It is not what we can appear to be, it is what we are as family physicians that really matters.
More Facts and Statistics on Family Medicine than you have ever seen at
Attempting to approach this via my own interpretation of the truth spoken in love:
The Future of Family Medicine was done with corporate sponsorship but the
leadership in family medicine determined that this was a better use of
resources. They chose to expend political and economic and personal capital that
could have been used in some other areas, or even applied to some interventions.
I am not privy to all of the preparations and reasons for such efforts, but I
feel that it is a time to raise questions. This is not the only opportunity
cost.
Our Title VII efforts, which are poorly targeted to the goals of the program and
thinly veiled attempts at supporting our infrastructure, seem to me to tie up
our political capital each year instead of us making a break with the status quo
and embracing a rising star such as Community-Based funding of health care (CHC,
Migrant, etc.). We obviously know how to deal with this each year. It has become
comfortable and routine, but the effort is not going to help us with the future.
Similar problems have befallen the maternal child entitlements that wall in
ob-gyn to prenatal efforts rather than helping society address the real causes
of poor birth outcomes, the ones that were present at conception (education,
smoking, drugs, abuse). Perhaps we are also being walled in by our own
"entitlement."
Our family practice committees and terms of service give us just about enough
time to understand what is being done, but whisk us off before we are able to
even think about the future for the area involved with our committee, much less
how this impacts family medicine. Given the dedication we have to our practices
and families, perhaps longer terms and smaller sub-groups would be better.
Our meetings and our own legislative bodies are filled with social, political,
and business distractions while serious problems remain in the wings. Where is
our focus? The entire character of family medicine is likely to change based on
the liability problems that we currently have, and not just the impact on
obstetrics. Breaking the hold of insurance through coalitions and legislation is
a major priority. If family medicine is able to build corporate sponsorship and
gain capital for great endeavors, here is one worth the investment, if not
providing reinsurance funding for a massive nationwide FP insurance conglomerate
at least working on federalization of liability for those working hardest to
meet the country's workforce and access goals.
Are we afraid to talk about our problems for fear that we will lose residents
and students? Well, perhaps we are losing residents and students because we have
failed to deal with our problems. Is this also true of our relations with
government, foundations, and other key players?
We continue to exclude osteopathic and international and other groups from seats
at the table even though in many ways these represent the Future of Family
Medicine. Our rural and underserved practice and medical education components
continue to be underrepresented in the infrastructure and resources even though
a key component of the students that will become family physicians, comes from
such groups. It is hard to plan a future without important representation.
We have some of the best medical education models in the nation, but they remain
models and some of these are being closed. The quality of such models is
documented by a number of family physician-educators past and present who had to
embrace teaching, research, and administration to get the kind of training that
would be best for students and residents. Students love to work with our
practitioners. They often rate these the best learning experiences that they had
throughout medical school, however students still get the less than 4 months
primary care experience that overwhelms instead of the 6 months that would bring
them to neutral or 9 months that would have them embrace it (Verby studies).
Extended models such as the Minnesota Rural Physician Associate Program have no
current equal in clinical education. Models such as the Nebraska Accelerated
Rural Training Program reveal the value of longer and more dedicated family
medicine training that continues to push the envelope of capability vs
responsibility. Longer rotations also benefit our clinicians and communities who
have been subsidizing us, medical schools, and the nation for decades.
In my study of FP Graduates past and current, I am amazed at the fine folks that
we attract and graduate in family medicine. In my contacts with residents and
students in teaching and Balint, I feel badly for the treatment that they
receive now and in the future, not just in the attitudes, but the continual
attacks on their ability to practice medicine by active participation. I fear
for them in the future, and for us, and for the health of the nation if we
continue in this pathway. Until they master medical basics and feel comfortable
and competent, they will not branch out to impact the forces that will control
their destinies in hospitals, corporations, insurance board rooms, medical
schools, and out in the community, state, and nation.
At the end of this Future of Family Medicine study, I doubt whether we will be
closer to understanding a simple and major question like what goes on the minds
and hearts and activities of our young people that make it more or less likely
that they will choose FP as a career, and particularly as a means of expressing
their desire to make a difference in the lives of others. If we understood this
one question, we could interact in a very positive way with the counselors,
teachers, advisors, parents, admissions committee folks, and health policy
people who can work with us. We spend far too much effort at the wrong end of
the pipeline. Our future is tied to that of rural and inner city populations and
their high schools. It is tied to college health advisors and small colleges and
partnerships with medical school admissions. It is tied to broadening the
opportunities for a diverse range of students to participate in medical
education rather than allowing narrow minds to focus in on MCAT and GPA. It is
tied to us reaching out to those who are not polished enough, our leadership,
our meetings, our residents, and our students, so that those with less polish
can become the type of students that admissions committees feel are worth the
risk of academic failure.
