Monday Jan 09, 2017
No, I'm Not 'Settling' for Family Medicine
During a recent internal medicine rotation, a senior resident expressed disappointment that I've chosen a career in family medicine. He was concerned that my talents would be wasted, because -- in his words -- I wouldn't get to care for the "more complex patients" he sees in internal medicine. Although I appreciated his confidence in my abilities, I felt my heart sink, as it does each time I am faced with misinformed perceptions about family medicine.
I thought back to my last family medicine rotation, and the following patients came to mind:
- A young woman with a previous diagnosis of idiopathic anaphylaxis was experiencing syncopal episodes of unclear etiology.
- A man with an extensive history of IV drug use, hepatitis C and multiple other chronic conditions was admitted to our service with a dental abscess, lumbar osteomyelitis and discitis.
- A woman with end-stage renal disease secondary to lupus nephritis was also struggling with severe depression, multiple chronic conditions (including chronic pain) and debilitating opioid dependence.
These were just a few of the patients I encountered during a two-week family medicine elective, and the complexity of their conditions was comparable to -- if not more complex than -- that of many patients I have seen on other rotations.
There is a fundamental difference in the way in which we view "complexity" in family medicine. We account for all of the biological, psychological and social components that culminate in a person's pathology, recognizing that neglecting any of these factors is neglecting to provide adequate care. This approach sets us apart from many of our subspecialty colleagues.
But, let's face it, constantly explaining this and defending our choice to pursue family medicine can be exhausting.
Meeting fellow medical students who are passionate about family medicine often feels like a breath of fresh air, a meeting of kindred spirits who understand one another's struggles. Although many of us have support from family medicine faculty, mentors or our medical school's family medicine interest group, that support doesn't shield us from the pervasive sentiment that family medicine is somehow inferior to other specialties. We tend to dread questions such as "What do you want to specialize in?" or "Do you know what you want to do after medical school?"
Even though we may feel immensely proud of our career path, most of us have experienced pushback in the form of "advice" that we are "too smart" to "settle" for family medicine, or that we should choose a residency in internal medicine so that we can "keep our options open" in case we eventually decide to narrow our specialty.
Often, the message is less direct. It may be evident in the subtext of conversations or in offhand remarks we overhear during rotations in other specialties. It also may be evident in institutions' disproportionately small amount of time allotted for family medicine rotations -- or total lack thereof. This is all part of a phenomenon known as the "hidden curriculum," which nudges students with high exam scores toward subspecialties. It's important for students and educators to understand that this problem exists and can have toxic downstream effects.
In reality, many students do express an interest in primary care at some point during medical school, likely because the values of primary care align with the reasons that many students chose to pursue careers in medicine. We see this reflected in students ranking family medicine as their top specialty choice in 2016, as well as in the fact that one in four medical students is an AAFP member.
Nevertheless, as students, we are not immune to the disparaging comments of the hidden curriculum. And when issues such as the looming burden of student debt and crippling burnout weigh heavily on us, it can make those higher-paying subspecialties seem appealing.
It's increasingly crucial that student interest in family medicine translates to students actually choosing careers in family medicine. In the next 20 years, there is a projected shortage of more than 33,000 physicians in the primary care workforce(www.annfammed.org).
This is problematic not only for individual patients, but for our health care system as a whole. As the Health is Primary campaign(healthisprimary.org) has shown us, prioritizing primary care leads to better health and better care at lower costs. Areas with more primary care health professionals per person experience lower mortality rates for cancer, heart disease and stroke. An increase of just one primary care physician per 10,000 people can significantly decrease costly and unnecessary care. These are just some of the many benefits of ensuring a robust primary care workforce. We can see that when family medicine is a priority, patients are a priority.
Viewing family medicine as a "backup" career option is not only problematic within the context of medical education, it's a dangerous notion that contradicts patient-centered principles and undermines the optimal functioning of our health care system. Everyone deserves access to high-quality health care and a meaningful relationship with a primary care physician, and now more than ever, we need to work to protect those rights. This means we need the best and brightest medical students committing to provide that high-quality care to patients and enlightening their peers and medical educators about the invaluable role family physicians play in health care.
To medical students who are still pondering their specialty choice, I want to say three things. First, in a profession that has maintained a hierarchy of prestige, I know it's difficult to commit to a medical specialty that doesn't always garner the same level of admiration as medical and surgical subspecialties. Second, I want to assure you that this outdated perception of prestige is changing; it is becoming increasingly evident that family medicine is the backbone of U.S. health care, and health policy and physician payment reform have begun to reflect that.
Finally, I want medical students to know that by choosing family medicine, you are not compromising on the scope or complexity of medical practice. The level of patient complexity and diversity of pathology seen by family physicians matches and often exceeds that of other specialties. Family physicians are on the front lines of health care, providing compassionate, comprehensive, whole-person care to anyone who walks through the clinic door.
AAFP Board Chair Wanda Filer, M.D., M.B.A., tells medical students in no uncertain terms, "If you aren't passionate about your patients, we don't want you in family medicine. If you're in medicine for the money, we don't want you. If you won't be an advocate for your patients, we don't want you."
This is family medicine, and it's not for the weak of mind or faint of heart.
Lauren Abdul-Majeed is the student member of the AAFP Board of Directors.
Posted at 03:42PM Jan 09, 2017 by Lauren Abdul-Majeed, M.D., M.P.H.