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Resident: Hey, I diagnosed a black child with thalassemia today

Attending: Oh, really

Resident: Yeah, the funny thing is it was picked up on the newborn screen. Child and parents are obviously of African-American decent. They are not aware of any Mediterranean ancestry.

Attending: And that’s why we shouldn’t take race too seriously when screening folks for disease.

Medical learners are taught from an early age to speak clinically in a very distinct language. We call the method of communication regarding patients a “presentation” and typically the pattern is age, race, sex presented with symptom constellation. The story then goes on to recount pertinent positive and negative information, past medical history, family history, social history, physical findings, and ends with the clinician identifying the diagnosis and plan. A lot of information is distilled to keep these presentations concise. The shorthand starts with the age (if the complaint is chest pain, heart attacks don’t occur in 14 year olds, for example) and sex is an important component (a man with “blood on underwear” has fewer moving parts “down there”). Race has always been included in the construct. What goes with race?

Unlike veterinarians, we physicians only have to deal with one species. I have to admit, I almost always assume the entitiy being presented by the learner is human. Having said that, within the homo sapien species there is a lot of genetic variation. If I know something about their family (the patient’s mother and father both have sickle cell trait) then I can draw a conclusion about the patient (this person has a 1 in 4 chance of having sickle cell disease). Otherwise, unrelated people have 3,000,000 distinct variations and people of the same “race” differ by as much as 85% from each other. What of the other 15%? Turns out less than half of it can be traced to similarities in skin color, hair form, and nose shape. In other words, what we see as commonalities that track together (skin, hair, and nose) are for the most part the only things that track together. Diseases tend not to cluster based on these, even less so given our current patterns of population movement. Biologists abandoned the construct of “race” for plants and animals a long time ago, because of a lack of utility. The concept of different races, itself, dates from the fifteenth century when, in response to the Catholic church‘s new “anti-enslavement of humans position,” King Alphonse of Portugal sent ships into Africa and found folks who spoke no European or Arabic tongue and had different skin, hair, and noses, so were obviously NOT human and therefore enslaveable in the eyes of the church.

The  problem with using (skin, hair, nose) to categorize people medically is that it misleads. A tragic example of this occurred in the south. Several physicians, including John Searcy of Mount Vernon Hospital in Alabama, noticed a cluster of folks with a distinctive skin rash beginning in 1906. Now known as pellagra and due to a deficiency of nicotinic acid in the corn-based diets of poor people (a byproduct of the introduction of modern agricultural methods to corn harvest), it was proven to be a consequence of poverty and inadequate nutrition by 1912. However, despite the elegant proof, the deaths continued because of the insistence of leaders in the field that it was clearly an inherited condition because it tended to run in poor black families. Coincidentally, so did poverty.

By continuing to include race on the front end we perpetuate the myth of causation instead of using it to identify groups that need special attention. Per the new England Journal:

It is indisputable that social perceptions of what a person is or is not influence the availability, delivery, and outcome of medical care. It is incontrovertible that these perceptions apply with dismaying regularity to black people and other minorities in the United States. And it is undeniable that lifestyle, socioeconomic status, and personal beliefs are powerful influences on health. But these are matters of morality and culture, and we must clearly distinguish them from the biologic aspects of race-based medicine — from the danger of attributing a therapeutic failure to the patient’s “race” instead of looking for the real reason.

When this article was written in 2001, there were 1300 articles published containing the search terms “Negroid race” in the previous two years. In what is clearly an improvement, there have only been 700 articles in the last two years,

What we know is that (skin, hair, and nose) is at best an incomplete marker for geographic genetic origin, which might be a useful clue for certain diseases. In this country, we know that it is a marker for poverty and oppression, which does seem to be correlated with disease. Instead of Black, White, Hispanic, maybe I’ll make the learner say something to the effect of “This 52 year old ‘manual laborer who lives in a bad neighborhood among drug dealers and has to sleep in his bath tub for fear of being shot accidentally’ female comes in for high blood pressure and headaches.” Too long?

cartoon9I have to remember that I’m an officer and when I give a Marine an order they will obey no matter what. When I use the tonometer and say “don’t blink” I had better remember to follow up with “blink” before they get dry eyes.

Conversation with a Navy Optometrist

I remember fondly my time being a doctor to the Marines. Wet behind the ears, eager to hone my craft, suddenly given superhuman abilities such that with only an internship I could function independently in a remote setting…oh, wait, that last part didn’t happen. Fortunately there was, on the base with me, a wizened old doc (I think his name was Wenzel) who had practiced in rural Kentucky prior to going back and studying pediatrics. His counsel was always wise and when distilled down often ended up being “When in doubt, turf it out.”

