Create a family practice mystique in medical school

For at least the last 20 years, graduates of U.S. medical schools have resisted pleas from organized and disorganized medicine to become primary care physicians (PCPs). Since there is already a severe shortage of PCPs, pundits are wondering who is going to take care of the hordes of newly insured by 2014. Many have speculated about the possible reasons for this dilemma such as the relatively paltry earning potential of PCPs, the amount of debt incurred by graduates of medical schools, and the perceived lack of prestige of a PCP career.

I have some theories of my own. One, primary care is boring. It has been estimated that 90% of patients appearing in PCP offices have no treatable illnesses. This leads to another issue which is that a physician assistant or nurse practitioner can treat most of these patients, often without input from a physician. PCPs function as triage officers. If an interesting case should somehow happen along, the PCP refers the patient to a specialist who deals with the problem. Since the advent of hospitalists, PCPs are never seen in hospitals which almost guarantees that they will not be involved with anything interesting.

What is the solution? About 15 years ago, medical schools in the New York City area were scrambling to climb aboard the family practice bandwagon. (Grant money was available for schools to establish departments of family practice). This was a real problem for the schools since there were about as many family practitioners in metropolitan New York as there were blacksmiths. One school managed to set up a family practice department with a chairman who practiced in a town about 50 miles north of the city.

Students were offered tuition forgiveness for the fourth year of medical school if they promised to do a family practice residency after graduation. Of some 12 initial enrollees in the program, a grand total of one ended up in family practice, proving one couldn’t even bribe students to become PCPs. I recall asking a few students why they thought the program did not work. The answer was that the new rotation in family practice was too realistic. It was as boring as actually being a family practitioner.

The solution to recruiting more students into family practice is to replicate the situation that exists in specialties the medical students highly desire like emergency medicine, anesthesiology and dermatology (the most competitive residency training program in all of medicine). Most schools offer very little or no exposure to these disciplines in their curricula.

Medical schools should disband their family practice departments. Thus, a mystique would be created and the students would be seduced. I believe this would work. If needed, I am available to chair a task force or blue ribbon panel on this issue.

Skeptical Scalpel is a surgeon blogs at his self-titled site, Skeptical Scalpel.

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  • Mark Ryan

    I assume this post is tongue-in-cheek.

    • http://skepticalscalpel.blogspot.com/ Skeptical Scalpel

      Of course it was tongue-in-cheek but either it was too well-written or too poorly written for people to tell.

      • Mark

        I think the reaction you’ve gotten reflects that fact that primary care gets the short shrift of most everything: respect in academic settings, funding, reimbursement, etc despite the fact that evidence points to a sound foundation of primary care as being critical for a responsive, affordable health care system.

        Too often we hear people say what you’ve written–only they mean it.

        You certainly struck a nerve…

  • http://medicaleducation.wetpaint.com/ Deirdre

    If most medical students think family practice is boring, maybe we need to rethink who we want to train to be family doctors.

  • ninguem

    In other words……..lie.

    Misrepresent the field to medical students, entice them to sign on, and when they figure out the truth, it’s too late.

  • Sharon MD

    Primary care is boring to a surgeon who spends most of his patient time performing procedures, many of which are done under general anesthesia.

    Guess what? To this primary care provider, *surgery* looks boring! Unimaginable to someone who loves procedures, I suppose, but I actually find interacting with my patients and getting to know them and their families interesting. I find my mentally ill and substance abusing patients fascinating. I love that in a day I may see a neonate, a new diagnosis of pregnancy, a geriatric patient, or a post-op surgical patient. It’s exciting!

    What is *not* exciting about primary care? It’s not the medicine. It’s the endless physical forms, pre-op clearance forms, disability forms, pre-authorization for testing, pre-authorization for YOUR surgeries, trying to get a patient in to see a surgeon promptly when it needs to be prompt. That’s what makes it miserable and boring.

    If primary care providers made more money it would help, but if reimbursement for primary care were higher, and/or if we were reimbursed for all these extra activities, we would be able to employ ancillary staff to do the majority of this work, and we could spend our time being doctors.

