Editorial appearing in the spring 2003 edition of The Scope

(Alabama Academy of Family Physicians quarterly publication)

An open letter to my family practice friends and colleagues:

It has become obvious that one of the major issues facing family practice in Alabama, and in the nation as a whole, is the decreasing interest in family practice training. Even UAB, the flagship hospital in Alabama’s medical education system, apparently has no interest in training FP’s. Other family practice training programs appear to be suffering from political pressure, financial pressure, and indifference, if not overt hostility, toward their existence. Student interest is waning for a myriad of reasons. The Scope (first quarter, 2003) addressed the FP shortage in Alabama. The picture seems bleak and depressing. Maybe it is time to take a new approach to the entire training process. It would be a painful and probably contentious process, but the reward for the health of the state and nation could be enormous.

To review our history, family practice as a specialty was born out of a desire to define quality primary care in an age of increasing specialization. A group of brave and dedicated souls created the specialty of family practice and developed an inspired model of training excellence including structured residency programs and mandatory recertification. Initially scorned by the narrow specialists, this visionary concept of recertification has now been emulated by virtually all of these groups and has become the standard for establishing excellence. I was privileged to be briefly acquainted with Dr. Nicholas Pisacano, one of the most vocal and influential leaders of the early family practice movement and the first Executive Director of the American Board of Family Practice. He was passionate about family practice as a specialty and tenaciously guarded against any and all attempts to dilute or weaken the specialty or the standards supporting certification. I cannot imagine that he would, if he were still living, be sitting idly by and watching our specialty be pushed to the point of irrelevance. I think he would argue for another revolution in our training process. I know he would forcefully object to the limitations the narrow specialists continually attempt to impose on family practice. He would tirelessly expose the fallacy of groups such as internists, pediatricians, Ob-GYN doctors, nurse practitioners, physician’s assistants, chiropractors, dentists, and herbalists using the term “family doctor” to describe their activities. Unfortunately, as heirs to this great trust, we have fallen short of Dr. Pisacano’s vision and fortitude. Excuses abound, but the fact is we have allowed ourselves to drift back to a greatly weakened position because we have been neither vigilant nor aggressive. We have become appeasers. The public seems to have little or no knowledge of what our specialty represents. Insurance companies view us as being on par with nurse practitioners and physician assistants – maybe even less desirable because they still have to pay us more. The various concerns expressed in the recent edition of The Scope relate to the problem of the present and future deficit of legitimate family practitioners. The obvious question is how to correct this problem. I risk exposing a poor grasp of reality by proposing some fundamental changes.

The first thing we must do is turn an honest mirror on ourselves. Are we, on a daily basis, living up to our stated goals as comprehensive family practice physicians? If not, then why should we expect a medical student to aspire to become a board certified family practitioner? How many of us still perform OB or major surgery? How many of us still see nursing home patients or make house calls? Indeed, how many of us have abdicated our hospital practices to “hospitalists”? I certainly have failed to exemplify the ideal family practice model. I suspect most of us have yielded in one or more areas of our practice due to expense, regulation, expediency, or sheer exhaustion and frustration. Still, if we are to attract quality students to our specialty, we need to start practicing what we preach!

The existing medical education structure assumes a standard four year undergraduate medical education (two years in class, two years on clinical rotations) followed by an internship or residency. For family practice, a three year residency consists of rotations through the various narrow specialties while developing a personal “practice” within the residency program. This has worked reasonably well for the past thirty years, but it was designed to “look” like narrow specialty residencies. One of the pitfalls of this system is that the original founders of family practice are rapidly disappearing from the teaching programs. Virtually all of the original family practice teachers and attending staff were experienced doctors who came back from “real world” practices to teach the next generation of doctors – and they were highly effective. The combination of their academic curiosity and practical experience made them priceless assets. Naturally, the best and brightest of their students were encouraged to become teachers and staff physicians without ever going out into a “real world” practice.

The current supply of family practice faculty evolved from this natural progression. While most teaching family practice staff will bristle at the suggestion that they are not really family practice doctors, the simple fact is the vast majority of full-time current family practice faculty have never sustained an independent practice for any significant length of time. They have not been held personally responsible for the financial survival of a practice. They have not had to struggle with being alone in a small town hospital in the middle of the night facing a medical crisis without immediate narrow specialty consultation. They have not been forced to forgo CME meetings because there was simply nobody else available to care for their patients. More often they have practiced in an artificial environment supported by a guaranteed and predictable salary with an institutional budget, residents to do the mundane chores, and daily noon conferences (with food) to learn twenty ways to treat plantar warts or some other similarly relevant topic. They hold “clinic” several times a week when they actually see a few real patients. They are allocated time for research and teaching. They have paid vacation and regular time off. They live with the comforting knowledge that the narrow specialist is always only a phone call away in the teaching institution.

My point is not to be critical of our current family practice faculty. I simply mean to illustrate that these people, as skilled, motivated, and intelligent as they are, do not live and practice in the same environment our founders knew, nor do they practice in the environment found in rural or underserved areas. As such, they cannot, even with the best of intention, adequately model the life of a “real-world” small town doctor. If a student is fortunate enough to rotate through one of these family practice programs, he finds a terribly skewed version of family practice. If this student decides to become a resident in such a program, the model he experiences is often designed to interface with a teaching hospital and competing narrow specialty residency programs. He is automatically a stepchild on every rotation. Residents in community based programs fare a little better since they don’t generally have to compete with other programs, but they still frequently lack respect from the narrow specialists serving as preceptors on rotations.

