Rural Physicians Entering Academic Family Medicine (25% of faculty have been rural physicians in 1995 survey of family practice programs)
As a rural physician (10 years in a town of 4500) who invaded the city for 12 years as a teacher after rural practice, I have to say that I did not enjoy the patient care rendered even by my family physician colleagues in the residency program I was in. I found my colleagues wonderful people, good friends, talented in research, administratively sound, but who lacked
patient care and practice management experience. I am back in rural practice but still teaching.
As the program director of the urban academic residency for 3 years between 1991-94,(large program, 42 residents), I felt that my faculty colleagues resisted change and protected their academic and administrative time at the expense of the family practice values they were supposed to be role modeling. While at the University Residency program, I found the values of family practice largely eroded. I felt like a lone ranger on faculty. Approximately 90% of the 30 or so faculty there had had very minimal (2 years or less of negative experience, most of them none) private sector experience. It was often said to me that I didn't realize the differences between a teaching environment and the private sector as I tried to uphold such things as continuity of patient care, office efficiency, and working in
communities. I remember one faculty member adamantly differing with me in rounds because she did not believe that as a physician you could be friends with a patient and/or their family and socialize with them. She felt you needed to separate your professional and private life totally "for the good of the patient." It was a conflict of interest. I would find myself pretty lonely in Baraboo, Wisconsin here if I followed her advice.
I advocated for residents to follow their own patient from community to hospital to nursing home and back to community. I was told it was impossible in that system. I found the "model family practice center" offices very inefficient. The state personnel system was difficult to work with in hiring and firing of office staff. Lateral transfers from department to department were common, like revolving doors. Staff turnover was high.
Some of the family physician "role models" in the department were subspecialists themselves in preventive cardiology, substance abuse, sports medicine, or geriatrics. In academic medical centers requiring tenure, family practice faculty feel pressure to develop a research focus, obtain grant support and publish in peer reviewed journals. They wish and are
required to be just like their transplant surgeon or cancer specialist colleagues. Know your field well, quote studies, evidenced based medicine, roundsmanship, strut your publications and grants. Academic development in one area, however, came at the expense of broad clinical skills essential to rural (and urban) family practice. These faculty dropped maternity care, critical care, or procedures common to rural family practice to focus on teaching and research in a subspecialty area. They dropped call and office precepting leaving these "scut work" tasks to smaller groups of individuals who valued teaching good family practice care (there weren't many of us--we at one time called ourselves "grunts"). These limitations resulted in fewer comprehensive practice role models for residents interested in rural
practice where a more comprehensive set of clinical practice skills is needed. I was one of few. As a generalist, I felt alone at faculty meetings.
It is much more rewarding for me to be back in rural practice. I now feel I can share my experience with residents in my RTT. I can actually write letters of recommendation for residents now with more confidence because I have seen them deliver more than one baby, take care of hospital patients, do office procedures, and practice in the nursing home. My interactions with 42 residents at 4 different clinics, 2 inpatient hospital services at 2 different hospitals, and 2 maternity delivery suites at 2 different hospitals prevented me from writing these letters with confidence before. I had scant exposure to even my own clinic residents. I do hospital work now more than 4 weeks/year (the usual for the faculty in the residency). This makes me a better teacher I feel. I see our RTT residents' intraining exam scores above the core residency average score and above the national average in every area, every year. I see our graduates want to go into private practice and do obstetrics (100% of our graduates so far) rather than wish to take a fellowship in research, work urgent care, or subspecialize in a family practice subspecialty area.
The challenge is getting residents out to learn with my colleagues and I in the rural area. None of us desire the type of fractionated care that was modeled in our urban academic family practice residency one hour away. I feel these rural faculty have much to offer. Four of us in our practice in Baraboo are authors and/or editors in the ALSO provider syllabus including one pediatrician in our practice who teaches in our RTT--yes family physicians and pediatricians can get along. Our local 39 yr. old board certified surgeon feels strongly that "his residents" should learn how to do an emergency C-Section and teaches them this procedure (see latest ALSO syllabus chapter on this). He loves to bike with the residents and often ends up forming a personal friendship with many of our residents as the rest
of us do. These rural faculty have talent, they get along, are friendly with students, and they are happy in their lifestyles. They are confronted with much sicker patients in their rural practices and know how to problem solve without neonatologists, obstetricians, and trauma surgeons in house. They may not quote studies as well but they know what to do when the patient arrives sick on the floor.
