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I was pleased to read a student impression of the National Conference for Family Medicine Residents and Medical Students. I go almost every year and am impressed by the student interest and the efforts of those of us in Family Medicine to get students to the conference. This year South Alabama sent 11 students to the conference and they all seemed to come away with good knowledge about the specialty and an excitement about Family Medicine. The Medical RNinja reported on one session on the Patient Centered Medical Home where prospective residents were given a list of questions to ask prospective programs when interviewing. It is a very good list, so good that I will reproduce it below and encourage anyone applying for Family Medicine residencies to look at it before your interviews…

Access to Care

1. How does your practice provide patient-centered enhanced access (e.g., evening or weekend hours, open-access (same day) scheduling, e-visits)?

Electronic Health Records

1. What aspects of your medical home are electronic (e.g., medical records, order entry, e-prescriptions)?

2. Does your practice use a Personal Health Record that allows patients to communicate their medical history from home to the healthcare team?

Population Management

1. Do you use patient registries to track your patients with chronic diseases and monitor for preventive services that are due?

2. Does your practice use reminder systems to let patients know when they are due for periodic testing (e.g., screening colonoscopy, PAP smear, mammogram) or office visits (e.g., annual exam)?

Team-Based Care

1. Who comprises your medical home team and how do they work together to deliver comprehensive care to your patients?

2. What services can non-physician members of the team (nurse practitioners, medical assistants, social workers, etc.) provide for patients (e.g., diabetic education, asthma education)? How do you train them and ensure competency?

Continuous Quality Improvement

1. How do you monitor and work to improve the quality of care provided in your medical home?

2. How do you monitor your ability to meet patients’ expectations (e.g., patient satisfaction surveys)?

3. Are residents involved in helping to enhance practice quality and improve systems innovations?

Care Coordination

1. How does your practice ensure care coordination with specialists and other providers?

2. How does your practice ensure seamless transitions between the hospital and outpatient environment?

Innovative Services

1. What procedural services are offered in your medical home (e.g., obstetrical ultrasound, treadmill stress testing, x-rays)?

2. Does your medical home provide group visits (e.g., prenatal group visit)?

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In this country we have an odd way of doing workforce planning for physicians. Many years ago medical schools in this country were optional, set up to supplement the apprenticeship system that functioned in the seventeenth and eighteenth centuries. As described by Abraham Flexner in 1910 “The likely youth of that period, destined to a medical career, was at an early age indentured to some reputable practitioner, to whom his service was successively menial, pharmaceutical, and professional; he ran his master’s errands, washed the bottles, mixed the drugs, spread the plasters, and finally, as the stipulated term drew toward its close, actually took part in the daily practice of his preceptor,—bleeding his patients, pulling their teeth, and obeying a hurried summons in the night.” Students who desired to learn a more rigorous practice could supplement this apprenticeship with medical study in the larger towns in America. Mobile had medical schools early in its history and a very good one (Medical College of Alabama in Mobile) was established in 1859 to “supply physicians to rural Alabama, to reverse the economic and cultural drain among Alabamians that out-of-state education implied, and to educate medical students regarding the unique health care requirements of a predominantly rural Alabama populace.” Medical schools were commonly established near hospitals to expose students to people with various ailments with the Hospital Physician charged with oversight of these students.

The additional training of doctors freshly out of medical school in hospitals became popular in the 1870s and the City Hospital of Mobile had such a training program prior to 1895. The emphasis was on personalized instruction, use of laboratory to make diagnoses, and (after antisepsis became widespread) the use of surgery to cure illnesses such as appendicitis. Beginning in the late 1800’s but accelerating after WWII, physician specialization required additional training in a hospital after medical school. Where such training took place often dictated where one could practice following training (and still does to some extent) so there were not as many coveted positions as there were medical students. Medical students would go on interviews and were lucky enough to receive an offer would be given as little as several hours to think it over. This was not conducive to good medical student mental hygiene.

