc) will educate the public rather than continue to publish erroneous data while glorifying institutions that minimally provide solutions to primary care workforce production.

Forbes did:
"(This) error was widely reported in the media after Match Day last week. On Match Day, medical students learn where they will continue their training.This year, the number choosing primary care specialties such as internal medicine, pediatrics, and family medicine rose.... About four percent of American medical graduates are choosing careers in primary care. As the number of primary care residents grow, this number will probably increase a bit, but I wouldn’t count on it. About eighty percent of the time, primary care residents choose to move on to a subspecialty. The reasons are complex, but not unknowable." 

Future of Family Medicine: 2013 Match Day Breakdown

Another year and another successful Match Day for 4th year medical school graduates.  Once again, both primary care and family medicine residencies gained interest, applicants, and matriculants. The 2013 Match results demonstrate gains in these areas for the fourth year in a row.

2013 NRMP Match Results:  Family Medicine had 2,914 of 3,037 PGY-1 spots fill this year, which is a 95.9% match rate.  This is up by 0.6% from last years 94.5% match rate when 2,611 of 2,764 PGY-1 positions were filled. Of note, however, only 44.6% of PGY-1 spots were filled by US medical graduates, marking a significant decrease from 2012 (48.3% last year).  For reference, Internal Medicine residencies saw a 49.9% US medical graduate rate. To drill down on this further, their were actually more US graduates that applied to family medicine in 2013, but the additional 273 new spots nationwide altered the percentage that were ultimately filled by US grads.

Also read AAFP News Now coverage of Match Day at: Family Medicine Match Summary.

The Osteopathic Match: Family medicine continues to be the largest matched specialty among osteopathic medical students, which announced the results of the 2013 osteopathic match in mid-February. Family medicine saw a 11% increase from last year, and was the largest matched specialty with 472 positions filled. This is well inline with studies that indicate that over half of DOs practice in a primary care field.
More medical schools continue to open, and existing schools expand class sizes to meet the growing health care needs of the American people. It follows that this year’s match had more applicants than any previous year.  In all, the 2013 graduating class matriculated 800 more foreign-born and International medical school graduates as well as nearly 300 more Osteopathic grads than last year.  

For the past four years, the Match has shown an increasing trend of medical students choosing paths in primary care.  Many suggest that this is a result of the more common occurance of primary care in the grander dialogue of the future of health care, or the boosts that primary care has recieved in policy and legislation recently.  However, some contend that the increases that we are seeing are simply in response to the greater competition that now exists within the Match.  As the applicant pool continues to widen, we will be eager to watch this trend in the coming years.  Either way, it is exciting that more than 3,000 new family medicine physicians are about to embark on a new journey into primary patient care!
See for more detailed match analysis. Follow AAFP detailed analyses at: also!