PRIMARY CARE MEDICINE:

"My concept of medical school is changing. It seems that students can hold up so far, before they cave in and go for more limited areas of medicine, such as a subspecialty. As medical education continues to face challenges from changes in care of the indigent and liability problems, there is less access to patients and students do not get to make decisions. This passive education keeps students from maturing and advancing in medicine. More mature and advanced students will see the importance of physician relationships with patients and populations and the powers that be. Less mature students carve out a smaller niche with a defined subset of knowledge and relationships.

Primary care is more challenging. Cures are usually not possible, or rare. Long-term care is common. Successes are often unseen and un-rewarded. Students who choose primary care are usually older, married, etc. Primary care has a very small part of the medical curricula- so small as to actually overwhelm students. It takes 6 months of primary care rotations to become comfortable with it in studies in students spending 9 months in their M-3 year in rural Minnesota. At 3 months these students were overwhelmed with the complexity of primary care. Most medical schools a lot closer to 3 months and almost none come close to the minimal 6 months noted in the study (Verby, RPAP, Minnesota).

Overall cancer mortality dropped for the first time in studies by the National Cancer Institute and reported in Primary Care and Cancer Jan 1997. These studies noted a 2.6% drop in mortality in a 5 year period. The report attributes much of the success in reducing cancer to declines in smoking beginning in 1965. All of these are wonderful advances and yet the reason for improvements are not cures, but changes in lifestyle. The front lines for cancer (and heart disease, adolescent health problems, mental health, etc.) are not cures and specialists and research. The front lines are primary care people who deal with deferred gratification, care for the elderly, do mental health, etc.

COGME studies continue to note that these are the specialties in most need in medicine. Considering that we do not select for these in medical students, this is not a surprise. Things like emotional IQ are more difficult to measure, short of trained interviews and more detailed gathering of info from direct observers of the students qualities.

In many ways, I really like college advisors as an objective resource for helping to determine these qualities and I wish that more medical schools worked in collaboration with college advisors to help them choose better forks, those with service orientation, emotional IQ, and have passed the tests of deferred gratification."

Robert C. Bowman, M.D, rcbowman@atsu.edu
Co-Chairman, Rural Medical Educators Group of the National Rural Health Assn, UNMC Dept of Family Medicine Director of Rural Health Education and Research