Our strength is our dedication, our innovation, our understanding of people and
our breadth of experience involving health and so many other fields. Nearly all
of medicine has become irrelevant to the national interest. Few remain that are
dedicated to direct care of patients. Few remain who resist the overwhelming
societal pressures to line our own pockets at the expense of our patients, or
the national interest. We are being pressured to join this crowd and we must
resist.
But experience with organized medicine teaches me that resistance is futile and
that attempting to be "pro-active" is, in reality, reactive and defensive.
Perhaps we should change from the methods of organized medicine that are doomed
to fail, to the collaborative mode that we enjoy with patients, students, and
colleagues. The one that marks us as a discipline with a heart and soul to
direct the mind.
With this mode comes the responsibility of participation, in small groups, and
at all levels.
It is our time now in Family Medicine. Our forefathers have given us this
opportunity to lead, by effort and by example, and we must do so.
Robert C. Bowman, M.D.
rbowman@unmc.edu
Family Physicians Are Different
To all,
The Texas FP Leadership conference just concluded and we had a wide ranging
discussion of the FFM project (for full information see the Waco FDC site
www.wacofdc.org where notes etc will be posted soon in the leadership conference
section). We broke up into discussion groups and each group focused on an area
from the FFM project. I was part of the Academic Health Center discussion and
here are my brief notes.
Academic Health Centers:
Here are a list of the concerns voiced as to why these environments are so ill
suited to primary care and Family Medicine.
Felt this was a root cause for difficulties in Family Medicine
These centers are not patient oriented, they are research oriented
These centers have become a scene for turf battles that do more to defend the
income of a specialty than serve the patient
Purpose is to serve the physician
Care of the primary patient is not a goal (care of the specialty patient is more
a goal)
Operate in a void, disconnected from the real world
Primary care physicians are having to work harder to cover their costs directly
leaving les time for teaching and research
Solutions voiced for how to survive in these settings
Develop interdisciplinary activity and collaborative activity with other primary
care specialties (strength through numbers)
Develop practice based research to look at outcomes data from the real world
(data that makes a difference to the patients we serve)
Model on the success stories of academic medicine in Washington and Minnesota
Strengthen rural bonds
Change the culture of the admissions committee in order to change the criteria
for admission to medical school (focus again on students interested in serving
patients)
Strengthen the representation of Family Medicine in the AAMC
Look to the community to strengthen our base through preceptors for
students and residents
Not every center needs and FP program, and not every slot needs to be
filled. Choose only quality residents, and have residency programs only at
quality centers
with proven outcomes of quality patient centered/centric care (live
the competencies)
*Push the exposure to Family Medicine into the basic science years
through embracing the epidemiology and biostatistics courses to serve as a
basis for teaching
EBM
*Utilize our strength in applied medicine through the instruction of the
students in EBM (claim this as our own and teach it passionately)
I place an asterisk by the last lines because this is where I have seen the
students come to understand the intellectual joy of Family Medicine. We
should aggressively claim EBM as our own, and push to teach all aspects of
this science to all levels of medical education. We can use this a
springboard into the MSI and MSII classes through the epidemiology and
biostatistics course work. If the students in other institutions are like
those at Texas A&M College of Medicine, then they have groaned out loud for
more clinical relevance to these course subjects. Our students wanted to be
taught by people who are clinicians, folks who have utilized these concepts
in practice so that they can see the value of learning the material.
My two cents.
GCG
Gil C. Grimes, MD
Assistant Professor
Family Practice
Scott & White
Killeen Clinic
'Constancy is the foundation of virtue'
- Francis Bacon
Gil C. Grimes, MD
Associate Professor
Texas A&M College of Medicine
Scott & White
Family Practice
Killeen Clinic
Scott & White Hospital
Constancy is the foundation of virtue.
- Francis Bacon
I would support all that Gil mentioned, however I would caution us strongly
to put working with the other primary care specialties on the back burner. The
last time the AAMC met to consider rural medical education was 1989 in San
Antonio (quite a while). This meeting invited some of the finest minds in the
nation involved in rural health (I was a stowaway in the back). I watched a good
effort turn into chaos when a respected dean brought up the "merging the primary
care specialties" concept.
We have tried this combination and it has compromised us in a number of ways. In
meetings, in "combined" rotations, in committees, etc. I continue to remember
the studies by Verby noting that RPAP students were overwhelmed by primary care
at 3 months, neutral at 6 months, and did not want to leave at 9 months. Granted
these were fp oriented folks, but still the minimum 6 months was needed in a
single location with some hint of continuity. It takes time to gain
understanding of the complexity of the resources, supports, and ways to overcome
problems. Combined rotations and brief exposures are not likely to anything more
than cause more medical students to fill out their match tally away from FP and
their AAMC GQ box that says that primary care exposure was excessive.
