P&S Journal: Fall 1994, Vol.14, No.3
Primary Care Medicine at P&S and Beyond
By Anna Sobkowski
Family practice as a specialty of breadth, instead of depth, hits home to Gary Sobelson'81 every day in his practice. Jim Woody'96 discovers his image of a doctor best fits family practice. Treating patients in the context of their families attracts Zenobia Poynter'97 to family practice. Brian Wagstaff'94 found too much to like in many areas of medicine to specialize in just one. And George Edison'53 describes his general medicine practice as a mix of patients' emotional problems and "everything else."
For generations, P&S graduates in large numbers have chosen careers in specialty and subspecialty medicine over general medicine, primary care, or family practice. Today, however, a small but growing number of students set their sights on careers in primary care, reflecting emerging trends in health care.
The national debate on health care reform places primary care physicians-general internists, family practitioners, and general pediatricians-at center stage. Taking a cue from other industrialized nations, health policy experts and the insurance industry have concluded that Americans would be better served and health care costs would be lower if generalists made up half of all practicing doctors. Generalists are defined as those who treat the entire body, rather than specific organs. Today, about 70 percent of U.S. doctors are specialists; 30 percent are generalists. In many other countries, the numbers are reversed.
The trend toward specialization gained impetus at P&S and other academic medical centers in the years following World War II. Heavy investment in research by the federal government led to a congregation at these centers of the finest scientific minds, producing an explosion of knowledge and the development of new techniques, procedures, and medications.
"For all these decades, the academic medical centers have set the standard for what constitutes good health care and have made the U.S. health care establishment the best in the world," says Dr. Christopher Wang, director of the nascent family practice residency program at Presbyterian Hospital, which will admit its first residents in July 1996. "The challenge for the centers today is to help apply these tremendous medical advances to all sectors of the population in a rational way."
Dr. Wang argues that the ferment in the health care system is not a passing fad. "Regardless of whether the Republicans or Democrats are in charge in Washington, and regardless of what happens with the Clinton reform plan, the shift now under way will continue, mainly because the insurance industry has already reorganized around managed care."
An estimated 42 million people-20 percent of Americans-are enrolled in managed care plans. The primary care physician, the bedrock of managed care, provides the initial patient contact, oversees continuity of care, and makes decisions about referrals to specialists.
The oft-cited reasons for students' aversion to primary care careers can be summed up by the perception that primary care consists of the three L's: long hours, low pay, and lack of prestige. In addition, the dearth of primary care role models at academic medical centers is believed to affect students' choices. Students choose careers as specialists for reasons that include the desire to master a well-defined field, increasing success in diagnosing and treating previously untreatable conditions, and greater financial reward.
With the start of curriculum reform at P&S under a 1992 Robert Wood Johnson grant, three courses were developed to expose medical students to primary care. "The feeling in the administration was that primary care is an important aspect of medicine that is becoming ever more important and was an area we hadn't given proper attention to," says Dr. Ronald Drusin, associate dean for curricular affairs.
A mandatory five-week primary care clerkship began in June for students entering their third year. Most students decide what field they will enter by the end of the third year, after rotations in many different areas of medicine.
Under the direction of Dr. Matilde Irigoyen, associate clinical professor of pediatrics, the clerkship focuses on the care of ambulatory rather than hospitalized patients. Until now, a student's outpatient experience was limited.
"Caring for patients in the hospital is very different from caring for them outside," says Dr. Irigoyen. "Inpatients have essentially been 'packaged,' that is, they have already been diagnosed and a course of treatment has been decided by the time they are admitted and the student sees them. Outpatient care requires a much greater development of a student's diagnostic and decision-making skills."
Proficiency in outpatient care is seen as crucial because of the trend away from hospitalization, increasingly reserved for critically ill patients or those who can't be cared for safely at home. Patients are discharged earlier, sometimes before fully recovered from their illnesses, often to be managed at home by primary care physicians.
The clerkship teaches students about common medical problems, management of chronic problems, preventive care, beneficial doctor-patient relationships, and placement of illness in the context of the whole patient. The clerkships are offered through affiliated hospitals, from urban to suburban to rural, to give students exposure to variations in the delivery of primary care. The hospitals are Harlem Hospital; Bassett Hospital in Cooperstown, N.Y.; St. Joseph's Hospital in Stamford, Conn.; Morristown Memorial Hospital in Morristown, N.J.; and Overlook Hospital in Summit, N.J.
