Where are we losing America’s future primary care physicians?

I know where America’s future primary care physicians are, and more importantly, where we are losing them. I am one of them, and I almost got lost.

Maybe I was naïve. I’d had no math or science classes as an undergraduate, and I’d never really thought about the mechanics of medical education. Even while jumping through all the prerequisite hoops before applying, it never occurred to me how inadequate my non-traditional background was for sitting still long enough to memorize what seemed like every enzyme in the human body. Fueled more by the art of medicine than the science of it, I told myself I was ready, that I was to be a doctor, and the process could not deter me.

So began two years of sitting in a windowless dungeon of an auditorium watching PhD after PhD lecture on the various “basic sciences of medicine.” It was a collision of what I perceived to be two very different types of creatures: I seemed to have absolutely nothing in common with the quite intelligent, distinguished individuals charged with preparing me to become a physician. For starters, most of those individuals did not want to be physicians. Even the few MDs sprinkled into the curriculum seemed to spend more time with microscopes and cadavers than with patients. Neither ambition is wrong or less noble. They are just completely different. So I adapted, each day moving closer to equating medicine with basic science, memorizing as much as possible and trying to survive and trust the process.

Somewhere in those days in the dungeon, the skills that I had originally thought would make me a competent physician — compassion, observation, critical thinking, communication — were replaced by ideals like competition, memorization, and a realization that medical school rewards those who can regurgitate the most details for the next exam. Even now in my clinical years, those who put the most time into doing question banks and memorizing review books are rewarded on standardized shelf exams over those who would prefer to spend a little extra time in a hospital learning the bedside art of being a physician.

Each year, the more I focused on memorizing and building the endurance for four-hour examinations, the less I focused on cultivating skills like critical thinking, reason, logic or the use of the scientific method. There is one correct bubble for each disease, no discussion. No time to think or reason. Much smarter people have already done that for me. Slowly, the art of medicine was swallowed by science and by an educational system that has failed to change over the last one hundred years as administrator after administrator has misinterpreted the Flexner report, which reads, “Scientific inquiry and discovery, not past traditions and practices, should point the way to the future in both medicine and medical education.”

How can we expect and hope to change the demographics of the physicians produced or the problems inherent in our health care system when we’ve followed the same process for over 100 years? Why would physicians today think any differently than they did 20 years ago if we are still selecting and training them in the same way?

I am not naïve to the importance of research nor the importance of each branch of medicine. I appreciate the advances in science and medicine over the last 100 years. I merely write to tell you that I was drawn to medicine because I know there are competent artists still among us. I met some of those individuals — many of them rural family docs practicing in Tennessee where I’m now in school — before I decided to apply to med school. Some of them — some of you — not only know the mechanism of each pathology you discover in a patient, but you also have the tact, skill, and compassion to explain it to a rural patient with a third-grade reading level and select an adequate medication that the patient can afford. Those physicians are out there. The problem is, you aren’t in here, in medical schools, where all the future primary care physicians are.

The future of primary care is in that dungeon, waiting for one of you to come walking through that door. The future of primary care is here with me, stuck in a 100-year-old process that doesn’t allow us a moment to hone the skills that make a truly competent primary care physician. The skill set we acquire doesn’t lend itself to a primary care career where answers are not black and white or as simple as filling in the right bubble on an exam.  But we have to survive, so we develop the skills that are presented to us, and in the “process,” many of us fall off the path to primary care, feeling uncomfortable in a profession that requires a skill set that we do not get to cultivate in medical school.

Don’t assume there is someone at each school casting the net to encourage primary care during the basic science years, even at “primary-care friendly” institutions like mine. Admissions standards are not changing, LCME requirements are not changing, and I don’t think medical school leaders have the gumption or grace to deviate from the model enforced by the more prestigious institutions.

Take responsibility. Come find us. Recruit one student and you’ve replaced yourself, recruit two and you are part of the solution. We need primary care doctors, not academics, to infiltrate our system and show us what you do. Force your way into my curriculum. Show me that primary care is a viable choice. Future primary care physicians are out there. Please come find us.