In 1952 a group of medical students got together and determined a method that internships (and further training  called residencies) could be announced using a computer to match the medical student choices with the hospital choices. That process is now known as  the match. In 1952, when the match was created, the money to pay for internships and residencies was put up by the hospitals. There were no work restrictions and the job became an apprenticeship type experience with some education provided. The book “House of God” is a good description of the training from that era.

Over the ensuing 50 years, much has changed regarding residency training. beginning in 1965 the federal government began paying for medical education through the Medicare program. Hospitals took advantage of this opportunity to add a number of training programs. These programs benefitted the hospitals by allowing them to provide more extensive care but did not necessarily lead to good training and the programs offered had no relationship to the needs of the community. In addition, physicians from other countries were encouraged to train here (and ultimately the system came to depend on these 5,000 physicians brought over every year) but were offered training that they could not use in their country for the most part because of a lack of available technology. Beginning in the 1980s efforts were made to control both the quality of the training programs and the importation of physicians from other countries, with mixed results.

What does this have to do with workforce? Graduating medical students select a specialty based on what they think they might like to do, where they might want to live, and (some more than others) how much money they anticipate making. Hospitals, who have little skin in the game when it comes to training residents and actually make money for having residents, want to be successful in attracting residents so they tend to offer training programs that are desirable to prospective residents. In an odd coincidence, those programs that graduates think will allow them to make a lot of money tend to fill first, before those that are needed to provide care for the poor and underserved (primary care). In the annual ritual, we offer more specialty care positions than we need as a country to provide optimum care, celebrate all of our bright students getting into these programs, and then bemoan the waste that comes from doing too many cardiac catheterizations. After all, a cardiologist has to eat.

After all was said and done, this years match actually ended on an optimistic note for my specialty. Although only reflecting an improvement of about 100 students, there were more US graduates going into Family Medicine than in previous years. Doctors in our specialty may not make as much as some of our limited specialty colleagues but I hope that one of the results of tomorrow’s vote will be to eliminate some of the stresses that contribute to professional dissatisfaction. It appears that at least some US students are anticipating this. Maybe next year will continue the trend…

I recently gave a “State of the Department”  report to the Executive Committee of the College of Medicine. I took over as Chair in 2005 and have attempted to create a training environment that would facilitate entry of students into a primary care practice with a focus on rural and underserved Alabama.  The template we are working off of is above.
We’ve not done very well in the 4 years since I became Chair.  Only 5% of the students have gone into Family Mediicne and those going into Internal Medicine and Pediatrics have mostly left the state. In the course of the discussion, the non-Family Physician faculty became very defensive and felt that they should not be asked to take responsibility for an outcome that they were unable to influence. In addition, they felt that test scores were an outcome that they should be able to influence and rural students would have trouble keeping up with our current students.
Fortunately, the National Rural Health Association is working on a position paper to counter this argument. In it, they point out that “Medical education programs that include a focus on attracting practitioners to rural settings offer both recruiting and retention benefits to rural communities. In one study, six medical schools that made an explicit commitment to increasing the rural physician supply, that had a defined cohort of students, and that offered a focused rural admissions process or an extended rural clinical curriculum placed an average of 57% of their graduates in rural areas (compared to a 3% of medical students who report intending to practice in rural areas and the 9% of physicians who currently work in rural areas) and, of the two schools for which statistics were available, 79% and 87% of these physicians were still practicing in rural communities from 1 to 20 years after graduation. Implementing similar strategies for 10 students a year in the 125 United States allopathic medical schools would conservatively create an estimated 1139 physicians in rural practice, more than double the numbers expected without these strategies in place.”
This study does not mention test scores but it has been my experience that the NBME exams measure one clinical competency (medical knowledge) and do it on a threshold basis (can you make the minimum on the exam). Maybe we need to assess medical schools differently…

In my previous post, I sited a research project that found the average amount of journal reading in 2000 for a practicing internist was around 4 hours per month. This is not an awful lot of reading, given that there are 17,000,000 articles currently available in MedLine. Our field is especially prone to information overload, given the breadth of patients and illnesses we come in contact with. When I graduated from medical school, I did as I was told others did, browsed the medical literature, pulled out articles and put then in a “journal file”, and felt guilty about not doing enough to “keep up”. No wonder the average physicians’ medical knowledge base was directly related to when he or she graduated from residency.