We were at a fairly busy ambulatory clinic and urgent care center in Kaneohe, Hawaii. All of us took call. I remember making multiple trips to the civilian hospitals to transport patients. The active duty dependent and military retiree patients had to pay quite a bit out-of-pocket if they used the civilian facilities without consulting us first. We used to get folks driving PAST the civilian hospital to come to our ambulatory dispensary having heart attacks (I can remember one dying on the H-3 while in the car, wife driving 80 miles an hour) and  respiratory arrests (one of the most harrowing ambulance rides of my life, ever) in addition to the assorted 21-year-old Marines who never failed to learn the lesson that alcohol renders no one invincible. The lessons I learned there about the limits of an ambulatory practice setting, the triage and transport of sick people, as well as the health risks folks will take as they try to save a buck,  have stayed with me for 25 years.

I also learned some very concrete lessons on practice organization and care delivery. First, we had a very robust quality assurance program and worked hard to create a culture of quality and safety before it was fashionable. Second, against the wishes of the base commanding officer who wanted to have “his own hospital,” any attempt to be who we were not (a small ambulatory presence designed to get folks the care they need when they need it) was resisted by folks above my pay grade. Third, the Navy was experimenting with nurses in charge of practices such as this and I was extremely fortunate to work with several very good Nurse Corps OICs and learned to work as a member of a care team.

The military is a unique practice environment. The emphasis on readiness as well as wellness provides lessons for all of us in healthcare. Unfortunately, military medicine may be in trouble. The remote locations, providers who may not be invested with tours of only 3 to 5 years, and inexperienced physicians who are moved rapidly up in rank based on medical training apparently has led to problems.  The New York Times has recently published a story highlighting the downside that is worth a read. I was most struck by the quality and safety problems highlighted in the article. Physicians are apparently being placed in small hospitals with skills ill-suited for the location and/or patient population and attempting to provide care comparable to what they learned in their training. In addition, data aggregation techniques now used in the civilian world to assess quality and improve care are not in common use in the military hospitals. Leadership positions are being given to physicians who have a high rank by virtue of their residency training but limited real world or even military experience. The military is not entirely to blame. When they try to consolidate hospitals or provide care in a different fashion they are obstructed by the community, who uses their congressperson to keep the jobs local.

Our troops and their families as well as those who have retired from active duty have the expectation of high quality and safe healthcare, as does the general public. We need to equip all physicians with the skills necessary to practice in the environment in which they find themselves. Surgeons in isolated areas need to focus on doing small procedures well and leave the complex cases for hospitals with teams to provide care, whether on a military base or in rural Alabama. We need to teach how to assess and incorporate meaningful quality and safety practices starting at day one of medical school and not assume competency by virtue of a residency training certificate. The Milestone project seems to be a good start at making sure this happens at the residency level. Lastly, we need to teach leadership. Physicians are expected to be leaders. It’s time we give them the tools to do it.

william-haefeli-if-you-bring-joy-and-enthusiasm-to-everything-you-do-people-will-think-y-new-yorker-cartoonI received the following comment to my previous post (which I have paraphrased some) and feel compelled to respond in depth:

I am a new 4th year medical student who entered medical school to become a Family Physician. However, the challenges facing family medicine give me great concern and I was wondering if I could get feedback on a few of these concerns.

(1) The Turf War between Nurse Practitioners and Family Physicians.

It seems to me that Family Physicians are treating only a fraction of disease entities that comprise the requirement for licensure and graduation from medical school. From what I have seen Family Physicians are not even reading EKGs and require a cardiologist.

To me, this creates a opportunity for the nurse practitioner to boldly say they can function as family physicians – by addressing that small fraction of entities which makes up the current repertoire of FPs. 

Family physicians need to be vocal about what their training and expertise bring to the table. Most of the noise regarding nurse practitioners and physicians assistants becoming the primary care provider of choice is just that, noise (go to this link for more details). First, as Bob Bowman I’m sure will elaborate, the workforce and work product from these types of providers has not been shown to provide for the needs of our country.  Every other country uses generalist physicians to lead the primary care team. The move to exclusive use of these providers for primary care would be yet another natural experiment in health policy for our country should we chose to go in that direction. The ones to date have not been shown to lead to better quality, less cost, or better health for Americans. We are now in the process of transitioning to the Patient Centered Medical Home team based approach to care in this country. The team will almost certainly include other providers and I would argue we need to be more expansive and include pharmacists and care managers as part of the team. Yes, Family Physicians need to maintain core skills but in our 11 years of training (as compared to 5-7 for PAs and NPs) and 21,700 hours of clinical training (as compared to 5350) we learn how to provide the first contact care that Americans need. As we transition it will be important for physicians to reacquire skills that may have atrophied as they focused on acute, self-limited illness care (which is likely more suited to care in a collaborative fashion by a PA or NP).