Not all is bad with academic centers however. Collaboration between community and academia is important. Research is better done in these academic departments. Rural physicians can learn teaching skills from experienced academic family physician teachers through faculty development programs. Academic family physicians can broaden their horizons by observing the case management as practiced by clinicians skilled in rural medicine. "Town/gown" rivalries that might exist can be bridged by having these physicians work together on an educational venture to improve access to health care in rural communities. The University of Wisconsin Department of Family Medicine is now supporting the RTT model in Wisconsin. I am able to do what I am doing because of the people I met in the academic center. I feel there is much development that can be done for family medicine education with proper support. I strongly feel that RTTs need more exposure and have much to offer.
James R. Damos, M.D.
Baraboo Medical Associates
1700 Tuttle Street
Baraboo, Wisconsin 53913
Jim, thanks for sharing this info/emails to the group. Certainly some interesting perspectives on the other side of Family Medicine fence. There is no question in my mind we are in difficult times. Of interest, in looking at the current proposed RRC changes, I don't see much change - just rewording to make it clearer to programs that have tried to be creative in
meeting some of the requirements and allowing non-FPs provide backup for FP residents for continuity patients if approved by the director.
In regard to academic FP programs being expensive, that is a relative term. MBA's and deans can do some creative accounting. At times I question the ethics after looking at our own state's budget documents for one of our state medical schools. (another story)
Any way, having said this. It is not just academic Family Medicine that is having problems in insuring adequate education. I can easily make an argument that many other academic specialty programs are having the same problems - less patients, less procedures, performing procedures later in the residents' education, frequent turn over of faculty, inadequate staffing, inadequate funding, etc. The real issue is how are we going to
provide medical education for the future, not just family medicine. Insurers and patients have found they can frequently obtain cost effective good care outside of the "ivory towers".
Our future challenge is how are we going to restructure medical education so it can occur in the community. If we don't, we will see a continuing "dumbing" down of undergraduate and graduate medical education in the future. Why a Preceptorship Is Better Medical education whether we like it or not is going to have to increasing occur in a community setting. Insurers, patients and legislators are not going to let patients be driven back to the AMCs. FP is certainly the best prepared to do community medical education if we can get the RRC to be more flexible in letting program experiment in new models and not be so rigid in hours and who teaches, but looking at educational outcomes. see Accreditation and Acceptance Issues
Roger Hofford, M.D.
Two emails follow. One pertains to the changing of family medicine RRC requirements so academic family practice departments in University centers can continue to meet RRC requirements for family practice. Family medicine skills in these academic centers have been eroded (doing less OB, less procedures, trouble getting patients etc.) so they feel the RRC guidelines are too strict. I have my biases about changing family medicine to meet the eroding definition of family medicine in nonsupportive academic centers. The second email states that FM residencies are expensive to run in academic centers. No one mentions RTTs. I have my bias as to where funding should go--urban vs. rural. Maybe this is a reflection of the over supply of family physicians in urban areas. These emails are long so trash this if not interested. If interested, read on.
Response to 2 emails sent by Jim Damos:
I find these emails very timely and critical at a time when family medicine faces a crisis of identity and confidence. It calls all of us to reexamine where we are going. I have long held that wherever we go we cannot divorce the academic institutions from clinical practice. An ecological approach to this situation tells us that academic medical centers need practicing family physicians, and practicing physicians need academic medical centers. However, it does not necessarily mean that residency programs in academic health centers need to survive in their current format.
