You are currently browsing the category archive for the ‘Specialty selection’ category.
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.
There 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?
Larry Bauer has once again posed questions to a group of us “Family Medicine Bloggers.” I find them interesting questions because, as someone who trains family Physicians, I often get asked about training philosophy. In addition, because of changes in accreditation requirements and work hours, there is often a question among educators as to whether we are leaving out the best part of medical training. Larry has posed two questions:
In your training, what 3 things (maximum) were stressed/emphasized to you regarding how to take good care of people?
In your experience, what 3 (maximum) lessons have you learned about taking good care of people? (if you had just three suggestions to pass on to students and residents regarding how to take good care of people, what would you say?)
My medical school training was at Tulane and my clinical training was mostly at Charity Hospital (also known as “The Big Free”) in the mid 1980s. It was a different time and a different place. There were no work hour restrictions, there was very little contact with attending physicians in conjunction with patient care, and as a student you had the distinct impression that you were an important part of the health care team (and occasionally the only thing standing between your patient and death).Everyone, from the dean down to the intern on the serviced stressed one thing:
“Know Your Patient!”
In a place like Charity, this could not be overemphasized as to call the “health care team” stressed would be a generous understatement. Although the health care environment our resident learn in today is quite different, I still cannot overemphasize the importance of this.
The hospital had open bay wards where everyone could see everything. I still have a distinct memory of me as a 3rd year medical student watching a gangly white medicine resident trying to describe in very technical terms (using the barium enema image as a teaching tool) what Crohn’s Disease was to an impoverished African-American patient who clearly did not believe that the image was of his insides, much less that his insides were defective in some way. It was clear to me from that day forward that I had to:
“Speak the patient’s language.”
It may be through a translator or to the patient and a parent, or to the child of an elderly patient, but it is less important for me to be accurate than it is for me to be understood.
I did my first year of residency at Portsmouth Naval Hospital in Internal Medicine and stayed on working the Emergency Department for a year waiting to become a Diving Medical Officer. As a ED doc walking in with one year of post-graduate experience, I could not be accused of being over-confident in my abilities. Many of the residents who had been with me throughout my PGY1 year were still in training and I interacted with them on a regular basis. I was functionally the “admit resident” and they were my consultants. The ED staff and my colleagues hammered home to me the lesson that:
“Medicine is a team sport.”
Never be afraid to ask for help. Always accept criticism and try to improve. Know what your role is in the health care team and hope that everyone else does as well. Put a good team in place and good care follows.
After I finished dive school, I was stationed in the clinic in Kaneohe, Hawaii. I got the job because no one else wanted it, based on rumors of what the job might entail. At the end of three years I had made a bit of money on a condo, seen almost everything to see in Hawaii, made friends for lifetime, learned I wanted to do Family Medicine, and had a wealth of experience in leadership positions. In other words:
“Make the best of the hand you are dealt.”
Admittedly, raising your hand to volunteer to go to Hawaii isn’t like agreeing to fight “a land war in Asia” but it might have turned out badly.
I did my residency in Family Medicine at South Alabama. Ellen Sakornbut knew that I wanted to do Academics and challenged me to acquire and maintain OB skills (I still take OB call 20 years later). In her words:
“OB keeps your practice young.”
As I find myself caring for an increasingly aging patient base (despite miraculously not aging myself!), I am grateful for that piece of advice when I see a pregnant patient in my practice (often, these days, the child of one of my older patients).
The last lesson that I learned in medical school and had emphasized in my internship, Navy career, and residency is this one:
“Always do the right thing.”
Of course, trying to figuring out what that is can be tricky!
I like reading what Atul Gwande has to say, despite the fact that he is a surgeon. I was sent a link to the commencement address that he gave this season to the graduates at Harvard Medical School. I have sat through a number of these and typically am underwhelmed but this one is worth a read in its entirity. There are two passages in particular that I want to call attention to:
“[The values needed for medical practice] include humility, an understanding that no matter who you are, how experienced or smart, you will fail. They include discipline, the belief that standardization, doing certain things the same way every time, can reduce your failures. And they include teamwork, the recognition that others can save you from failure, no matter who they are in the hierarchy These values are the opposite of autonomy, independency, self-sufficiency.”
