Tuesday, March 19, 2013

Can you be "too strong" for family medicine?

Last week medical students and residency training programs received their “match” results, the end product of a complex computerized process. Now (except for the 1100 students at US allopathic schools who did not match and programs that did not fill), students know where they will be training and residency programs know who will be joining them. The number of “un-matched” US students is greater than last year; so is the number of positions. This is the result of recent expansions in both the number of medical schools and the number of students in existing medical schools.

The Association of American Medical Colleges (AAMC) has been lobbying hard for the expansion of residency positions, arguing that expanding medical school class size is not going to translate into more doctors if there are not more residency positions. AAMC is not, however, calling for those increases to be tied to a certain percentage of primary care. Since primary care residents are not big money-makers for the hospitals that are the main sponsors of residency training, and not in great demand by medical students (see more below), it is quite likely that, absent specific stipulations, the opposite will occur – most of the expanded number of residency slots will be in non-primary care specialties. This will, of course, further exacerbate the already unbalanced subspecialty/primary care ratio that currently exists.

Unlike AAMC, many family medicine organizations are calling for expansion of residency slots to be tied to primary care, and I am in agreement with that. However, the concept of “forcing” students to choose primary care residency slots who may not want to makes many people uncomfortable. They would prefer to “make family medicine” more desirable to our students. I would argue that this is going to be an uphill battle given the priorities of many current medical students.

As a family medicine educator, I try to stay on top of the trends in medical education, student preference, and workforce. I also interact with a lot of medical students, so have, I think, some idea of what their priorities are. Sometimes, however, I am surprised by the lack of knowledge about family medicine among students who, I thought, should “know better”. For example, a student recently contacted me about a friend who had applied to family medicine residencies as a “backup” for their preferred, more “selective” specialty, and did not match; the perception was that this student was rejected because they were seen as “too strong” for family medicine. I was surprised. I wrote the following in response:

"I don't think it is possible to have someone be "too strong" for family medicine regardless of how you define strength (grades, board scores, compassion, ability to learn and apply learning, multi-tasking, or how much you can bench press). Family Medicine is truly the most complex and difficult specialty. The breadth is enormous, as I am reminded as I -- for the sixth time in my career -- study for my recertification boards, and study maternity care, sports medicine, caring for people with heart disease, well-child care, ICU care, lung disease, diabetes, fractures, arthritis, acutely-ill children, preventive care, epidemiology, nutrition, diabetes, gynecologic problems, management of psychiatric problems, adolescent issues, and on and on. There is nothing like it. It is also true that the skills, preferences, and experiences that make someone strong for one specialty may not make them "stronger" for another.

"As far as the practice is concerned, family physicians have to see undifferentiated patients and try to come to a conclusion about what they have and how to manage them. This is a lot more conceptually challenging than seeing someone with a ready diagnosis or a narrow scope of diagnoses and applying your in-depth knowledge to figuring out a best method of treatment for it, or doing a procedure on it. Family Physicians (and other primary care/generalist physicians) do not care for one disease or organ system of a person, they care for the person. They manage multiple co-existing chronic diseases -- our adult patients typically have a large number of them such as hypertension, diabetes, heart disease, arthritis, depression, and social stressors in their lives, for example -- and balance the treatments for each so that they do not make the others worse and are best designed for that individual person. And to, while doing so, learn and care for the person. This is harder than doing the same limited set of procedures or treating the same limited set of diagnoses day after day. While a typical subspecialist may have 5 diagnoses that account for 80% of her patient visits, for family medicine the top 20 diagnoses do not cover more than 30%!

"I do not mean in any way to insult or seem to be critical of other specialists; they do important things and we need them to refer to for the procedures that we don't do or the uncommon cases of diseases that are rarer or unresponsive to usual treatment (although I do think that the current balance between subspecialists and primary care doctors is way off). I also do not mean to seem ignorant of the fact that many other specialties, including orthopedics, are much more competitive than family medicine to match in. This is because demand (from students) exceeds supply (of positions) and allows those specialties to set higher (by whatever they mean by this, usually grades and scores) standards. But this should not be confused with the complexity of the specialty. Demand is driven by many things including (but I am sure not limited to), the particular interest of a student in the diseases cared for by a specialty, their interest in performing psychomotor skills (such as procedures), anticipated income, anticipated lifestyle issues, and many others. It is also true that many other specialties require strong medical students. But do not confuse supply/demand issues with the intelligence, hard work, difficulty, decision making ability needed, breadth, and conceptual complexity of a specialty. For these, nothing exceeds family medicine."