(2) The huge number of referrals from a family physician also results in disrespect from the medical and patient community.

– Examples include dermatology, minor procedures, ophthalmology referral for a retina screening 

Family physicians have been trapped in a world where they were seeing patients every 7 minutes, which is untenable. This was an artifact of our payment structure which valued volume over value and encouraged physicians in some settings to refer rather than perform many services they were trained to do. As payment methods change, chronic illness care is valued, and patient satisfaction is measured to reflect the skill and care of the physician, this will change. You need to learn how to perform procedures skillfully while being cognizant of your limits. Realize also that in academic settings referrals are made often for political reasons and do not reflect the scope of practice that physicians can enjoy away from the academic health center. The following is from an open letter to new graduates after the question was raised in one of our journals several years back

Avoid the temptation to limit voluntarily the things you do simply because the subspecialist does it better or more frequently. Your patients want and need you to do all that you can for them, not for you to be a speed bump on their road to care. If your consultants do not respect you enough to return your patients after answering the question you asked, find other consultants. Their role is to answer a question or perform a procedure you choose not to perform, not to expound on their superiority in some field or another. Your job is to take care of your patients, not to make the limited practitioners feel better about themselves.

(3) The future of Family Medicine :
I believe, that if Family Physicians continue to practice in this manner of treating only a fraction of what they know how to treat, within the next 10 years no one will go into family medicine…. Right now the numbers going into family medicine ranges below 10% at the “top schools”.

I believe that medicine is changing. Our specialty went through a thought exercise about 10 years ago now and put out a series of articles regarding where the specialty needed to go called, ironically, “The Future of Family Medicine.” Our Academy has taken up the mantle and provides information for students such as yourself here. The future of all health care in this country is a team approach to care with a focus on improving the health of the population at a high quality and lower cost. Family physicians have been shown to do just that. We have taken the principals developed in the Future of Family Medicine project and, working with the American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association among others, embraced the Joint Principals which led to the Patient Centered Medical Home (more information found here)

(4) Also can Family Medicine training agree to evolve the services of a Family Physician? Or is the plan to stay the same?

If only a minority of Family Physicians take the lead in providing full-spectrum services while the vast majority treat a fraction of what they were taught to treat – there will be nothing to distinguish their service from the one provided by the nurse practitioner.

Family medicine (and all residency training) programs are dynamic processes. About 70% of the curriculum is proscribed by the governing body, the Residency Review Committee. This curriculum is reviewed about every 5 years and another review is due out any day now. It is anticipated that there will be major changes in training requirements to reflect the changing needs of our health care system. We are already training our physicians to be leaders of the care team, knowledgeable about chronic illness care, and able to care for all patients as a physician of first contact. I anticipate that this is the direction training will take. In addition, 30% of the curriculum can be set by the program to reflect local strengths and all of the curriculum acquires a local flavor. Our program, for example, has a strong underserved component. Our patients cannot get in to see a dermatologist closer than 4 hours away (an insurmountable barrier to those with poor transportation). As a consequence we are very good at managing diseases of the skin without a dermatologist. Programs in the west offer a lot of OB. I would encourage you to look at the 400 family medicine programs in the country and find one that offers training you find appealing. My experience in training residents who have taken positions everywhere from rural Alabama to Alaska tells me you will find a practice that will value your skill set.

Good luck with your decision. I hope that others will pitch in their two cents about “Why Family Medicine” as well because people like you are our future.

11046819There was another article on NPR this morning about Brad Duke. For those of you whose memory of current events is slipping (I didn’t remember him either) he was the Powerball gazillionaire from 2005. Well, not a gazillionaire but a $225 millionaire. In this follow-up he seemed like a very nice young man, the kind I would want my daughter to marry (well, the cash WOULD be a plus). He lives modestly, manages his money well, and in general he is doing quite well. He told interesting stories of all of the people who tried to separate him from his money. In the story, an interesting fact came out. It seems that 70% of Lotto winners who win over $10,000,000 will be broke in a couple of years. Advice to lottery winners from financial planners: Don’t forget who you are.

Lottery winners and students who have made it into medical school have a lot in common. Many really good students are strongly encouraged to buy a ticket in the pre-medical school lottery. I suspect the enticement of money doesn’t hurt. Preparation for the required entrance testing begins before high school. Failure to perform well on one of the pre-admission tests results in disqualification. Once accepted into a pre-professional college curriculum, a single bad semester will result in disqualification. Though not as bad as the odds of winning the lottery, not great odds.