This is what medical school curriculum has to focus on and I’m afraid we are not getting it. We seem to still be in the “science of discovery” mode and not the “science of synthesis.” This quote needs to go to everyone on the curriculum committee of every medical school in the country.
And for the admissions committee members:
“The revolution that remade how other fields handle complexity is coming to health care… I see this in the burst of students obtaining extra degrees in fields like public health, business administration, public policy, information technology, education, economics, engineering. Two years ago, the Institute for Healthcare Improvement started its Open School, offering free online courses in systems skills such as outcome measurement, quality improvement, implementation, and leadership. They hoped a few hundred medical students would enroll. Forty-five thousand did.”
Addressing the goals of health care reform will take a combined federal, state, and local strategy involving resource deployment and actions designed to expand the available short-term and long-term supply of well-trained primary care professionals who are ready and willing to serve the newly insured. Ensuring access to care will depend on our ability to achieve smart growth in both insurance coverage and primary care capacity.
1. The Number of Primary Care PhysiciansRecommendation: Policies supporting physicians providing primary care should be implemented that raise the percentage of primary care physicians (general internists, general pediatricians, and family physicians) among all physicians to at least 40 percent from the current level of 32 percent, a percentage that is actively declining at the present time. The achievement of this goal should be measured by assessing physician specialty once in practice, rather than at the start of postgraduate medical training.2. Mechanisms of Physician Payment and Practice Transformation for Primary CareRecommendation: To achieve the desired ratio of practicing primary care physicians, the average incomes of these physicians must achieve at least 70 percent of median incomes of all other physicians (According to data from the Medical Group Management Association cited in the report, primary care physicians’ median annual compensation was $186,044 in 2008 versus $339,738 for physicians practicing in other specialties). Investment in primary care office practice infrastructure will also be needed to cope with the increasing burdens of chronic care and to provide comprehensive, coordinated care. Payment policies should be modified to support both of these goals.3. The Premedical and Medical School EnvironmentRecommendation: Medical schools and academic health centers should develop an accountable mission statement and measures of social responsibility to improve the health of all Americans. This includes strategically focusing and changing the processes of medical student and resident selection and altering the design of educational environments to foster a physician workforce of at least 40 percent primary care physicians and a health system that meets societal needs.4. Graduate Medical Education
Recommendation: Graduate Medical Education (GME) payment and accreditation policies and a significantly expanded Title VII program should support the goal of producing a physician workforce that is at least 40 percent primary care. This goal should be measured by assessing physician specialty in practice rather than at the start of postgraduate medical training. Achieving this goal will require a significant increase in current primary care production from residency training and major changes in resident physician training for the practice environment of the future.5. The Geographic and Socioeconomic Maldistribution of Physicians
Recommendation: So long as inequities exist, policies should support, expand, and allow creative innovation in programs that have proven effective in improving the geographic distribution of physicians serving medically vulnerable populations in all areas of the country. This should be done through mechanisms such as the National Health Service Corps and Area Health Education Centers.
I do not know about you, but these are pretty bold recommendations and very exciting for the future of our great specialty. Will these recommendations gain traction anywhere within the government? While it is true that more primary care used appropriately and effectively decreases the amount spent on healthcare, will there actually be an increase in salary? Or would we go as far as entering into the blasphemous territories of decreasing the median specialty salary? ::GASP:: My guess is it would probably be a little bit of both.
I interview approximately 60 prospective physicians for medical school over the course of the year and 40 physicians who are applying for the residency program. The pre-med students (almost all of whom are the age of my children) tend to have pretty good interview skills and are trying very hard to get into medical school (“I’ve wanted to be a doctor for as long as I can remember”) so the interviews tend to be somewhat predictable. Every so often I’ll get one who considers ObamaCare to be the devil’s work but for the most part they are good but non-controversial interviews.