Fast forward 20 years. The Internet was invented by Mr Gore and the personal computer by Mr Gates. Mark Ebell outlines how physicians should use the medical literature. He points out theat the most useful information is relevent, valid and takes little time to access. Computer accessable information is more useful that textbooks (many of which are outdated prior to hitting the shelf). Many physicians now use decision rules to help sort out complex clinical situations. These rules are typically evidence based and often have been validated in “real world” situations. Examples of such rules include the Framingham Cardiac Risk Assessment and the Wells Criteria for suspected pulmonary embolism. Services are now available which aggregate literature and offer clinical “answers to questions” that have been developed using a standardized process. Up-to-date is one such service popular with our residents. If a single journal article is used, it is important to look for those journals that have started to include an assessment of the evidence which supports the recommendations. Then there is searching the 17, 000,000 articles to find the needle in the haystack. What used to be time consuming and complex is now available to anyone on PubMed or Google Scholar.

In short, where previously 15 to 20 clinical questions went unanswered in a typical day, now access to clinical information at the point of service has never been easier. The most important thing is that it’s only going to get easier.

In addition to teaching residents Family Medicine, I am the course director for the Fundamentals of Doctoring course that is in our first and second year student curriculum. I have the responsibility of offering instruction in “professionalism” to these proto-physicians. Preparing for the course this semester and participating in the instruction being offered over the past 3 weeks has allowed me to reflect on training in professionalism both at the medical student and the residency level.

1) Technical competence is expected: Earle Scarlett observes that the non-technical skills are important in part because the technical skills are expected. It is important to us as a profession to assure our patients a technical product that is predictable, safe and reliable.

2) We must not only say we subjugate our needs to the needs of others, but do it: All of us are almost guaranteed the opportunity to a good income when compared to others in our community and our country. Patients are glad for us to make this living but feel betrayed when they discover that decisions were made with the pocketbook. The medical home concept  will allow primary care docs to provide for the health of the community with the incentives aligned correctly.

3) We must be committed to continuing learning and excellence: Prior to the founding of Family Medicine as a specialty, it was assumed that physicians would maintain their knowledge base (or that medical knowledge was static upon completion of residency). Physicians did not share their dirty little secret that medical knowledge was not static but their learing was often dependant on visiting pharmaceutical representatives. Family Medicine was the first specialty to include a retesting of knowledge on a periodic basis. As a specialty we now have several different mechanisms that assure members are maintaining their knowledge and ablity to apply such knowledge.

4) Humanismis in: Time and again we are reminded of the need to communicate with patients at so many different levels. Learning how to communicate effectively and actively doing so leads to improved patient satisfaction, less litigation, and happier physicians. This communication is not limited to being a conversationalist but needs to include the values of honesty, integrety, caring, compassion, altruism, respect, and trustworthiness. These values are difficult (but not impossible) to teach and get little attention in medical schools.

5) We need to be hard on ourselves: The licensing bodies have begun to pay much more attention to performance in training, in part because of increasing evidence that problems in school predict subsequent problems. One of the hallmarks of a profession is accountability and self reflection. As a program director, I find it much easier to work with a resident who has a knowledge base deficit than one that is “non-cognitive”. I hope that the increased emphasis in medical school will lead to improvements at all levels of the profession.

The picture at the beginning of this post demonstrates a hallmark of medical education. It reflects that once trained, physicians see the world differently.

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