    Dermatology is very popular. Do you seriously think that treating pimples and removing moles is fascinating? No, it’s a great lifestyle and the pay is extremely high. Med students are following the money (dermatology, radiology, surgical subspecialties, GI, cards), the thrills (surgery, ED), the prestige (cards, specialty surgery, GI) and the lifestyle (dermatology, nuclear medicine, rehab med, ED). You’ll notice that dermatology meets 2 of the 4. Primary care meets none. General surgery only has one also — hence the rapid vanishment of generalist surgeons (which I would imagine would be far more interesting than the surgical subspecialties).

    Don’t blame it on boredom just because you think it’s boring! The medicine is not boring; the administrative work is, and the lack of respect (from the author included) is evident from day 1 of medical school. And yes, at the end of the day, given the choice of interesting, prestige, money, lifestyle, of course you’re going to pick the specialty that has 3 or 4 of these attributes instead of just one.

  • http://www.blog.greatzs.com Zmd

    So you don’t think the paltry pay, tedious paperwork, and condescension from patients and fellow physicians have anything to do with the problem?

  • http://drpullen.com Ed Pullen

    I think a lot depends on who we recruit to medicine as students. If we look for the absolute brightest and most academic undergrads, we will get students who may find the personal relationships and emotional aspects of these relationships boring. If we look for students who excel in relationships, service experience, and caring, we will get students who cherish the relationships found in primary care.

    • r watkins

      False dichotomy. Why not look for the students that excell in both?

      • Sharon MD

        i agree r. there are plenty of students who have both

    • http://medicallymindnumbing.blogspot.com Shawn

      Good luck testing for students that excel in relationships, service experience, and caring.

      Medical schools already look for these things in extra-circulars, letters of recommendation, and the interview process. Pre-meds know this, and do whatever it takes to get these things – even if they aren’t caring, compassionate, or excellent in relationships. They just need to fake it, to get in.

      How about a personality test? Won’t work. Pre-meds will figure out what kind of personality they need to be in order to get into medical school, and pre-med exam courses will give away the answers to that every pre-med fits this mold.

      How exactly do you select for students who excel in things that cannot be measured? Good luck.

  • Ashley

    KevinMD,
    It sounds like this surgeon is specialty bashing and intent on contributing to the problem, versus actually endorsing care that might be appropriate, balanced and first and foremost—PATIENT CENTERED. Value based, team-based (interdisciplinary) care that is built on a primary care based system with appropriate specialty referral is what the country needs…not insult and insinuation.

  • r watkins

    Any FPs and IMs interesting in referring cases to this surgeon?

    • http://curbside.posterous.com Nuclear Fire

      I would. Good sense of humor is important in life and medicine.

  • Kent

    90% of patients in primary care have no treatable illnesses… That doesn’t mean they can’t be treated.

    • http://skepticalscalpel.blogspot.com/ Skeptical Scalpel

      Yes, they can be worked up with echocardiograms that no one ever follows up on and are in fact usually treated with antibiotics, antidepressants and/or PPIs.

      • Sharon MD

        Many patients in primary care have psychosocial problems that certainly can be treated with interventions such as cognitive-behavioral therapy, increasing exercise, and seeking more social support. If you take the time to listen to people, you usually don’t need to do any of the things Scalpel lists.

        But point taken. Patients are over-treated. I’m the first to agree. The solution is not to devalue primary care but rather to value it and allow primary care doctors the time to tease out what’s really going on with their patients.

      • Kent

        Never mind.

        If this whole thing was intended to be satire, you should’ve used some kind of disclaimer. As a surgeon, nobody would be surprised if you were serious.

  • http://abovethelaw.com/duval-stachenfeld Bruce Stachenfeld

    Very interesting and informative post.
    @Kent – Are you sure that those patients have no treatable illnesses.

  • Ahmad AlSabban

    ugh

    i work as family medicine in Saudi Arabia

    looks like we have the same proplem as u have in the states
    in regards to the primary care
    what we do we try to bring physicians from Egypt and Pakistan to fill the gaps

    well, what else to say ?
    this topic is painful – Skeptical Scalpel u injured my heart
    should i change my specialty?
    of course NO
    i like Family Medicine
    well there is a third way , for those who want something extra, u can take a fellowship in palliative care or geriatric and so u can work 3 days in the hospital and 3 days in the primary care and every one will be happy !!

  • mark

    I love the people who say we need to change who gets in to medical school. How are you going to keep us out? We’re the ones who are smart and work had. I know many who studied 1,000 or more hours for the mcat. We’ll figure out and crush any test you can come up with.

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