Robert C. Bowman, M.D.
(Subtitle: confessions of a cybercultist)
"A wealth of information creates a poverty of attention." - Herbert Simon, Nobel laureate economist
Post Modern Era Conflicts Comments Regarding the Future of Academic Medicine
At a time when we are wondering what is happening to medicine, family medicine, and medical education, we should probably wonder also what is happening to us as people. Awareness of some influences might help us to take a more assertive role in determining who we are as persons who together make up the group known as family physicians, rather than letting subtle forces make this decision for us.
We have often concentrated on how we can impact others through training, or through our practices, but is it possible that there are forces out there that are impacting students and patients that are more influential? Many of us have had a chance to get to know Richard Swenson. For those that have not been to see him at physician meetings or church events, here is a nice summary by Louis D. Whitworth regarding Dr. Swenson http://www.probe.org/docs/margin.html : The pain that progress has brought us is evident in three areas. First, we have lost ground in the social sphere as pressures have increased on all relationships: family, friendships, neighborhoods, community spirit, and church life. Second, we are often emotionally drained, stressed, angry, isolated, and frequently unfulfilled and don't know what to do about these problems. Third, we are spiritually weakened by the pace of life, the lack of community, lack of time and energy to cultivate our relationship with God and with our fellow man. This, Dr. Swenson says, is the price we have paid for progress.
Pause and reflect on this and what it means for family medicine. Progress and technology have had particular impacts on relationships, our own peace of mind, and things that we value, such as continuity and community.... Does this sound like the findings of our reports, at less cost and with more specifics?
Creating the margin to make good decisions about the course of our lives is a good idea, but we also need to understand some other impacts on our lives. In the past week I have learned about Quentin Schultze, Chuck Colson notes him to be "a very able professor of communication at Calvin College.... He has written a very interesting new book titled Habits of the High-Tech Heart: Living Virtuously in the Information Age. In it he writes that information technologies are not just tools but also value-laden techniques. We not only use them to help us organize our lives, but we also increasingly rely on them to understand nearly every aspect of our lives."
Well I must confess to being a cybercultist. After all someone who creates a web site called the World of Rural Medical Education and lives and breathes it so much as to ask for prayer to keep it from taking over too much of my life, must certainly need help in this area. This may also explain why I have such high expectations of the work that I do, even though it is known by a limited few. My work may help me feel better, but it is certainly not changing medical education or family medicine or admissions or many of the things that I write about. Some of those who could best learn how to be more effective are people like me. Who live in another world away from those who make the decisions that we would like to be more a part of. Perhaps I should devote more time to other modes of communication, some more traditional ones, ones that require a bit more discipline and work with others.
Being a physician is challenging. Few areas are impacted by technology as much as medicine. Not only this, but the forces driving technology development and utilization are all commercial. Decades ago pursuit of a patent or any sort of sales or marketing of information or technology was a great taboo in medical faculty. Now these same markers determine salaries and promotion. In fact researchers who are not at least part promoter suffer in our centers. Even our most objective sources of information, the medical journals, have been compromised.
In many ways we owe the creation of Family Medicine to the very vacuums created by progress and technology. By the time we were resurrected, the generalist leaders and principles that we once had were long gone. Not only have we faced this obstacle, admissions changes have cut off our very lifeblood, the students who choose family medicine. Although perverse primary care environments are partly to blame, a major factor is loss of students with the kind of character, service orientation, socioeconomic origins, and backgrounds that choose family medicine and resist the specialist environments of nearly all medical schools. Even major medical leaders such as Jordan Cohen regularly cry for admissions to put less emphasis on the numbers and more on the personal characteristics. Madison's study and the work of others noting service orientation as a key factor in selecting for generalists go unheeded by most institutions. Admissions for generalists and rural physicians
I will state again, the major problem with family medicine is that we need more of the right kind of students to be admitted, the ones that will be drawn to careers of service. For us and our department, these are the students who have shaped our volunteer programs, helped adapt our curricula, and reinforced our preceptorships. They drove us to create special programs for them such as rural training tracks and accelerated rural training programs.
Unfortunately the things that help develop character, factors such as suffering, overcoming obstacles, persevering, balancing time demands, making sacrifices, all take more than we as students or faculty or a society seem to be able to give. Those facing great trials and tribulations and overcome, the ones who do develop character, also often have holes in education or career orientation. Some have lowered GPA and MCAT scores because of where they have been rather than who they are. Others have a past that keeps them from being admitted.
Finally I am tired of one way translations of technology by medical schools and accrediting bodies. These have tended to isolate the ivory towers and reinforce top down approaches. Key leaders make great speeches about thinking out of the box, but the emphasis is still on process, even with great outcomes such as location in underserved areas. Medical schools and accrediting bodies have not understood how technology has greatly improved learning in areas important to family medicine, such as in rural sites, rural training tracks, preceptorships, and other situations. When you have a specialty of breadth, search engines and interactive modes bring an immediate wealth of information and expertise. Technology can help us make medical education town plus gown, rather than town vs gown. Why a Preceptorship Is Better
Translating this for family medicine: We must make a self-conscious effort to cultivate generalist ideas about medical education and medicine. Of course this is a greater challenge when our own leaders are constantly debating what we are all about. I would assert that we know what we are about, service, character, doctor-patient relationship, etc. We need most of all to find ways to get students that are like us, no, better than us, to be admitted. These are not the brightest, they are simply the best. Patients, family medicine, and medicine itself can ask for no better.
A final comment from Colson, "It's actual communities that require us to think about the needs and interests of others. And it's in real communities, starting with the family, that character is formed. And for all the talk about Internet diversity, only a real community—one based on shared space, not just interests—can teach us how to live with people who are different from us. As Schultze reminds us, this is the biblical model for community. Messy? Sure. But if our goal is real virtue, then there is no avoiding real people."
We cannot tolerate medical education that deeply discounts community, character, and relationships.
Those who have heart and whole-heartedness, by Charles Spurgeon
Learn more about Dr. Schultze’s research. Quentin J. Schultze, Habits of the High-Tech Heart: Living Virtuously in the Information Age (Baker Books, 2002). I had not read this but it am doing so now and it is every bit as good as promoted.
More Than Duct Tape Cyberculture's Values http://www.breakpoint.org/Breakpoint/ChannelRoot/FeaturesGroup/BreakPointCommentaries/More+than+Duct+Tape.htm
A Better Kind of Space Real Community and Virtue http://www.breakpoint.org/Breakpoint/ChannelRoot/FeaturesGroup/BreakPointCommentaries/A+Better+Kind+of+Space.htm
Robert C. Bowman, M.D. www.ruralmedicaleducation.org