Our closest allies are our patients and the rural, underserved, inner city, and
vulnerable populations that we serve so well. It makes little sense to work with
IM and Peds. It makes a lot of sense to work with osteopathic. If we cannot get
students, for a reasonable period of time, to a battleground that we own, we may
as well pack up. If we cannot get the students that are more likely to choose fp
and rural admitted, ditto.
No one can come close to the education of 9 months in a rural area with a top FP
doc and a supportive rural community, no one (Verby studies, Gjerde, Paul James
studies, and others). Verby
Articles
Few can find a way to impact rural economies as greatly as such efforts with 1
million in impact per rural doc, or 2.2 billion to Greater Minnesota since 1971
(Bowman calculations of RPAP grads).
No one gets as many fp and rural docs in allopathic medicine as Duluth plus U
Minn.Duluth Plus RPAP
Having a devoted FP doc, often from rural practice, as head of an admissions
committee can mean more to the economics of the rural areas of a state than most
other expenditures of state money, as graduates return and serve. Focusing on
rural and service-oriented kids can do much more.
a. Such selections can also mean awards for the school as a top community
servant among medical schools.
b. It can allow a department to develop the graduate, undergraduate and combined
programs to meet a variety of student's needs from inner city to rural
underserved
c. It means that we can fully meet the needs of our communties, state, and
nation, demonstrate our value, and ask for what we need (a far cry from other
med ed entities who tend to take more and give less)
Not having documentation outcomes such as access, economics, distribution is a
real problem.
We have failed several tests at a number of levels when lines in the sand were
drawn, personally or beyond:
Where were we when Duluth was combined with U MN, when the Georgia
preceptorships were threatened, when LCME does strange things, and when the
accelerated programs were trashed, including ones with excellent track records
of education and outcomes such as rural location? Why do we allow some of our
best efforts to be compromised? In our efforts to survive are we pushing our
best to the back?
Why do we tolerate ACGME when we could do our own accreditation or could work
accreditation with osteopathic FP graduate folks, who share our principles? We
need each other here. I like the folks involved at RRC and think they do a good
job, but frankly they will never let us become the FP that we need to be.
Where have we been when those who would become FP docs were being closed out?
a. When collegues or others mention HIPAA as means of stopping what we need to
to, such as shadowing or research. This is certain to impact the unprivileged
kids in the nation? The same goes for anecdotal use of liability concerns as a
problem for shadowing, precepting, etc.? Perhaps used by business-oriented folks
as a means of increasing productivity. What else do we compromise when we fall
into this trap?
b. When new college health advisors need advice regarding their students?
c. When small, rural, and minority colleges receive cuts in our states instead
of the admissions tracks that would restore them?
d. When education is cut to rural schools, inner city schools?
e. When we were asked by students to allow them to shadow?
f. When we went into rooms to see challenging kids and did not do the best that
we could, not realizing that these would be leaders in the future, for good or
evil.And that those not doing well would take up funds from our state in prison,
education, mental, and social, and result in Medicaid and FP funding cuts. Where
were we when the state held meetings, committees, or chose personnel for state
jobs.
In a 15 year period 1978 - 1998 we had over 2000 fewer rural kids admitted into
medical school. Perhaps many more as of 2003 matriculants. These rural kids are
still taking the MCAT in the same numbers and distribution, just not getting in.
In their place are ultra urban kids from "college-style" high schools. These
same kids have had far less exposure to FP. Such declines in any minority, would
have sent folks screaming, yet there is silence....
What have we done to restore some sort of community central for health career
advice for rural communities, whose kids often have little clue how to get into
any professional school or health career, particularly medicine. My nominee is
the restored Critical Access Hospitals, working closely with schools. Working
with the kids is great, but they leave in 1 - 2 years and there is no residual
expert advice in teachers, counselors, etc. Need a consistent point of contact
for health careers even in the smallest communities. My model is a rural
hospital administrator who hires 5 or so kids a year to spend half time working
for the hospital and half time shadowing. My other model is getting rural kids
admitted to medical school, back in contact with rural high school and middle
school students.
Otherwise admissions with continue to be based on where you went to high school
rather than what you are or what you could become.
And more to add from previous email:
Why is it that the most knowledgeable folks on some AAFP committees are those
who have been ex officio, for years?
Why is the Rural Medical Educators Group working with the National Rural Health
Association, instead of AAFP or STFM? Answer: because they were the only one
that said yes.
Why is it that it took me months to prepare a database that FP could do in
weeks? Because I have been told no for years. (I have had some indications that
this might change.)
Perhaps I should not send this, since I am still hoping to talk to Graham Center
folks about my research and to attend a National Association of Health
Professional Advisors conference to represent FP, but then again, who am I…..
Robert C. Bowman, M.D.
rbowman@unmc.edu
What we can do to change family medicine, from the background up at Rural Background
