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Monday Mar 13, 2017

Help Students Cut Through the Bull: FPs Are in Demand

"My attendings tell me there is no future in family medicine," said my medical student. "They said that if I went into family medicine, I would be wasting my education. They told me that I am too smart for family medicine, and that primary care would be taken over by APNs and PAs."

She looked worried, but I'm afraid I laughed at her comments because they were the same warnings I heard as a medical student 25 years ago. You would think the subspecialists' arguments would have changed at least a little in a quarter century, especially in light of the rapid change in technology and medicine.

I explained to the student that this was an example of "bulshytt," a term coined by author Neal Stephenson in his book Anathem. Stephenson offers a couple of definitions of the term, the most relevant of which appears to be "a derogatory term for false speech in general, esp. knowing and deliberate falsehood or obfuscation." 

It is true that medical technology is changing rapidly, and there are forces at work within our society that will stress and change our profession. IBM's Watson(www.wired.co.uk) (and other expert- and crowd-based systems), genomics and telemedicine are just a few of the emerging technologies that we will be contending with in the next 25 years. However, there will always be a central place in health care for family medicine.

Frankly, I would be much more concerned about going into radiology, oncology or other subspecialties. Watson is effective at algorithmic medicine based on the latest research, and it apparently reads X-rays nearly as well as a radiologist(www.businessinsider.com). Surgical robots such as da Vinci and STAR represent a maturing technology that continues to improve. It is hard to imagine an autonomous surgical robot, but autonomous cars were science fiction just a short time ago.

What will remain fundamental are the relationships we have with our patients, the healing power of touch, the reassurance and wisdom of a trusted adviser backed up by all this amazing technology. And this is where it gets really cool.

As technology improves, the price drops and it is easier to use. Look at ultrasound, for example, and CLIA-waived tests that we can perform in our clinics. We will be able to do more and more in our offices or even in our patients' homes at a fraction of the cost of hospital-based care. More and more, hospital systems will need us, but we will not need them. In the long term, I think this is where medicine is going, and it will be family physicians doing the work.

In the short term, there is a tremendous need for well-trained, full-spectrum family physicians in rural and inner-city populations. Infant mortality rates in both of these populations are much higher than in the general population and are frankly appalling. We desperately need well-trained generalist physicians(www.scientificamerican.com) in both these areas who are capable of providing the full continuum of family medicine -- from maternity care and well-child checks to end-of-life care and emergency medicine. Backed up by technology such as telemedicine, care can be provided in a critical-access hospital that is on par with offered in tertiary-care hospitals.

This touches on the social determinants of health, which are likely more important than much of what we do with medicine. With advances in population health and data management, family physicians are uniquely qualified to work at the intersection of primary care and public health. Imagine the impact that a clinic that harnesses individual patient encounters with a truly effective and integrative medical record could have on community health, especially when coupled with strong and effective advocacy. These are areas that will require a family physician's depth and breadth of knowledge.

I've recently attended lectures by people who considered physicians to be superfluous and anachronistic. Smart devices, hologram projections and big data will remove the physician from the equation, according to these speakers. I heard the same argument about how the Internet would make doctors obsolete 20 years ago. I didn't believe it then, and I don't believe it now. Algorithmic medicine works best when the problem is defined. Patients who present to primary care are unselected, complicated and often in need of emotional support. Despite our recent technologic development, we are social animals. Technology provides little comfort. It cannot touch. It has no wisdom.

A wise man once said, "Predictions are difficult, especially about the future."

There may come a time when physicians are no longer needed, but one thing I know is that family physicians will be the last doctors standing. And if a large meteor ever hits Earth or there is a zombie apocalypse, family medicine will be the specialty most in demand. Given those two boundary conditions, and the growth of technology that will benefit primary care, there is a definite future in family medicine, and we will continue to need our best and brightest students to go into it.

I'm sorry I laughed at my student. I'm not usually so socially inept. But really, the arguments haven't changed in more than 20 years.

A bigger question remains. How do we address the same old bulshytt that continues to be perpetuated in medical schools?

John Cullen, M.D., is a member of the AAFP Board of Directors.

Posted at 07:00AM Mar 13, 2017 by John Cullen, M.D.

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