The acceptance to medical school is the winning ticket. Those who are successful in obtaining entrance into medical school have a 98% chance of becoming a physician. They are exposed to multiple strong role models throughout their medical training. Though they will likely say in the admissions interview “I like science and I want to help people” the evidence shows that are they will pick a career based on projected income, and perceived specialty status (the higher the better) when making their final career selection.

While our students may have won the lottery, Alabama has not.  Of our 67 counties, 60 of them have insufficient primary care. An additional 128 primary care physicians are needed now to relieve the existing shortage and over 400 are needed now just to provide optimal care. Given that the average age of the primary care physicians in Alabama is 50, we need our own lottery ticket and creating medical schools is not it. 86% of the students in our medical schools are Alabama residents but only 14% of these students come from rural Alabama. The results of the most recent “match” provide evidence that the existence of these medical schools is insufficient to respond to this crisis. UAB, the largest of the allopathic medical schools in Alabama,  put 12 students from a class of 200 (7%) into family medicine. Although 35 students were placed into Internal Medicine, the literature suggests that at most 8 of those will specialize in primary care. South Alabama, with a class size of 77, put 7 (10%) into family medicine and 21 into internal medicine. Based on projections, 4 of these IM residents will go into primary care. Given these numbers, best case scenario is that 28 graduates of the allopathic medical schools in Alabama will provide primary care. This is well under half of the projected need. In addition, 50% of these  medical students will leave the state upon graduation, presumably including at least some of students choosing primary care.

So what do we do? First, we need to stop treating medical school admission like winning the lottery. As my friend  Josh Freeman points out, we are lottery winners because we physicians have rigged the game. This needs to change. Secondly we need to rig the game to make sure the right people get a winning ticket. We know that it is possible to select students who are much more likely to seek out primary care and rural practice. Students are more likely to return to a community of the size they were reared in. Students who attend osteopathic schools are more likely to practice primary care upon completion of their studies. Students who attend a small college are more likely to practice primary care. Students with a spouse from a rural area are more likely to return to a rural area. These folks, if qualified, deserve a ticket. Lastly, a grown-up somewhere needs to take control of how many and what kind of doctors come out of the residency end of the pipeline?

As it stands now, the lowest paid physician is in the top 3% of all wage earners. Can’t we find people who consider this a winning ticket?

al-ross-is-there-a-doctor-in-the-house-that-s-the-call-harold-s-been-waiting-new-yorker-cartoonMedical students no longer dissect a cadaver in most medical schools. After hours call, or working outside of regular work hours to provide care to hospitalized patients needing assistance, is rapidly becoming an anachronism as well. Teaching hospitals used to use residents and students in lieu of hiring physicians to work at night. The learners would take care of sick people at night and in exchange teaching would occur during the day. One attending I had fond memories of his call days as an intern, sitting at the nurses station playing the guitar.

When I was in medical school, call was busy. The medical student would be expected (at least at Tulane in the 1980s) to come into work at Zero dark thirty and work all day taking care of the daytime patients. When the day’s clinical duties were winding down, the student who was on call would find the resident that was on call (protocol varied from service to service) and get “sign-out,”  or in other words find out what tasks needed to be done between now and 0 dark thirty tomorrow. The time that sign-out occurred varied depending on the speed of the clinical team you were on as well as the willingness of the other team to accept sign-out. You might be finished by four but if the on-call team wasn’t ready for you, tough. The feeling was that you were responsible for your patients 24/7/365 and the privilege of sign-out could only be enjoyed if both parties were ready. I remember several nights when I was not on call but was not afforded the luxury of sign-out until 8 pm or later.

The job of the person on call was to work-up all of the new admissions as well as take care of the work that was left over from the folks who signed out. Oh yeah, there was nobody to draw blood, transport the patients to x-ray, or any other menial tasks. Oh yeah, and no radiologists, either.

Resident: Take the new admission up to CT, he’s still not right and I don’t think we can wait until morning. After you drop him off go run this blood to the lab and tell them we need it STAT! Then go find an endotracheal tube. We’re going to have to intubate.

Me: On my way

Me, to CT tech: I’m leaving this guy here and going get some stuff. He needs a CT without contrast. Yes I paged my attending (a white lie) and he says we need it. Page me if he stops breathing.

Me, to lab clerk: We need this STAT

Lab clerk: The tech is on break, feel free to run it yourself (which we actually did at Charity)

Me to central supply clerk: I need a number 7.5 ET tube

Bored clerk: It’s in the back somewhere, knock yourself out.