Michael Bradfield is a medical student who blogs at Primary Care Progress.

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  • Patient Kit

    With all due respect and admiration to you and to all the good people who are choosing, at this point in time in our healthcare system history, to become doctors, especially primary care docs, I would ask, at what point in medical education does that expensive education start to prepare you for the real world that awaits?

    Here on KMD, I read so much about docs who sacrificed so much when they were young to become docs, only to want so much to find a way to opt out of their profession now. It all reminds me of how very young doctors actually were/are when they make the decision to become doctors — kids, really. It also reminds me too much why it is so easy for the powers that be to send young idealistic men to war.

    I sincerely hope you find what you are looking for in medicine and that you were able to keep intact those wonderful qualities that drew you to medicine in the first place. We do need good doctors. But I also sincerely hope that you are proceeding down this road with your eyes wide open.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I have a question: Aren’t those competent artists in rural Tennessee the products of the same dungeon system, seeing how it hasn’t changed much since Flexner?
    … and another: So how come the system is all of a sudden failing to produce the future of primary care?
    … and one more: If the education system remained constant for 100 years, but the enthusiasm for primary has changed, shouldn’t we look for the reason elsewhere?

  • LeoHolmMD

    I just had a conversation with a FM resident about how a return to apprenticeship could substantially improve our education system. In Primary Care, if you really want to learn how to practice rural medicine, or practice in a well run clinic, you go hang out with someone who is doing it. You don’t hang out in an academic center. You have correctly noted that medical school does not prepare you to practice medicine, even at a fundamental level. Does anyone else find that peculiar?

  • NewMexicoRam

    Back in the day, those who shoveled coal into the train engines furnace eventually needed replacements. Bet that was a tough sell.

  • Dave

    I think the culprit may be that the people who truly have the heart for primary care get into their clinical years and realize that primary care today is a lot of clicking boxes and closing pop-up windows and copy/pasting. These people don’t come into medical school daydreaming about long days of churning out scripts and referrals in 2-minute visits; when they see the reality of day-to-day primary care, many look elsewhere. Money is a big part, but maybe not as much as the daily reality of the job. If I wrote the number it would take to get me to change fields and be a PCP, you’d think I was nuts.

  • buzzkillerjsmith

    Re: basic science: Nah. Basic science is of some importance to a physician. Without it you’d be about as competent at diagnosis and treatment as old Uncle Joe.

    Re: all those PhDs crushing the will to be family docs: Nah. It’s the money/work tradeoff. Double our income and half proceduralist incomes and we’d have med students waxing poetic about how their absolute delight in family med got its start in first-year micro lab.

    It’s the money/work tradeoff. Always has been, always will be, in medicine as in other jobs.

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  • Amy C

    This blog literally reached through the page and grabbed me. The last paragraph was a powerful call to action for me. Michael wrote about the lack of “real-life doctors” in the medical school education system. The only models students receive are academia types, and, as a result, students lose interest in primary care as a career. ( I remember those days in MY education, too.) His last paragraph tugged at my heart strings in a very strong way.

    I now need, no…. MUST- go lecture at his school in Tennessee, to show them how a primary care medical career can be exciting, profitable, and fulfilling in every way-with adventure, travel and heartfelt passion at each leg of the journey. Primary Care has always been about being a Pioneer, and
    if you lose that spirit, you will be delegated to a J-O-B to which you never remember agreeing to participate.

    I have visions of a multimedia presentation with my pictures and video embedded from Air Force missions,work with NASA, mission work in India, and from all the creative places where real healthcare was rendered without borders. Back on the homefront, I could also share with them that work as a full time provider, and living your “retirement life” can exist in parallel, at the same time! (I ride and compete year round on the Equestrian Showjumping circuit). Students need to know that so many options DO exist for them. I see a field trip in the future to teach a lecture that no one will fall asleep at, even after lunch!

    Thanks, Michael, for the inspiration.
    Amy Coleman, MD

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