Robert C. Bowman, M.D.
As we have discussed, there is a declining pool of serving-type students. When I did some initial research with the AAMC GQ in 1995, the same pool of rural interested students was twice as likely to have done a rural, an international, and local volunteer work. They also were more likely to have interest in the military. http://www.unmc.edu/Community/ruralmeded/model/medsch/aamcdat.htm
I initially looked at this as a competitive thing, with those choosing military, or international (missionary or humanitarian) or inner city competing with the rural group.
Another way to look at this would be that these are all complimentary and reinforcing for one another. In today’s medical education environment, all may be necessary for students to come up with any semblance of preparation for and career orientation to serving type careers. My experience with such students fits more the complimentary assessment than the competitive.
The international, whether for medical school or college or residency, offers more opportunities to do hands-on work at various levels. Being outside of the US is a good way to gain perspective into what true needs really are as well as how very blessed we are and how much we do not appreciate what we have here. One of the drawbacks has to do with dealing with inadequate resources and getting overwhelmed. In international situations, even secondary or college educated people can make a real difference. My sister in law with little medical training made major contributions to a mission to Mexico with dentists and doctors. Attitude and willingness to serve are the major prerequisites.
The local volunteer work is convenient and a great break from studies. It also keeps students aware of their need to serve, something that drives many such students. It gives students leadership opportunities. The problem here is that the medical curriculum is so demanding that it tends to train service and volunteerism out of students.
The rural is a good chance to get into an environment where learners are more respected as compared to today’s academic environment. Rural docs also spend an hour a day teaching one on one. They also know their patients better, and are more willing to let students do more. Some students do more deliveries on rural rotations than the rest of their time in medical school. In rural (and international) you get to know much more about the life of the doctor, the medical stuff, but also the personal side. This is good and bad. It is bad because being a doctor is a real hassle in 2003, especially in primary care where you are not surrounded with a bunch of skilled assistants who do much medical work for you (this does not discount the superb efforts of nurses, techs, and receptionists). Of course these same medical assistants can get in the way of learning at non-rural locations. Good rural doctors and rural doctors who stay have learned great personal management skills. The role modeling opportunities are excellent. Many rural docs also do an excellent job of teaching. Some rural doctors are fairly overwhelmed. Others do not supervise well. The rural experience can be variable. Supervision by academics can make it town plus gown, the best of both worlds. http://www.unmc.edu/Community/ruralmeded/precept.htm
That Was Then… It used to be that you could get the characteristics supplied by today’s local, international, and rural all at once. My ob and neonatal rotations had it all, hands on, great teachers, great volume, real respect for students since they depended on us so much. We also got to lead and teach other students. We did not see attendings much, but we had the see one, do one, teach one down.
My first delivery of a baby: It was my first night of the rotation. I had a few hours starting IV lines and then a woman was close to delivery. The nurse ushered me hurriedly into the room and on the way in I remember asking her, “Don’t you think I should watch one first.” Of course she was already gone. Soon the baby came and I managed not to mess up something that happens all too easily, most of the time. Now this was not the best way to teach at that moment, but the hospital had some of the best care in the nation, even though it was delivering 17,000 babies a year. Help was a few steps away, 24-7. I went on to deliver close to 250 deliveries in medical school and residency. A few months later in medical school I was doing the most difficult resuscitations of babies. Perhaps more importantly with the volume, came some of the complications. As I began to manage more and more of these unexpected events and learn about others, I gained confidence and competence. Because there was a great balance between the opportunity to do and the supervision of faculty, residents, and other students (supervision was better than in my first routine delivery), the learning curve was steep and incredible satisfying (similar to the international). In fact, it was highly addictive. I am not sure that today’s students get addicted to a medical career as much, possibly because they just don’t get to be doctors as much.
In one year the student develops surprising professional maturity. In the classroom of real life he has learned tha sound medical practice is born of sound medical theory. He has seen how rural family practice can bend or break a man but how it rarely bores him. He has witnessed the challenging clinical mix of the mundane and the monstrous. And he returns to academia a wiser, more confident, more searching student. JK Heid RPAP preceptor 1979
Medical education is far different now. Changes in medicine, liability, insurance plans, the mobility of the population, the loss of public hospitals for the indigent, managed care changes, and declining teaching time of attendings with students have led to a major loss of the ability of American medical education to supply the kind of experiences needed to train future physicians. Teaching regulations limit the number of encounters that residents in primary care can experience. They also inhibit local and rural experiences.
When I was in Canada recently talking to some family practice faculty who worked with medical students, I found out that Canadian students preferred not to go to the states to do rotations as compared to past years. Their reason was that they did not get to make decisions or do procedures in the states.
Now this does not mean that doctors do not make up some of this training later, but it does retard the medical competence until later years, later in residency and in fellowships. This retardation is a problem because many trainees in medicine tend to concentrate first on mastery of medicine, and then they begin to fit other things like practice management, community health, and relationships with government, staff, and other key areas onto this framework created by mastery of medicine. Later mastery of medicine means less depth and perspective in graduates.
International, local, and rural have become more important. Also primary care has all but been crowded out of the picture. Studies by Verby on rural primary care motivated M-3 students demonstrated the following: after 3 months in primary care, students are overwhelmed, at 6 months they are neutral, at 9 months they do not want to leave it. Few if any medical students get even the 6 months that would help some of them to be able to make an informed decision about primary care. Most of them get only the 3 months of primary care experience where they are overwhelmed or see it in simplistic terms. Four times yesterday alone I heard physicians dismiss family medicine as better left to nurses and assistants. Obviously these physicians have not had the honor of experiencing a great physician at work dealing with uncertainty, complex problems, and relating to people and families well. Nor have they read studies about health care efficiency in this and other nations when primary care is given a more important role. Given the insulation that many physicians have between them and patients, this is not a surprise.
I suspect that many of our last 15 years of graduates have dismissed primary care as worthless. The sad thing is that the only thing that separates them from the opposite opinion is a few more months working with a dedicated primary care physician. Again international, local, and rural experiences can move the experience more toward the 6 months that would make a real difference in their training, and in their respect for doctors who serve.
Of course all of this means that having students with maturity, service orientation, self made folks, prior interest in Family Medicine, etc, are the few that can make it through such an environment and into underserved primary care. We might gain a few more if the obstacles were not as steep. I know we gain some in our location just because there is a cohort effect of learners on the same pathway, not true at many other locations. A better environment may get more into this area, and for the right reasons.
Education - the entire pipeline