After a night of admitting sick people, running labs, gathering equipment, and in general feeling useful, we (after, as Doctor Eaton points out in the comments, “morning report” where the attending would grill us for not knowing what we were doing) then had to work the next day until “sign-out.” The difference being that as the off-coming team we got to sign-out first.

This was the job of residents and students because, as we used to say at Tulane, calling an attending after hours was a “sign of weakness.”

At least that is the way it seems in my 30 year old memories. In actuality, what I remember is being bone tired, being scared to death that I wasn’t doing the right thing by the patient, but living with the certainty that late in the night New Orleans in the 1980s I was the best shot for these folks to get better because the alternative was death on the streets.

Today, the trends that led to my bad call nights have accelerated. Hospitalizations are much shorter (Average length of stay 11 days for hospitalized Medicare patients in 1980, 5.7 days today) and patients are much sicker (50% of hospitalized Medicare patients are obese up from 25% in 1980, over half have over 2 chronic conditions, and almost 1 in 5 are on dialysis).  Consequently, the world of hospital call (and medicine) has changed. Medical students and residents are only allowed to work 80 hours in a week, and if they are working a 24 hour shift they must be allowed to “strategically nap.” Sign-out is now termed Check-Out and is much more formalized. The expectation is that, though the patient has a primary physician, a team will see the patient through the hospitalization. That team includes physicians, nurses, techs, and others whose job it is to get the person healthy enough to leave the hospital as soon as possible. Many times check-out is to a night float resident (and a night float attending) who only work from 7pm to 7am.

We are still working through some kinks such as how best to handle the hand-offs. Despite these challenges, I believe that teaching hospitals are almost certainly much safer today as a result of the changes.

imagesThe physicians had a special relationship back in the pre-forties. They were respected by the entire community; the were looked upon as gods in their own rank.

Chandler Bramlett at age 74, as quoted in Health Care in Mobile: An Oral History of the 1940s

The Alabama Academy of Family Physicians flew me to Washington DC last week to represent the interests of family docs to our congressional delegation. I have been up to the Hill several times representing the interests of my rural colleagues, but this was the first time I was exclusively representing physicians. When you are representing all of rural Alabama’s health care needs, people tend to give you a lot of respect. When you are representing the economic interests of a group of people who, although relatively underpaid, still make in the top 3% of Americans and the top 1% of Alabamians, respect is not nearly as forthcoming.

I had the privilege of having John Waits as the other half of the small Alabama delegation. John is a family physician in Centreville, Alabama, who has established an FQHC and is in the process of using the Teaching Health Center mechanism to bring family medicine training to his small town with the first class starting this year.

The five-year, $230 million Teaching Health Center Graduate Medical Education (THCGME) program is designed to boost the number of primary care residents trained in teaching health centers (THCs), which are community-based ambulatory care centers that operate a primary care residency program.

Unlike Medicare GME funding, which goes mostly to hospitals, THCGME funding goes directly to community-based sites. The funding is tied to specific health care workforce goals, and THCs must report annually on the types of primary care training programs offered, the number of resident positions, and the number of residency graduates who care for vulnerable populations in underserved areas.

That’s the good news. The bad news:

One area of concern, however, is the funding uncertainty for the future of the program…. The THCGME program is funded only through 2015, which creates a challenge for the THCs…. Unless Congress provides additional funding for 2016 and beyond, THCs may have residents in the middle of their training without THCGME payments to support them.

It was this message we chose to bring to our delegation, asking them to help us make a difference.

We were doing OK with our message except for two little roadblocks. The first, especially problematic for our deeply Red delegation, is how the program got its start. It was included in the Affordable Care Act. Given that we were there on a Wednesday and the vote scheduled for Thursday was REPEAL OBAMACARE (which won 229-195 on a partisan vote), no one in our delegation could see a way to supporting a part of a law which was described this way by one physician congressman:  “Obamacare is terminally sick and we need to call the time of death.”

The second obstacle was, well, the physician congressmen. While Alabama has no physician members, our delegation tended to defer health issue specifics to a group referred to as the “Doc Caucus.” Formally known as the Republican Doctors Caucus, it was formed by Republican House physician members and includes all 15 GOP physician members as well as a psychologist, two dentists, and three nurses. Their issues (from their website) include: Repeal ObamaCare and end federal government’s involvement in healthcare; Encourage (but not mandate) state based high risk pools; Encourage (but not mandate) adoption of Electronic Health Records; Tort reform; Medicare and Medicaid reform (through competition and the repeal of the IPAB); Allow health insurance to be purchased across state lines (not through the exchanges in ObamaCare); Transparency of quality data (different than what was in ObamaCare or outlined by Dr Berwick while he was at CMS); Fix the sustainable growth rate.

