In desperate times, family medicine programs have often attempted to be all things to recruits in the hope of becoming their number one choice. In at least two programs where I was faculty in the past, I constantly heard complaints about coming in number 2 in the eyes of recruits, resulting in another poor match. One program changed its image with some aggressive residents who asked recruits if they measured up. Residents and faculty alike worked on what the program did well and quit trying to attract a broad range of recruits. The result was good matches in tough times.
The US military also demonstrates this example. In BreakPoint with Charles Colson Commentary #010125 - 1/25/2001 An Army of One?: Embracing Radical Individualism, the Army is advertising individualism in order to meet declining quotas. Linda Wolf, head of the agency that created the
campaign, explains that the ad is aimed at young adults "who don't like being told what to do." She says, "They really want to be in control. They really want to make the decisions themselves. And the whole idea of 'An Army of One' does just that."
Many of us in family practice are judgmental toward younger generations. We often assume a poor work ethic, rebellion, and individualism. We often throw up our arms as faculty, teachers, and parents. There is a different approach that is far more rewarding.
The Marines have taken a different road, Colson continues: "In the late nineties, in the midst of great recruiting shortages, then-Commandant Krulak actually raised recruiting standards and toughened physical training requirements. And in spite of -- or, perhaps, because of -- this tough approach, the Marine Corps achieved all its recruiting goals. General Krulak said it best: The Marines "recognize what Generation X and Generation Next want and haven't been getting. They want standards. Instead of softening up, we tightened up," he said. Well, Krulak is right. Tough standards that mean something develop strong character. Marine recruiters recognized our need to be part of something bigger than ourselves. The motto, Semper Fidelis – always faithful -- says it very well. But "An Army of One" misses it badly, and I hope the Army abandons this campaign."
We in family medicine are the moral fiber of medicine. We still aspire to the service ethic for patients and for communities and for the nation. It may be a difficult task to communicate this to students, but this does not mean that we cannot do it. Like the Marines, we need to be the ones on the front lines doing the difficult work. We are the few, the proud, the FPs.
Response:
When I read your email, I also had to laugh. It does seem pretty extreme from that perspective. Of course if we really did a good job of giving complete information about rural practice to male or female trainees, no one would come. Our interviews with current rural practitioners reveal this. Also I keep thinking back to the RPAP data where females that went to Duluth and then RPAP were less likely to go into rural practice than females who did Duluth and then did not do RPAP. Nine months in a rural area gives a lot of reality check. Also there are few role models in rural Minnesota for female students so that they can have a closer identification, see the coping mechanisms, figure out how their career goals and expectations fit with present examples, etc. I think we still depend on getting new recruits to rural practice who are highly service-motivated and yet fairly naive.
When I talk to female students and residents, especially single ones who worry about going out into the boonies, I focus on issues of control. I point out past women practitioners and their track records with finding a spouse and setting up practice. I also use examples of current residents and especially one resident who just went to Nigeria. I note they if they truly want total control over their life, then rural practice is not for them (neither is medicine a good career). If they want to fulfill a career dream, a calling, a mission, or let God be in control, then they should be open to what happens in their life and trust that their dream or God's will
will be fulfilled. Thanks for your permission to put this on the list serve.
Robert C. Bowman, M.D.
Actually, I don't find this motto offensive, as I am sure women are included - in fact, my mom was a marine in WW2 (she was a DI, which made growing up interesting and may account for my personality in part) although the 'women's marines' then was far from fully equal, ya gotta start somewhere, and they have been heading in the right direction. Who says women can't be a few of the proud? Or even a part of a few good men...(in the generic sense of the word)
Roxanne Fahrenwald MD
Residency Director
This is an interesting point; I'd never really thought of it this way
before! Do others agree that this type of approach ("the few, the
proud...") isn't attractive to women? Can the essence of it (high esprit de
corps, commitment to values beyond personal aggrandizement) be preserved in
a gender-neutral fashion? Worth more than a little thought; I'll be
interested to see what the list comes up with.