The resident interviews are more fun for me. These are physicians-to-be who want to be in Family Medicine, want to see what our program has to offer, and have at least a passing understanding of the advantages our program might have over our competition. These are interviews with much more substance. The three on Friday were especially enjoyable.
One of the candidates was from Louisiana and grew up in a part of the state that my family is from as well. After a discussion regarding Cajun territory, the conversation veered towards Family Medicine and why he wanted to become a Family Physician. The candidate had done most of his clinical work in Lafayette, a regional clinical site where Family Medicine is taught. Like all good clinicians-to-be, on every clinical rotation the instructors not only focused on his clinical learning but also on his career choice. “Why Family Medicine” they would ask. He worried about the prestige factor as he was choosing a specialty. His decision was cemented, though, by a decision LSU made to place him with a rural Family Physician for an extended period. He saw this physician as a mentor and it was this relationship that cemented his decision to go into Family Medicine. He said “At the (teaching) hospital in Lafayette, the Family Medicine team is down here and the specialists are up here. Out in the community it is completely reversed.”
The second candidate was a student who had come for an interview the previous year. I remember the interview from last year very well. I was very surprised when I heard that this student selected Pediatrics instead of Family Medicine. She came back to re-interview because she said she had discovered her mistake and wanted to be a “Family Doc.” She said she was admitting a very young patient to the inpatient service for failure-to-thrive. It is uncommon for infants to fail to thrive and it is almost always a parenting problem and not an infant problem. In this case the mother seemed to the resident to be suffering from post-partum depression. Unfortunately, she was told that it was not her place to treat the depression, only the poorly fed infant. She said to me “I want to be able to treat the whole family.”
The third was a non-traditional candidate who was originally from Mobile. He left Mobile almost 18 years ago and after a roundabout life course ended up in medical school. He told me “I want to take care of people who are underserved in a holistic way and I want to do it here at home.” The fact that he was of African-American descent was meaningful. Traditionally we have had trouble attracting African-American candidates from Mobile into primary care, as have others, in part because there is a tradition in the community to encourage minority medical students to pursue limited specialty choices. I suspect this is a reminder of our racist past in this region, where African-American physicians were excluded from specialty training. Having Family Medicine seen as a “specialty” by this student is clearly a victory.
So three candidates and three conversations that give me hope for our specialty and the future of medicine.
The Wall Street Journal published a very good article several weeks ago about how payment is set for physicians provided clinical services. It does a good job of highlighting a little known aspect of care, the “fee schedule.” Historically, fees were set in a very disorganized fashion and the introduction of Medicare necessitated the creation of an infrastructure (one might even describe it as a bureaucracy) to establish a fair amount to pay physicians. Importantly, many other insurances use Medicare as a basis to set their rates. Over the years there has been much give and take regarding who can request payment for a certain procedure and what the payment should be. For as long as I have been a physician, my colleagues have complained about non-physicians determining who gets paid and how much. Turns out it’s been the physicians setting the rates all along. Reading this article will give those who want to allow physicians to police their own profession without non-physician oversight pause.
Much of the payment structure was established when physicians did a lot more in the hospital with only occasional tweaking over time. The payment was bundled, with each procedure having a pre-hospital component, a component in the hospital, and a post-procedure follow-up visit. This was supposed to even out (I suppose) unpredictable complications. In the interim, much of the care has moved away from the hospital but
For instance, one operation to treat male urinary incontinence wraps in payment for 118 minutes of hospital visit time after the day of surgery, though 2008 Medicare data show it is done around 80% of the time outpatient or in a doctor’s office. Stephanie Stinchcomb, manager of reimbursement for the American Urological Association, says the surgery used to be largely inpatient; its payment was last updated based on a RUC evaluation in 2003. It’s not clear if a new analysis will find doctors should now be paid less for it, she says.