Rather than move backwards, I would encourage them to listen to one of their former colleagues, Bill Frist, and consider using the Affordable Care Act to effect change by fixing the payment system:

“We are convinced that reforming our nation’s health care system to prioritize quality and value over volume will not only improve health outcomes and the patient experience, but also constrain costs and produce systemwide savings.”

“Care is organized around what the patient needs, not around what is expedient for an individual provider,” says the report. “Information, such as lab tests, referrals, notes and updated medication lists, is shared seamlessly among health care professionals without the need for patients to intervene.”

Maybe the American public should get to be the gods for a change.




tmcn2697l.jpgThe latest Main Residency Match (registered Trade Mark) results are in. Officially it is an impartial venue for matching applicants’ preferences for residency positions with program directors’ preferences for applicants. Unofficially it reflects a lot more, as I have discussed before (found here). For those of you living in towns with medical schools, it is the day that the hometown paperbloggythingy is filled with pictures of medical students crying because they are so happy to be leaving their current God-forsaken burg for one of better value (in Mobile, typically one several states away). To make a long story short, without successfully working in a residency position for several years, a young physician will never be allowed to practice medicine in the United States (how much time in residency is required varies by state).

There has been discussion on e-mail by my colleagues about the Early Results (term not trademarked, results found here). The good news for family medicine is that of the 3037 positions offered, 2914 were filled (about 95%). That bodes well for primary care, say some, and thus the glass is half full. The bad news for Family Medicine is that out of the 17, 487 graduates of traditional US (allopathic) medical schools, only 1356 chose Family Medicine, filling only 44% of our positions and comprising only 7% of the graduates of these schools. 1097 graduates of these schools did not match into any program and though there were Family Medicine positions available, did not apparently want these either. They have chosen, I presume, to sit out a year and try for the specialty of their choice again rather than seek three years of training to make a nice living (over $200,000 a year after completion) as a family physician. Looking at it that way, the glass is half empty.

Our society needs physicians practicing primary care, and graduates of family medicine residencies are the most likely to practice this kind of medicine. Graduates of traditional medical schools tend to seek the “ROAD to success” (Radiology, Ophthalmology, Anesthesia, Dermatology) specialties, so named because the average work week is less than 40 hours and the mean pay is over $400,000. So, where do we look?

One place is Osteopathic schools. The students who attend these schools tend to have a lower MCAT (24, average for most allopathic schools 30-31) and lower GPA but more life experience. (MCAT and GPA beyond a threshold value have been found to only predict success on the first of three standardized tests and have no bearing on clinical ability.) The students are typically committed to a distributed education model and often chosen for interest in primary care practice. Previously, osteopathic schools were seen by some as the domain of those not “smart enough” to be admitted into allopathic medical school. For those interviewing with us this year, it was decidedly not the case. In our experience, osteopathic candidates for our residency resemble allopathic students in their knowledge base. Their clinical skill set is a little different than the allopathic students’ but different can be better. In our experience they are bright and committed to going back to their community to practice (often an underserved community). There were 2677 total applicants in the Main Residency Match and 2019 got a position. How many went into family medicine is unknown.

Another place is the Caribbean. Medical schools there have exploded in the past 10 years. This seems to be at the expense of the old 5th pathway program (US citizens going to Mexican medical schools a la Bad Medicine) and non-US citizens looking to come to America (the  J-1 programs, as seen here). It used to be that applicants with a marginal application (relatively low grade, MCAT, or both) would have a application with the following pattern: apply to allopathic school with a marginal MCAT/grades, get wait-listed, “make your application look better” by retaking the MCAT and bumping it up two points, work as a hospital orderly, reapply, repeat until accepted or life passes you by. This is dead. Many students give US schools one shot then apply to a Caribbean school.

Coincidentally, many of these students with marginal applications also have a strong interest in primary care. Many of them have parents who are in primary care and who did not go to US schools. Their children are not looking for prestigious medical school but for training that allows them to qualify to take the ECFMG test. Passing this test allows them to give residency training a shot, often in family medicine. In 2009 there were 3390 applicants from these schools and only 1600 matched. This year there were 5095 and 3601 matched. That is 15% of the matched pool. For these schools the standardization of testing for graduates of non-US schools (ECFMG, NBME, and clinical skills evaluation) has been the great levelers. These graduates are a large part of our current workforce and have filled our training programs for the past 10 years.