Robert E. Garrett, MD
Marines of Medicine. I'm an retired career military physician and I didn't read the military analogies as being about toughness, but about excellence. for the Marines, their toughness is just part of what makes them proud, and they are. They have discipline, comraderie, professional leadership, physical stamina, and a distinctive look. This stuff really works, and brings out the best in them. The same ought to work in medicine, or family medicine. The PDs and national leaders have to lead from the front, we all have to hold our residents to a high level of personal responsibility and academic performance. I think a professional appearance is important, but some of my residents don't, so we have tension. If we have to come up short on numbers to meet the goals of excellence, then we should do so. In our residency we have an agreement with the residents that if we can't fill with quality people we will go short. Like the Marines, a smaller, more professional force is often better in the mission than a larger, less disciplined one. I hate to use these military analogies but the principles are the same.
Frederic L. Jackson, DO, MPH, FAAFP
Director, Family Practice Residency
Fort Wayne Medical Education Program
Being in the military as a Family Physician for 21 years I would like to tell you that what you have just stated is well said. You are right on target with that.
Ted Epperly MD
My problem with this analogy is that we're not the Marines of medicine, i.e. we're not an elite branch of the profession. We're the grunts in the trenches, the infantry. Fighter pilots may get the girls (pardon the dated and politically incorrect analogy), but you can't win the war without us. Technology and specialization will come and go, but what we do will always be the essence of soldiering. I think an appeal to service and tradition is more appealing than an appeal to toughness. Bob Hope
The military analogy doesn't sit well with me. While there are writers
who claim that indoctrination in medicine is second only to the
military, I don't feel that its a compliment. One could hardly claim
that a military model is an example of health! Furthermore, war being
the greatest cause of disability and death in the past century, one of
our mandates should be to tackle the causes of said behaviour, not
emulate it.
Dale Dewar, MD. CCFP
Coordinator, Rural Division
Tolerance is a two way street. While it may be true that the military
analogies strike a negative cord in some, it may also be true that the
flannel shirt values strike a negative cord in others. We are all in
agreement about the important work of family medicine and the importance of
training our residents to achieve excellence in their field. If the way one
person comes at this is by drawing on their military experience, that does
not diminish anything. In fact, it is a meaningful approach for that person
and maybe others.
I once heard Gail Stephens speak of "grace" in relation to his care of
patients. As I understood him, this meant accepting patients where they are
at and dealing with their own values and reality as being meaningful for
them. Likewise I find it valuable to accept the values of our colleagues in
the same vein. We are all strengthened not diminished by our diversity.
Stephen T. Earls, MD, Barre Family Health Center
As a program director in a rural program I have decided to let applicants know during their interview that ours is not an easy residency, that we have a relatively tough (but within guidelines) call schedule, and that we expect our residents to work hard on ob and in the
ICU to get the skills they will need in rural practice, since rural practice invlves a high level of intensity and takes a lot of clinical skills. I think some applicants run like hell when they hear that, which is best for all concerned, but others respect us for it. I have certainly not found that women are turned off by this message, the women in our residency work hard and want to learn the skills you can only get by working hard, being around at night and weekends, etc.
jim calvert, klamath falls
Wonderful comments, Robert.
We had some comments a few months back, about losing things, and sacrifice,and such. Some commented about sacrificing too much, and overwork, and the other things that contribute to burnout. All too true. However, I see Family medicine on the threshold of greatness, but caught in
the economics of mediocrity. Committment and vision for the work we do (embrace), is key to our success. Sacrifice is a part of that, but if we raise the standard (mindset) of who we are, who we take care of, and why we are here, then reward will follow. In my short career, to date, from rural private practice to teaching in a community-based residency, there have been sacrifices and compromises, to family and friends, but no sacrifice that outweighed the joy of shared experience and reward with those I care about and for.
I don't want to be an indoctrinating slave driver, but do feel that Family Medicine needs to build a coherent vision, so that we become a true choice, for a wonderfully diverse group of physicians, who can care for wonderfully diverse patients, in a any number of settings.
Dan Sontheimer, MD Spartanburg FMR Spartanburg SC