It seems that the committee only moves in one direction
Out-of-whack Medicare doctor payments are supposed to be corrected in a required review every five years. MedPAC says in the three previous reviews, the RUC endorsed boosts for 1,050 services, and decreases for just 167. Many recommendations on which services to examine came from doctor societies. The upshot may be that payments don’t keep up with medical realities when procedures become easier or faster, MedPAC said.
And has ended up accomplishing one thing
A recent analysis for the Medicare Payment Advisory Commission, or MedPAC, a Congressional watchdog, calculated how much American doctors would make if all their work was paid at Medicare rates. It found that the primary-care category did the worst, at around $101 an hour. Surgeons did better, at $161. Specialists who did nonsurgical procedures, such as dermatologists, did the best, averaging $214, and $193 for radiologists.
These disparities have increased tremendously over the past decade. To be honest, I feel well compensated for what I do but I can guarantee you that students are well aware of the pay differential and it enters into specialty selection.
What should we do? One physician posted a comment
I don’t really understand this attack on medical specialists. I am one such physician and I can tell you that we serve a valuable role in the medical community. … Thus, I propose a different alternative. I believe the days of primary care physicians are coming to an end. Like the death of the dinosaurs. They will be replaced by lower cost medical providers like PAs and ARNPs most likely in the next quarter century. Perhaps PAs and ARNPs could serve as the hub/organizer to refer to the most appropriate specialist. This may save the system money. …. I am a big fan of primary care physicians but I still believe it is inevitable they will be extinct.
If you have read this blog, Josh Freeman’s blog, Paul Grundy’s work, or Barbara Starfield’s work you will know that this is not the case. This would, however, help certain physicians to maintain their income. As I have previously discussed, it will lead to more procedures on unsuspecting patients who are told that more is better. Let’s change the system instead, shall we?
As I alluded to previously, I was in the nation’s capitol as a part of the National Rural Health Association’s Policy Institute. Many advocacy organizations have such activities, bringing members in from throughout the country to discuss common issues with their members as a group. All 50 states were represented. We had three of us from the Alabama Rural Health Association and visited with the staffs of both of our Senators and 6 of 8 Representatives.
Although the political landscape is still uncertain, primary care (and more specifically family medicine) is on everyone’s mind. From the speakers to the staffers, there is an appreciation for what we do as a specialty and a concern that we will not accomplish sufficient change to enable family physicians to do their job as well as they should. Everyone expressed appreciation for “Family Docs”
The other striking thing is that all of the staffers were aware of the Patient Centered Medical Home and (although some were more convinced than others) were convinced of its potential value. It has been amazing to see how fast this concept has made its way into conversations about health care delivery.
I’ll have more later but if you still are unconvinced about the value of Family Docs, their commitment, and their abilities here’s something for you to look at…
I had a conversation today about a resident not in a family medicine program who wishes she would have chosen our specialty. Selection of a medical specialty often incorporates some of the common pitfalls in clinical medicine identified by Dr Goopman:
Anchoring – medical students tend to fixate on one specialty and do not open to other possibilities as they present
Availability – Students who identify with a resident mentor who was clinically strong will choose that specialty to emulate the resident
Attribution – Students will be offered stereotypes associated with various specialties from fellow students or non-physician teachers in the clinical years and will accept them rather than seek out information independently. They will then enter into the clinical years with this bias.
Fortunately, our specialty has put together a resource for medical students to assist them as they make career choices. They point out that
“Students who choose family medicine, for instance, do so because:
- They appreciate being an integral part of the nation’s health care system as a primary care physician.
- They enjoy the full spectrum of care in having patients of all ages.
- They find they can relate to people and want to develop long-term relationships with patients.
- They enjoy a mix of seeing patients in community settings, performing procedures in-office, delivering babies, and holding in-depth patient consultations.”
We (and our patients) are fortunate to get folks into the specialty who think this way, especially if the student realizes that Family Medicine is for them early in his or her training…