"Through this clinical rotation and exposure to experienced physicians at the sites, the students will have the chance to see how challenging, exciting, and rewarding the practice of primary care can be," says Dr. Irigoyen.
Other courses in the new curriculum include a clinical practice course directed by Dr. Constance Park, associate clinical professor of medicine, and primary care electives directed by Dr. Bruce Armstrong, assistant clinical professor in the School of Public Health.
The clinical practice course, taught throughout a student's four years, integrates the population and behavioral science aspects of medicine-epidemiology, biostatistics, and behavior modification-into a framework of comprehensive primary care, preventive medicine, and health maintenance. It also focuses on specific aspects of the patient/physician relationship and the relationship of the health care system to the patient's family, community, and society.
Primary care electives allow first-year students to work in community-based health care settings to learn about problems of the community and understand the impact health providers can have. (See Spring 1994 issue, "Students Find Learning Beyond the Classroom.")
The Department of Medicine has started a generalist track for residents interested in careers in generalist medicine. The track has 12 residents, two more than a year ago when the track was created. Residents spend more time in ambulatory medicine, have mentors in general medicine who help with career development and clinical issues, and pursue a structured curriculum. Residents are trained to become leaders in general medicine as practitioners, teachers, researchers, administrators in health care organizations, and policy-makers.
"The Division of General Medicine is attempting to help the medical center step up to the challenge of training high-quality generalist physicians and become a national model for excellence in generalist medicine as it is in so many other areas," says Dr. Steven Shea, associate professor of medicine.
A Family Practice Interest Group for students is a clearinghouse about family practice and general medicine. In the absence of a family practice department at P&S, the group works with the Institute for Urban Family Health in New York to collect information about residency programs in family practice. The group also brings family practitioners to speak to interested P&S students.
The changes expand horizons for all students, but curriculum changes are only part of the effort to make primary care attractive to students, says Dr. Drusin. "In their entry questionnaires, most P&S students describe themselves as idealistic and interested in serving humanity. By the fourth year, they may still be idealistic, but reality has set in. The reality is that many students graduate from private medical schools with major debt and choose specialties as an understandable way to pay off the debt. So things have to change. There have to be financial incentives and the expectation of a good quality of life for the primary care practitioner. We believe that if we expose our students to the same level of excellence, with the same caliber of exceptional role models in primary care as in other specialties, they will at least have the basis upon which to judge whether the field is right for them."
Despite the P&S tradition of producing specialists, several alumni have built careers in primary medicine, and students at all points of their P&S educations are planning generalist careers. Here are a few of their stories, which show the varied motivations and circumstances that influenced their decisions.
Dr. George Edison is a general internist in Salt Lake City, Utah. After graduating from P&S, he spent two years in a fellowship in the psychiatry of medicine and served in the Air Force. While setting up a private practice, he took a part-time job in the University of Utah Student Health Center, where he stayed for 22 years. He left nine years ago to concentrate solely on his "Mom and Pop" practice. Dr. Edison's wife is his office manager.
"It's extremely enjoyable," says Dr. Edison. "I take care of a range of patients from late adolescence to geriatric. Many of my patients have been with me for 30 years, so I've followed their ups and downs, been with them through many illnesses. And as with any primary care practice, I deal with my patients' emotional problems along with everything else."
At P&S, Dr. Edison was taught by the legendary Drs. Robert Loeb and Dana Atchley. "They taught us how to take detailed histories and exams, how to become good diagnosticians, and I've never forgotten their lessons."
Dr. Edison says he made the choice to become a general internist because he felt it would be intellectually stimulating and emotionally satisfying. "I haven't been disappointed. Quality of life and happiness in work should be the most important factors in career decision, and I've achieved that. I haven't made a ton of money, but I'm certainly comfortable enough."
Dr. Edison points out, however, that he graduated from P&S with no debt. "I had a scholarship and worked nights as a lab technician. And with tuition only in the hundreds of dollars, when I graduated I was free and clear."