Can we look to traditional medical schools to supply a larger percentage of the primary care workforce? Allopathic schools expanded their classes by 10% several years back to fill a “need.” That 10% was supposed to be selected to correspond to the needs of the “community.” The additional allopathic students, unfortunately, tend to look like the other 90%, overwhelmingly white, overwhelmingly privileged, overwhelmingly looking for a ride on the “ROAD.” Telling to me were the results for the 1487 allopathic graduates who did not get a position last year. I am assuming they have not been working as a physician for the past year (because they can’t). They applied for positions in this year’s match. 758 of them were unmatched for a second time. This means that rather than “settle” for a primary care residency that will net them $200,000 a year at the end of 3 years, they are going to sit out another year, presumably looking to get on the ROAD.

So, in our class we have 2 osteopathic physicians, 2 physicians who are from a Caribbean school, one traditional resident, and one resident who did not match last year and elected to apply in family this year. We are excited about training them and, since 60% of residency graduates tend to stay within 100 miles of where they are trained, I’m happy to welcome them to the community.

film-pitch-dkThe beauty of e-mail is you can watch conversations unfold over time (as opposed to Facebook where conversations are gone in 2 minutes). Some of my colleagues are trying to describe who Family Physicians are for a broader audience in 100 words or less. To be honest, it is unclear who this audience is and why they want to know what I do so I haven’t been that engaged in the exercise. I got sucked in for a brief period this morning so went back to the beginning of the conversation to get my bearings back.

100 words are not a lot to describe anything. It is an elevator pitch.  In other words, what the group is trying to do is put together a set of ideas that could be used by me for this:

Me: “Hold that elevator”

Bill Gates: “You look like a smart man who could use some money. I have a lot of money. While we ride up to the 40th floor, tell me what you do and how a lot of money would change that.”

Me, pulling out a piece of paper with 100 words on it,”Well…”

The format is typically: For (target customer) who has (customer need), (product name) is a (market category) that (one key benefit) unlike (the competition). The product (unique differentiators).

The elevator pitches that are being sent around now all focus on the key benefit. “Family Physicians are…” We are either are the best thing since sliced bread or (in something termed the foil position) we are the teats on the boar of healthcare. I would suggest a different format. Here is my pass at what I would tell Bill:

We have convinced Americans that, once broken, modern medicine can rebuild them better than new. Americans destroy themselves with tobacco and other poisons. America destroys its own with unhealthy societal choices such as our firearm policies. Our medical-industrial complex has taken advantage of goodwill engendered by the introduction of antibiotics and relatively safe surgery and is rapidly depleting our national treasure under the guise of “health care.” We must retool the entire system. Family physicians, as a consequence of their generalist training and mindset, are the least co-opted physicians in the current system. If we must use physicians, give me money to train generalist physicians such as FPs in team based, patient centered care focused on rational resource utilization and let’s use them to reformat the entire delivery system, as the ACA allows us to do.

Oh, well, 140 words…maybe he’ll hold the door…


I have been installed as President of the Alabama Academy of Family Physicians. The work should not be too hard and on occasion should be rewarding (or at least ego-boosting). Such was the case the other day when the Executive Director asked me to recall a patient from “my early days” that had made an impact so he could publish my thoughts, thus officially making me an old geezer. I thought back, thinking of the the heavy snow drifts I walked through to get to the hospital (unusual weather in Portsmouth but it was before “climate change”), recalling the large hill that I had to walk up to get both there and back, and this was the patient’s story I chose:
In April of 1987 when I was an intern at Portsmouth Naval Hospital I saw a 54 year old male patient for fatigue and discovered a previous diagnosis of iron deficiency anemia. He was again anemic. He was subsequently found to have Stage 4 colorectal cancer for which he received treatment. About 6 months later I admitted him from the emergency department (where I was working after finishing internship while waiting for training in Undersea Medicine) with jaundice. The ward team provided aggressive care but he died anyway.
The sad part of the story is that this patient had been seen by one of my intern colleagues in July of 1986 (the first month of our internship) for a complaint of fatigue. An iron deficiency anemia was initially found at that time. He was placed on iron, felt better, came back for follow-up, and was discharged from care. No follow-up to identify the cause of the anemia was done at that time.
Though the snow is less in Mobile and the hills less steep, the lessons I took away from that patient are still indirectly shared with every resident and student I teach:
1) It is my belief that quality care should not be dependent on specialty or level of training. My colleague should have consulted with the attending physician who was sitting in an office on the unit (and may have). My colleague could have read about the work-up of anemia after the visit and called the patient back. Being young and inexperienced, he appropriately treated the symptom but did not look for the disease. Avoidable mistakes such as this are not acceptable. We try very hard to put systems in place in our practice so that when the patient receives care, regardless if delivered by a faculty member or from a trainee, it will be predictable and of high quality.
2) Colon cancer is not a pleasant way to die. This patient was diagnosed with a rigid sigmoidoscope (a firm, hollow, silver tube about 2 feet long). Though we knew that early detection of cervical cancer saved lives, we knew little about early detection of breast and colon cancer. We now know that through use of colonoscopy and home stool testing, lives can be spared. I would like to believe that this patient, who was of an age that screening is now indicated, would have potentially been spared this death as the result of a caring family physician facilitating this screening. In our practice we have made early detection of eminently treatable cancers such as this a priority. We all work to assure that our patients have access to these screening tests.
3) We are all going to die. Having a terminal illness makes this likely to happen sooner. There comes a time to move to comfort measures. I want my faculty, residents, and students to be advocates for our patients in disease prevention and treatment. We also need to be advocates for moving from cure to comfort when it is appropriate. In my patient’s case, the Naval Hospital was his “provider.” We did not make that transition easy for him. I am afraid to say we have not gotten much better at this in the last 25 years.

