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Monday Jun 03, 2013

Family Medicine Wins … or Loses?

On the day before graduation at the University of Nevada School of Medicine, where I am Chairman of the Department of Family and Community Medicine, the school recognizes students who have performed well during an awards ceremony. The ceremony also offers an opportunity for students from both our Reno and Las Vegas campuses to recognize the faculty mentors who were important to them during their training through individual and departmental awards.

This year, I was honored to receive the Tow Humanism award and the Clinical Faculty Teacher of the Year award for Reno, while Kate Martin, M.D., assistant professor in family and community medicine, won the clinical teaching award for Las Vegas. Amanda Magrini, M.D., the chief resident in our family medicine residency, received the Resident Teacher of the Year award.

Not one clinical award was presented to a department other than family medicine, which also won Clinical Department of the Year awards for both Reno and Las Vegas.

You might think with this level of recognition that our family medicine program would be well on its way to recruiting more students into our specialty.

Not so fast. Only five of our 64 graduates this year chose family medicine. 

Our country has recognized the need for more physicians -- specifically, primary care physicians -- and our medical schools have responded by increasing enrollments. In 2009, there were 15,638 U.S. medical school graduates who participated in the National Resident Matching Program. This year, that number increased by nearly 2,000 to 17,487, an increase of almost 12 percent.

Meanwhile, family medicine residency training programs increased the number of available slots by almost 300 (from 2,764 in 2012 to 3,062 in 2013). The number of U.S. graduates going into family medicine also increased compared with last year's figure, but only by 39.

That slight increase in U.S. graduates filling family medicine positions combined with the much larger increase in the number of U.S. graduates overall means that the percentage of U.S. graduates choosing family medicine actually went down, from 48.4 percent in 2012 to 44.9 percent in 2013. 

The bottom line is that we have a need for more family physicians, and we have more available students to match to family medicine. And yet, a lower percentage of U.S. graduates are choosing our specialty. 

Five years ago, 20 percent of Nevada graduates chose family medicine. Now we are down to 7 percent.

Obviously, there is a huge disconnect. Our family medicine program is being recognized for excellence in patient care and teaching, so why aren't more of our graduates choosing family medicine? 

The Future of Family Medicine project pointed out two main reasons students don't choose family medicine: lifestyle and income. 

Students perceive family doctors as always being available for patients, working late hours, taking frequent phone calls and having our personal lives interrupted by patient care issues in the middle of the night, on holidays and weekends. To address this issue, a more patient-centered approach with an emphasis on prevention in the office might improve our lives outside of it.

Income is an even bigger issue. The disparities in income between specialties can be huge, with several hundred thousand dollar differences between the average primary care physician income and that of certain subspecialists. Narrowing that gap is definitely on the Academy's agenda.

We are looking to create primary care-specific evaluation and management codes that support the increased complexity of the family physician encounter.  In addition, we are advocating a CPT uplift for primary care physicians. As we move to a value-based system of payment, this should improve payment to primary care by paying for care coordination and population management of chronic disease.

In our department, we take exit surveys from our resident applicants who decide not to match our program. Three factors have emerged that touch on those issues of lifestyle and money: insufficient financial support for family medicine education, lack of an electronic health records (EHR) system and incomplete patient-centered medical home (PCMH) transformation.

The budget to support medical education in family medicine is lacking for both residents' and students' education. This shortfall relates to the income issue because our students see the faculty struggling to increase clinical revenue so they can carry out the mission of education.

We have not yet implemented our EHR, and our PCMH is in its infancy. There are plenty of data that show the practice environment and physician and patient satisfaction improve dramatically when technology is used and a practice transforms into a PCMH. We are working toward that goal.

So, what do we need to do, both at our local level and nationally, to attract more students into family medicine?

  • Continue to be great role models and teachers in family medicine.
  • Work to protect and increase graduate medical education funding so that students see that family medicine is valued.
  • Continue to move forward with information technology and the PCMH, and work to improve practice environments.
  • Move forward with the transition to a value-based system of payment. In the meantime, advocate that family physicians' income be increased and that the income gap between our specialty and others be closed.

Family physicians make great role models and teachers, but that isn't enough to encourage a sufficient number of students to go into family medicine. What else do you think could be done to draw more students to our specialty?

Daniel Spogen, M.D.is a member of the AAFP Board of Directors.

Posted at 03:48PM Jun 03, 2013 by Daniel Spogen, M.D.

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