When Zenobia Poynter was growing up on Manhattan's Lower East Side, she didn't have a doctor. When she was sick with a common complaint, she sat with her mother for hours in the emergency room of a local hospital.
"It was an all-day process," says Ms. Poynter. "We had to fill out reams of forms, then after waiting three or four hours we might get to see a doctor. If we needed medicine, it meant sitting for another three hours at the hospital pharmacy. Growing up in this environment was the main thing that pushed me into primary care."
Ms. Poynter has decided she wants to be a family practitioner, eventually working in a public clinic in an urban area, perhaps even the Lower East Side. "Family practice appeals to me because I love children but also love working with older people. And it makes sense to me to treat patients in the context of their families."
She has a government scholarship for medical students with exceptional financial need who promise to work in primary care for five years after graduating from a residency program in primary care.
Dr. Gary Sobelson is one of five family practitioners (soon to be seven) who make up Concord Family Medicine in Concord, N.H. A New York native, Dr. Sobelson joined the group in 1984, after graduating from the family practice residency program at Duke University, because he and his wife were attracted to the New Hampshire lifestyle.
The thriving practice offers a full range of family practice services composed of about one-third pediatrics, one-third adult medicine, and one-third geriatrics. One of the five physicians practices obstetrics in the context of family medicine.
"One thing about family medicine that's been such a wonderful surprise is that I've developed quite a love for geriatrics. With a lot of retirement communities in the area, I've met so many sharp, interesting older people. Through them, I've had to face end-of-life issues and how to maintain control and dignity when you're old and sick."
Family practice is often described as a specialty of breadth as opposed to a specialty of depth. "This is made real to me every day," says Dr. Sobelson. "I may go from treating an 85-year-old patient with multiple complications from diabetes and step into the next room to deal with a family in crisis over a child with attention deficit disorder."
Dr. Sobelson finds practicing medicine in a way that looks at the whole person, psychologically and in the context of the family, "life-enriching." "Because we are dealing with patients in so many different stages of life, we as family doctors are constantly faced with confronting how their issues affect us and our own values. This practice is not about facts. It's a blend with the entire range of the human experience."
Like many small communities across America, Connersville, Ind., has a severe physician shortage. The local community hospital serves a rural population of 44,000, but women travel 30 to 45 miles for the nearest obstetrician/gynecologist, and only two pediatricians serve the area.
Connersville is Jim Woody's hometown. A high school sports standout and honor student, Mr. Woody knew he wanted to be doctor from age 14. He signed a contract with his community hospital to return to Connersville to practice in exchange for payment of his medical school tuition. The contract allows him to enter a residency program in family practice, general medicine, surgery, or ob/gyn. If he decides not to return or to enter a different field, he must pay back the grants and loans.
Mr. Woody originally entered P&S thinking he would be a cardiac surgeon. "Since I came from a life of competitive sports, I was attracted to the competition and high pressure. But when I started hearing about 100-hour weeks, I realized I didn't want that lifestyle.
"My image of a doctor is what I'm discovering family practice to be. I find I like working with people. This really draws me, the constant day-to-day interaction. While family practice is still a pressured job, it's not the same as surgery. You can't talk to patients under anesthetic."
Mr. Woody does not worry about forfeiting a potential salary of hundreds of thousands of dollars as a surgeon. "Family practitioners do just fine. With a salary of over $100,000 a year, you can live quite well, especially in the Midwest. It's more important to me to be happy in what I'm doing on a day-to-day level."
Dr. Brian Wagstaff also came to P&S thinking he would become a surgeon, but he found he enjoyed working with a wide variety of patients and disease processes, and he did not want to limit himself to any one specialty or patient population. Dr. Wagstaff also found that he preferred seeing patients in an office setting rather than in the hospital.
"There can be a much more level interaction between doctor and patient in an outpatient setting," Dr. Wagstaff says. "In the long-term patient-doctor relationships of primary care, the physician can become a partner and guide helping patients toward better physical and mental health and a better quality of life. That is how I want to practice medicine."
Dr. Wagstaff's interest in primary care and his desire for a wide variety of patients contributed to his decision to pursue family medicine. He plans to practice in an urban environment after completing his residency at the University of Maryland Medical System in Baltimore. He would like to be involved with medically underserved communities and also teach future family practitioners.