As a southerner, I really like colorful expressions. “That dog won’t hunt” is one that I use when I am hanging with my Yankee friends and I want them to give me a “what is he talking about” look. “I wouldn’t know him from Adam’s off ox” is one that I love but I find I have to explain it way too often as I am not usually hanging with people familiar with oxen team terminology. One that I find more useful as I get older is “lipstick on a pig” as in “That’s just putting lipstick on a pig.” The expression, per Wikipedia, describes “making superficial or cosmetic changes in a futile attempt to disguise the true nature of a product.”

The medical education process seems to have taken a “lipstick on a pig” approach to reform. I have written about what people want in a doctor before (found here) and here is WebMD’s list from an article in the Mayo Clinic Proceedings:

Traits listed by the patients, along with the patients’ definitions of those traits:

  • Confident: “The doctor’s confidence gives me confidence.”
  • Empathetic: “The doctor tries to understand what I am feeling and experiencing, physically and emotionally, and communicates that understanding to me.”
  • Humane: “The doctor is caring, compassionate, and kind.”
  • Personal: “The doctor is interested in me more than just as a patient, interacts with me, and remembers me as an individual.”
  • Forthright: “The doctor tells me what I need to know in plain language and in a forthright manner.”
  • Respectful: “The doctor takes my input seriously and works with me.”
  • Thorough: “The doctor is conscientious and persistent.”

Contrast that with the criteria for selection for medical school (grades and scores on a single standardized test) and the criteria for selection for residency training (grades and scores on a series of 2 standardized tests). It is my experience that test scores often don’t correlate with the things patients want in a doctor.

Recently, post-medical school training has attempted to emphasize qualities other than test-taking skills. The ACGME Outcomes Project, for example, has been in effect for 14 years and requires residencies providing post-medical school training to measure growth in characteristics such as those listed above. Efforts to change the medical student curriculum, though emphasizing the behavioral buzzwords found in the WebMD article, continue to have an assessment component focused using multiple choice type questions. Growth as a person is subordinated to acquiring knowledge for assessment via multiple choice testing, rendering the curriculum change efforts “lipstick on a pig.”

I have focused most of my career attempting to mold learners in their post-medical school years and have found that attitudes are set. Where residents come into the program from medical school regarding their attitudes towards patients is where they tend to stay. I was excited to recently come across this article, implying that it may be our educational efforts in the early training years that are lacking, not the learners’ ability to change. The authors suggest that the learners’ ability to store and regurgitate knowledge (IQ) was fixed, but their ability to incorporate professional values such as compassion and integrity (EQ) is fluid. To accomplish changes in behaviors and attitudes is going to mean not applying more lipstick but getting rid of a lot of the pig. Picking “listen to the patient” from a multiple choice answer list will no longer be a sufficient assessment. Assessing the learner at baseline (even prior to admission), establishing a set of non-negotiable standards, measuring behaviors using Standardized Patients as well as real patient encounters on multiple levels, using peer evaluations to capture attitudes not observed in formal settings, and forcing reflection on the part of the learner with the learner at risk of failure for not performing up to par will be necessary to effect these changes. It will mean changes in the training milieu as well. No more “Butt Boxes,” lists of words mispronounced by illiterate patients, comments about patients’ lack of “personal responsibility” to justify providing substandard care, or other activities that belittle or dehumanize patients in public or (more insidiously) private.

The authors suggest that establishing a strict standard and enforcing a “zero tolerance” for learners and faculty are necessary to drive this type of reform. I can only wonder if we can meet this standard or if we will quickly run out of faculty and students while trying to do so.