I also sent a link to this (I think) wonderful post called "Desperately Seeking Herb Weinman" by Steve Lewis in Pulse, an online journal of narratives about health and medical issues, that gets to other characteristics of primary care doctors that are important to people. The author has a very scary health episode that takes him to the emergency room, and acutely feels the depersonalization of not having a doctor who knew him (like his old, now retired, doctor, Herb Weinman, did): “I know that the overworked ER staff who treated me were good and competent healthcare providers. But I also know that there was not a soul in the ER that day who would have cried if I had died. As Herb Weinman would. And I want that. I want that.”

A colleague, who also has concerns about the motivations of some medical students, reposted a post from a student on “studentdoctor.net”, the largest discussion group for medical students about whether Allergy should replace Anesthesiology on “the ROAD” [Radiology, Ophthalmology, Anesthesiology, Dermatology, which are widely considered by medical students to be the specialties with the highest income-to-work ratio] because it seemed like “…such a cush job.” Then followed a listing of the incomes of different specialists, which I will not replicate, but will note that the low end of all was much higher than the high end of primary care incomes; however, primary care doctors earn a lot more than the average person!

My colleague commented: ”We need a different pool of applicants...We need a different yardstick...We need payment reform. There are plenty of smart people who want to serve. There are a lot of folks who would be thrilled to be the smartest, best paid person in their town.”

I agree. I want many more medical students to want to go into primary care. If it is about money, we are not going to be competitive. It is going to have to be about wanting to care. And that means, to me, using different criteria to accept people to medical school.

More people like Herb Weinman, I guess.


Anonymous said...

200 million people in 30,000 zip codes need a design for most primary care delivery per graduate and most primary care where needed. Only FM distributes 53% where needed to zip codes with 200 million and 68% of the elderly and over 65% of all types of Americans in most need of care.

After 100 years of choosing what is right for "me" or my subspecialty or my hospital or my institution or my association

We must have a choice in favor of 200 million people left behind by design.

Michael Shihjay Chen said...

Thank you so much for your post. I had a similar experience as a medical student when there was a huge incentive to go into specialized medicine (even in a med school (U. of Missouri) where primary care was emphasized and had a great reputation). I ended up doing family medicine even though I knew it was going to be hard road ahead. Even though I ended up being burned by the pressures of the economy and commercialized medicine (unfair and declining insurance reimbursements for chronic care management and EHR meaningful use) and the increasingly hostile environment for independent physicians who are trying to do meaningful change to help our patients (especially those that are under or uninsured), I certainly did not envision how dire the situation had become now compared to 13 years ago when I finished medical school. I was in the front lines and am wounded but I'm still standing and I still do not regret my choice in family medicine. You can see my travails in my blogs at http://aboutfamilyhealth.blogspot.com and my new project at http://noshemr.wordpress.com.

Unknown said...

I'm a 3rd-year medical student planning on matching into Family Medicine next year, and I agree that it would be nice if my classmates had more altruistic motivations in choosing a specialty. Perhaps we could change our admissions criteria to seek out those who would be content to be a big fish in a small pond, but I think our current paradigm of medical training is at greater fault than our selection criteria.

We educate students in hospitals, typically in medium-to-large cities, where they see all the interventionalist heroics of a variety of subspecialists. In my third year I've spent about 90% of my time in the hospital and 10% of my time in an outpatient setting. Since nearly all my classmates have decided which residency to pursue in this year, this results an incredible bias against ambulatory care.

Many an inquisitive third-year student, just past Step 1, is wowed by the depth of the subspecialist's knowledge in comparison to the breadth of the generalist's. As a third-year clerk in the hospital, there is little context by which to judge that the venerated hematologist actually makes fewer and simpler decisions than the family physician who decided to consider leukemia in his differential. Our choices are bound by our context, and our context favors the specialists.

Changing the incentive structure may not work, but I also think that changing the applicant pool isn't the most feasible intervention. I have seen plenty of idealistic small-town kids decide after 3 years in the academy that the big city hospital is the place for them; I'm sure you have as well. It seems to me that it's about time for another Flexner report.

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