Family practice residents in both large hospital and community settings frequently “learn” that, to be a “good” family practice doctor, you must consult the G-I resident for endoscopy, the internist for pneumonia, the urologist for a UTI, the OB staff for uncomplicated pregnancy, the neurologist for headaches, the cardiologist for EKG interpretation, etc. Hardly any program would admit training their residents to be glorified referral agents or “gatekeepers”, but this is too often the result. When residents graduate, they must either be very brave, arrogant, or naive to intentionally step out into rural and underserved areas – those areas where they are most needed - without this large support system. Why would a bright and promising resident acquire overwhelming debt, risk burn-out, and work harder than his many peers who prosper and enjoy financial security by working for ER’s, walk-in clinics, multi-specialty groups, or even becoming “hospitalists”? Surely those of us who have chosen to practice in rural areas must have had a different calling and training experience than I have described above. Maybe we chose altruism, service, and the intangible rewards of serving a community where we really are needed over the comfort and security of a safe, employed position. Then again, maybe some of us are just plain stubborn! We still believe the ideals outlined by the founders of family practice can be achieved and modeled.

How does this relate to medical education? I am convinced we need to get medical students out into the practices of family practitioners living and practicing the art in rural America. A one month rotation, optional, usually late in the fourth year, and chosen for geographical location so that the student doesn’t have to leave home to participate, is a very inefficient and ineffective way to cultivate interest in family practice. A corollary problem is that busy family practitioners can ill afford to leave their practice, travel for substantial distances, and precept for a half-day once or twice a month to give advice to residents and patients they do not really know. True mentoring requires much more prolonged and intensive exposure. Further, I think every faculty member needs legitimate experience in the world outside of the teaching institution before being allowed to teach residents.

I propose some radical changes in the system to help restore family practice to its rightful place as a leader in the world of medicine while simultaneously raising the level of healthcare in our nation. A good start would be to require every graduating medical student to serve a one year “general practice internship” in an underserved area under the direct supervision of a board certified family physician. This would be especially important for those students seeking careers in narrow specialties such as radiology, pathology, and the various surgical disciplines. This would provide manpower to help provide healthcare in areas where it is now lacking, and it would give these future narrow specialists a much stronger base of knowledge, experience and judgment to use in their chosen fields. They would inevitably be more effective physicians by having this experience. They would also gain a fresh perspective of family practice. Because time is already a serious practical problem (four years of medical school and three or more years of residency), I propose restructuring the fourth medical school year and the first year of residency to allow this “general practice internship” to mesh with and to overlap the existing rotations and provide academic credit to both. Fourth year electives and required rotations in the first year of residency could be satisfied on location in underserved areas with proper planning.

Staffing and supervision for this “general practice internship” would be provided by properly credentialed local family practice physicians and rotating academic family practice faculty from participating teaching programs. Such an arrangement would allow current academic faculty to serve periodic rotations out in the “real world” for 3-6 months and learn about life outside of the teaching institution. This would be required of all full-time family practice faculty. Likewise, the presence of teaching faculty in a community setting would raise the awareness of academic concerns, academic thought, community research, and provide exposure to newer concepts and practices which may otherwise be overshadowed by the day-today struggle for survival in rural and underserved areas. The availability of teaching faculty to staff a practice could also provide a mechanism for local doctors to attend mini-residencies in order to refresh their skills. Patients benefit either way. Students and “general practice interns” would see true family practice in action. Perhaps some of these individuals will be encouraged to choose family practice as their career, but even if they do not, they will be better doctors after the experience.

Another way we might change our approach is to learn from the past. Until relatively recent history, the art of medicine was learned by apprenticeship. It may be reasonable to bring a form of apprenticeship back. Residencies could be restructured so that the third year might be optionally satisfied by practicing under the direct supervision of a single appropriately credentialed family practitioner. With modern communications, daily conferences and evaluations can be accomplished from remote sites. Assignments for such off-site training would be decided through a strict selection and matching process and reserved for mature residents with a specific goal of permanently placing these residents in rural or underserved areas. This apprentice third year resident would learn much from daily and constant exposure to a highly motivated and qualified FP.

Those of us who have had difficulty attracting partners because of our rural location might consider another variation of apprenticeship. We might “adopt” local students potentially interested in family practice during high school, college (pre-med) or early in medical school, and provide mentoring, encouragement, summer jobs in our offices, and possibly even other financial support for committed students. Cultivating a relationship with a student early in his career should greatly increase the chance of having him come back as a future partner. Even if the student comes back to the community as a narrow specialist or a competing family practitioner, the working relationship will benefit. If there are no local students vying for medical school, a clearinghouse could be set up to match compatible students and interested practicing FP’s.

I am arguing for a new paradigm. We cannot continue business as usual and expect family practice to thrive. Applications to family practice residencies have declined even as more slots have become available. This means the average quality of the available candidates is lower. Programs are increasingly turning to FMG’s and very weak students to fill their positions. We must make a fundamental decision. Do we continue to try and fill every slot by taking weaker applicants, and thus perpetuate the notion prevalent in teaching institutions that family practice is really not a demanding discipline? Is it not wiser to insist on excellence in our applicants, even if that means consolidating some programs and resources? It is better, in my opinion, to turn out a few high quality FP’s than to turn out many marginal physicians. We risk doing just that if we do not regain our proper identity.  The narrow specialists clearly have us measured. They want us to exist, but only to the extent that they need our referrals, and they consider us useful idiots for dealing with problems they consider too boring, time consuming, or without profit potential. It is time for us to become the comprehensive doctors Dr. Pisacano and his colleagues envisioned.



Thomas L. Horton, MD