Robert C. Bowman, M.D.
I have been reviewing rural preceptorships, problem-based education, and community-based interdisciplinary training. Almost all of these "alternatives" seem to enlist a common denominator. All invoke an intimacy with patients and/or teachers that is sadly lacking in medical education today. These so-called "alternatives" succeed because they encompass the core values of medicine, the development of a close relationship that facilitates change in individuals. This may be between patient and physician or between the student and the faculty in a small group setting.
The history of medical education (and perhaps medicine and other professions) in the United States is a history of professionals "distancing" themselves from patients, students, communities, and each other. The "Town vs Gown" battles are indicative of the degree of distance between clinical practice and academic medicine. This distancing I term "academization".
Academics thrive on analyzing, probing, prodding, testing, etc. The scientific method, the basis of our civilization's escape from the middle ages, dominates modern day medicine. To an academic, patients are not numbers, they are diseases or conditions. Researchers spend entire careers extinguishing the very individuality of patients that make them unique in order to standardize conditions. Academicians treat patients as conditions: i.e., the hernia in room 604. Academics are interested in knowledge and personal advancement. Students live, eat, and breathe this talk and it becomes a part of them. Not surprisingly their choices of the caring specialties in medicine diminish as they experience this attitude.
Perhaps the greatest illustration of "academization" is the changes in the delivery of babies. Obstetrical care, especially delivery, is one of the most intimate doctor/patient relationships that exists. This remains so with midwives and many family physicians who do continuity care. At many urban academic centers however, the continuity is lost. Stranger doctors touch the most intimate parts. The risk of liability is higher and after a few lawsuits, the relationship changes. It becomes "us vs. them" and "who got sued by whom". Students spending even five minutes in such an environment can quickly lose all desire to care for such patients, especially if they rarely get a chance to truly experience birth.
Family practice arose during the 1970's because patients wanted a doctor who was at least part friend. Students chose family medicine because it was different - it promised a relationship with patients instead of disease. Over the years however, even family practice is experiencing this distancing. Whether this is a result of emphasis on research and academic position is not known. The route to the top involves moves and career pursuits that often disrupt relationships with others. In some FP departments academic faculty argue over who "has to" teach the students and residents. New faculty, especially from rural practices, often have difficulty adjusting to this kind of environment, especially after working as a team with other professionals and the town for many years.
Perhaps these changes in family medicine are part of the reason that family practice is no longer attracting as many students. The specialty that promised to be different, became just like everyone else in the all important eyes of the medical students.
Another strong possibility is that medical schools are not admitting student who are interested in relationships and service. Admissions that prioritizes MCAT and GPA over personal characteristics would certainly do this. Admissions committee members are busy and it takes far more time to look over characteristics that it does to look at numbers and scores.
Fortunately there are examples of those who have kept the faith. One such example is the rural physician - one who boldly goes where no specialist or academician has gone before (Star Trek definition of rural - McCoy considered himself an old style country doctor in at least one episode). Rural medicine is not the only type of primary care, but it is the most pure form. It is farthest from the subspecialists and the closest to patients. Osler and Rural Practice I recently asked a rural doc to characterize the relationship that he sought with patients. He responded that he didn't think about it from an intellectual point of view. He just did it. He continued, "My partner and I have a very good relationship with people. We try to be open and honest. We try to avoid things that would create distance, like a white coat or a formal atmosphere." Students learn more than facts from their teachers.
Medical education is not just a program for building knowledge and skills in its recipients... it is also an experience which creates attitudes and expectations. Abraham Flexner 1914
They do pick up attitudes, behaviors, rationalizations, and motivations. We need to do more than "expose" students to rural practitioners. We need rural doctors as primary clinical educators. We need their experience and their environment to emphasize primary care.
There is a role for academicians. Academics can organize and choose primary care physicians who are enthusiastic about caring for patients and serving their communities. Academics can support these physicians with continuing education and clinical help utilizing ourselves and those we train. Academics can help bridge the gap between rural practice and academics so that students will have a chance to experience what it is to truly be a physician, working with and serving others. Facilitating Rural Health with Rural Faculty
The standard in medical education is to proceed from the molecular and simple to the increasingly complex. Students walk up the ladder to organs, systems, whole person, and family. Reformed medical education integrates the interpersonal and family throughout the curriculum. Unless students work closely with faculty, peers, and patients, their education is simply memorization and analysis. Students who really learn to establish relationships with preceptors and patients are learning basic interpersonal skills that will make them true physicians and facilate their growth to impacting on the community. This is the level of activity that tomorrow's physicians must demonstrate to solve problems of access, preventive health, and health care costs. The early analysis of New Mexico's primary care curriculum students has revealed that many of these students have become just such leaders. They learned these skills in intimate problem-based, faculty-peer sessions and during their preceptorship.
Sadly, even I, a strongly biased rural proponent, cannot claim rural as the secret of the success of these students and programs. The success is in the preceptorship model. Not only do students feel a responsibility to patients that enhances their motivation to learn, the preceptor has direct responsibility to work with the student. No longer do students wander from month to month with different residents, attendings, locations, and curricula. They spend months in a site where one or more preceptors who follow their individual clinical development. Even the students that they work with know whether they are keeping up and learning. Mercer students echo this when they value the preceptor’s influence on them more than the preceptorship.
Rural is important in that it is one of the few places where true primary care is practiced. It also is where some of the most caring physicians practice. This combination makes preceptorships successful. After all, it is easier to train for primary care in a place where it is actually practiced by people who
Do it as the top priority
Care about it
Care about helping students to train for primary care
Care about students themselves
The caring and the intimacy are a key part of preceptorships.
Students also learn from challenges. In an effort to attract students, many residencies cater to the wants and desires of applicants. Some reduce time in the more difficult rotations. This can dilute their experience and reduce their confidence and competence, especially for the demands of rural practice.
This is a time of tremendous challenge to all physicians. The gap between those who focus on patients and those who do not is widening. Probably the greatest turbulence is felt in family practice. Not only is it one of the newest specialties, it has been hailed as "the model for primary care". Emergency rooms, rural practices, HMO's, multispecialty groups, and academic departments all cry out for more family physicians. Many argue that the curriculum should be modified, Certificates of Added Qualification added, obstetrics eliminated, etc.
Eighty-five per cent of family practice program directors feel that they prepare their residents adequately for rural practice yet 30 % of seniors want more, esp procedures and practice management.
These efforts are led by those who understand the concepts, but not the reality. They will forever search for meaning, and fall short of comprehension. They will rail against the forces distancing the other specialties from patients, while failing to perceive that they have also lost touch. They turn to research for justification and to gain status, only to lose the future of medicine - its students.
For more about Family Practice and this Distancing Process.
Environment of Medical Education: Challenges for Generalists and Servants
www.ruralmedicaleducation.org/top_down.htm