The answer to this dilemma, I believe, lies in reconnecting to our roots and what is good for our communities. At a time when we have too many family physicians in urban areas and too few students interested in family medicine and rural medicine especially, it seems we need to reconsider departmental relationships with community residency programs, scaling down the size of our urban programs and total number of residency positions, and further developing programs like RTT's (and urban training tracks in truly underserved communities) that train physicians in communities where they are needed, while still maintaining a credible presence as a specialty in academic medical centers, even if it is primarily at the predoctoral and
Watering down the standards of the RRC seems to me to be a terrible solution to a problem we've created over 30 years. On the other hand, I think it is potentially presumptuous of us rural folks and also difficult to determine whether training is less expensive in these new environments where we do lose some economies of scale. I have yet to hear from the academic center with which I'm associated their cost per resident, because they don't know.
There is so much cost shifting and complexity, without clear lines of accountability, that I don't think it's even possible to know.
If we return to our communities, however, we could at least regain a moral mandate for public investment in our specialty. Here is a comment from CCPH Executive Director Sarena Seifer that is pertinent to this discussion:
"Service-learning is gaining recognition and support as a core component of health professional education. In its final report, the Pew Health Professions Commission concluded, "the nation and its health professionals will be best served when public service is a significant part of the typical path to professional practice. Educational institutions are a key to developing this value. Health professional programs should require a significant amount of work in community service settings as a requirement of graduation. This work should be integrated into the curriculum."
Recently, the Surgeon Generalšs deputy Dr. Nicole Lurie recommended that community service experiences be a required component of health professions education, writing in the January 2000 issue of Academic Medicine that "projects that focus on one or more of the leading health indicators, or other Healthy People objectives, are great places to start. Through such experiences students learn to see their roles more broadly, and can facilitate sustainable relationships with others in the community."
This is the approach taken by my alma mater the University of Pennsylvania, and it has been quite successful from the reports I heard at the NE STFM meeting last fall. For a bibliography and further information about successful initiatives in the area of service-learning, see http://futurehealth.ucsf.edu/ccph/guide.html#biblio
Our own institution at OSU is moving in a positive direction, promoting a "university-anchored" multiple pathway residency where, perhaps in time, only the first year will physically occur in the AHC, with subsequent training in the area of need, all the while remaining connected through telecommunications and face-to-face interaction, visiting each other through involvement of community faculty in predoctoral education as well as
academic faculty and students travelling to outlying sites and programs. I welcome Dr. Michener's invitation for dialogue!!
Randall Longenecker MD
Associate Rural Program Director
The OSU-Oakhill Rural Family Practice Residency Program
4879 US Route 68 South, West Liberty, Ohio 43311
Mad River Family Practice -- "A Rural Practice with a Residency"
Phone: 937-599-1411 (MRFP) or 937-465-0080 (Residency #)
I have come here from many years at a large academic medical center in the NE with many of the same problems but one which (more or less) supported family practice. We did a great job of training residents to be full scope fps including OB. When I left, by my calculations, about 1/3 to 1/2 of our graduates were doing OB. That said, maybe there are some academic centers where the department of FM should not have a residency. Spend the money on faculty academics and research in family medicine, we sure need it and we
don't need all the residencies we have now. If it is a money loser and research is obviously what you can do fiscally well and that the faculty want to do and do well, then WHY NOT DO THAT????
The cost of RTTs is very high to, per resident trained, and this is partly because those in more rural hospitals which are sole community providers, since BBA don't get IME at all as an add on. If you cant support it, don't do it. We have an RTT and are starting another one, we have a tight budget to make ends meet. We also turn out incredible highly trained graduates. BUT WHATEVER YOU DO don't dilute the high level training we need to produce family physicians who are fully capable of providing a broad scope of care to a population, including ob, orthopedic care, screening and diagnostic testing etc. I do not like the argument that "we can't teach fp like we should, so would you mind watering down the requirements?" Do it right or don't do it at all. And there is no shame in not doing it at all. Do what you do well and take pride and strength from that. I hate research and don't do it. I don't do sloppy or watered down research to superficially meet someone's requirement (who could that be....) that I be a research academic, or ask that my publications be considered kindly and "don't look too closely at those nasty statistics, just glance at the abstract if you don't mind...in fact, I 'll just leave out that whole Material and Methods
section to make it easier...."
WHAT ARE THESE FOLKS THINKING???????????????????????
There, I feel better now. Roxanne Fahrenwald MD
The Academization of Family Medicine
Accreditation and Acceptance Issues