Just had a conversation with a second year medical student just after his classmates bested our family medicine basketball intermural team. He started the conversation at the weight room asking about family physicians in Florida having a hard time finding jobs (apparently from FP newsletter). He continued with the line that he was concerned about job security for family physicians. Since he has previously discussed rural practice and is a bit older and yet is still this concerned, this picked up my interest. I thought he was supposed to be more resistant to this kind of information.
First I noted how Family Physicians were in the top tier of need for recruiters and those who feed them physician information (AMA Marketing). I noted how several family physicians had been told that they could not enter a certain market, yet had overcome. In my past I have been told I could not locate in small towns or Houston Tx, and still was able to do so. I pointed out how one of our recent grads was told that he could not located in Phoenix, much less start his own practice there, yet he has. I noted that certain areas were indeed more challenging. Doctors in larger cities have been known to work part time for less for a few years in order to get a full time job (Toronto Canada and some US Cities).
I noted how students were often fed information by other faculty (never family medicine ones of course) that were true, but a bit dramatic, and not representative. Some students were more susceptible. I never did understand how certain chairs could distract black student from family medicine with a dinner and conversation when we had 2 of the best black faculty and a very supportive black community at ETSU, but it happened. I noted how in the past some NMA officials had counseled black students to choose subspecialties for the potential impact they could have later. I was quick to point out that black family physicians had served as some of the nations top medical leaders.
I then asked what he thought would happen when the nation was spending nearly 20% of GDP for health and major employers were screaming for relief from health bills. By this time I expected that we in family medicine would have a strong following as the major ambulatory care provider and the recognized safety net for the nation's underserved.
Finally I made my major appeal. I noted that people needed to do what they felt that they should do as a physician. There was a difference in family medicine, and this difference was about serving and caring. We have tried to hard to recruit those who did not share these values at times, and this has not always worked out.
I do not know what he will choose, but I hope he heard the passion and commitment that I share with thousands of our colleagues.
I encourage you to get the word out and be very available, the myths are rampant and those who are willing to address the misinformation are few.
rcbowman@atsu.eduFrom Mike Borunda, M-2
Dr. Bowman,
Thank you for passing the information along. I believe that for me, choosing family medicine is not the problem. I am more concerned with what I will and will not be able to do later in my career. The letters to the editor in the family medicine newsletter last week worry me not because I wouldn't be able to find a job, but because I wouldn't be able to do the things I would like. I hear Dr. Hill talk about all the skills (colonoscopy c-sections, etc.) learned by residents in the accelerated program and it truly gets me excited about the program and family medicine as a whole. However, the letters talk about being interviewed for jobs, but explicitly being told that they will not be able to do OB or other procedures, that worries me. I don't want to be forced to work alone in a remote area to do the procedures or see the patients I enjoy. And like I said, we only hear the stuff that makes the headlines, but an FP losing OB priviledges in Sonoma county California and the ever increasing presence of PA's and NP's trying to "fill" the gap that family medicine has left make me wonder about my future in family medicine.
From what you said, I understand that a lot of problems FP's encounter, they encounter in metro areas, not necessarily underserved metro, but metro nonetheless. And from that I understand that a decision to practice family medicine is based on family and personal desires, but you must also take into account where you are needed most. Where there is a need, as a physician, you will not want, except maybe for more time off.
For me, rural family medicine is why I came here. I sent secondary applications to UNMC and Osteopath schools. I wanted to go somewhere that focused on rural primary care, an area I felt was important.
Thanks again, See ya in the gym,
Michael Borunda
RCB response:
Another study may interest you, Tom Nesbitt has kept a rural family physician liability database for 10 years involving 100 family physicians. With 1000 years of experience, only one lawsuit involving over $29,000 was filed and this one resulted because the OB-GYN doc was slow in responding and the ruptured uterus resulted in a damaged baby. Now it will take some time for this to get to press, but it will go a long way to reassure rural hospitals, rural hospital boards, rural nurses, and others that rural OB is safe.
The small towns likely to continue to deliver babies include those a bit larger and those with a few doctors that are more isolated: McCook, Alliance, Valentine, West Point, Wayne, O'Neill, Broken Bow, York, Aurora, Falls City, Seward, Sidney, Ogallala, Lexington, Holdredge. The larger towns of Columbus, Gering, Hastings, Beatrice, Scottsbluff, Norfolk, GI, Kearney, and larger will obviously continue. Another 6 or 7 smaller towns will likely continue depending on their getting doctors who will share OB. This depends on the ob experiences that these doctors get in medical school and residency. This depends on us and possibly on some state action to free up some of the ob experiences in the state to trainees.
Your interest and lobbying work in this area, combined with others in yours and surrounding classes, may do much to help the state realize what it needs to do. Many of our current rural health efforts date from needs assessments 10 and 15 years ago. Since we had some plans, when likely grants and funding came along, we were able to take advantage of the funding.
The accelerated residents (and also the RTT residents) have had a great impact on program design and experiences. There is no reason to believe that they will suddenly stop having impact when they get out in the state and practice.
Many of the adjustments to get procedural training are internal also. Scott Green, rural doc at West Point, was one of the first to take the OB rotation in Louisiana. After a few weeks of little involvement, he confronted the supervisors and they put together a hands on rotation that has benefited many. At Lincoln, he initiated the pizza reward program. When a nurse called him in to help with or do a section, he ordered a pizza for them. He got lots of ob training by individual effort and set the tone for others to follow at Louisiana and Lincoln.
Also, there is some evidence that the PA and NP programs have saturated their rural market as they have fewer locating in rural areas and more choosing states other than Nebraska. The people who play the numbers games live in places like DC and KC. They don't see the impacts at the local level. Rural communities make decisions about who practices there. PA and NP and FP in this state complement one another.
Bob Bowman
Obstetrics is one of the key areas for the state and for people like Mike. The accelerated program has done much to meet this need. Do we need more? What is the volume and training like for the RTT sites?
The relationship with Obstetrics, the volume of OB, and the situation with Methodist, Alegent, and Children's are important considerations.
Do we need to organize to have impact so that the state continues to have good OB access?
rcbowman@atsu.edu