They Shoot Horses, Don’t They?

As many of you know, I am a family medicine intern at Duke University, at least until June 9th which is, thankfully, my last day after which I start my Emergency Medicine residency. (The entire saga is recounted in previous posts for those who are interested.) As you also know, the Family Medicine residency program has been closed. We received an urgent email from the Program Head last Thursday “strongly advising” us to attend a noon meeting for all residents and staff. Lunch, we were informed, would be provided which lent a pleasant air of normalcy to what sounded like impending bad news.

I mean they’d probably have the ubiquitous ceaser chicken wraps. How bad could it be? Still, the program had not been doing well of late. After an internet smear campaign waged by several of the eight residents who have quit in the last two years as well as a general lack of enthusiasm nation-wide for family medicine, the program only matched two out of a possible six positions and scrambled for an additional two. Not very good results for a program at one of the most prestigious medical centers in the world.

Naturally I didn’t attend the meeting as I was rotating on OB. Since I am leaving I figured it was just another one of those meetings they are always calling to get some more resident input on how to fix the program. Generally speaking there has been little interest in anything but complete agreement so why bother? Besides, we were getting slammed and I delivered three babies that day just in triage. (Precipitous deliveries, you understand, when you reach in and feel the babies ears.)

So I forgot about the meeting until a lull in the action when I checked my email and found a message from a program director in California offering me her condolences that the program was closing and also offering me a position in her program.

So what happened? You can go here http://cfm.mc.duke.edu/News.htm and read the usual bureaucratic drivel. Let me give you my opinion.

Family Medicine is hugely unpopular as a specialty. I’m sorry if this is offensive but it’s the truth, at least as reflected by the small numbers of your classmates who will go into it compared to the ready availability of family medicine residency positions, a large portion of which go unfilled in the match every year. Whether it’s the low salary of family medicine physicians compared to specialists, the lack of prestige of the specialty, or the lack of interest in chronic care, medical students run away from family medicine as fast as they possibly can.

This is unfortunate because a good family doctor is an asset to the community and often the only physician you will ever meet who can see you in the big picture and not just as a life support system for a pair of kidneys or a shell through which the GI tract runs. There are also many outstanding family medicine programs which offer a very high level of training to their residents in both disease management and procedures.

Duke Family Medicine, however, as a program has been doing everything in its power to drive away residents by deliberately marginalizing the role of the physician, watering down their skills with irrelevancy, and assigning them roles which detract from their principle function.

The culprit is something called “community medicine,” a noble enough sounding concept that was even used as a selling point for applicants. Community medicine as envisioned at Duke, however, is nothing more than a capitulation to the idea that the physician is redundant in family medicine. This is certainly the idea you get at Duke where the clinic is staffed by Physician Assistants and other mid-level providers and where we are not even referred to as “doctors” or “physicians” but as “providers” to avoid offending the non-physician providers. Or they call us “learners,” a particularly odious term the offensiveness of which the faculty remains oblivious to despite many complaints.

On my first day in clinic I shadowed a PA. Not his fault of course but it shows you where the program’s priorities are.

Community medicine is integration of social work with medicine. In addition to diagnosing and treating their illnesses, we must now follow the patients into the community, identify their barriers to care, plead and beg them to take their medicines, and even if necessary wipe their asses for them. The patients, in short, are helpless pawns of fate who we must treat like children in our attempts to save them from themselves. In this we patronize them in a manner that is truly shameful. And racist too, as the underlying assumption is that blacks and other minorities are somehow unable to make good decisions.

I’m not saying, however, that we did a lot of social work, just that this was the zeitgeist of the program and the traditional practice of medicine (diagnosis, treatment, and management of disease) was definitely subordinate to it. One of the goals of the program, for example, was to have the residents staff a clinic at one of the local high schools. While I have no doubt that somebody needs to pass out condoms and give the fourteen-year-old girls their Depot Provera shots, is this really a good use of a resident’s time and, more importantly, is this a high yield educational activity seeing that the job could be easily handled by a school nurse or a moonlighting PA student?

The emphasis on social work was also reflected n the poor quality of the program’s didactic learning. The conferences were incredibly weak, usually on some subject that was only peripherally involved with medicine, and as they were directed to the mid-levels and social workers as much as the physicians were mighty thin gruel.

Mighty thin.

Contrast this with a program like Internal Medicine which has morning report, well-attended noon conferences on highly interesting medical topics, and weekly Grand Rounds given by physicians on the cutting edge of research. This kind of education is almost as important as your clinical duties and good programs don’t skimp on this. Many of the interns recognized early that we were being short-changed in this regard and suggested that the schedules be re-worked to carve out a set block of time every week for resident education. It is pretty difficult when you are doing off-service rotations to make it to noon conference at your program, especially as the Family Medicine center is some distance from the main hospital. Generally you attend the conferences of the specialty where you are rotating. This is fine, of course, but what’s the point of training for a specialty if you never get any training in it?

Many programs do carve out time for teaching residents. This time is “protected” and except when on critical care rotations the residents are excused from all clinical duties. Emergency medicine does this. It is complicated for all of the involved services and I’m sure that the services don’t like having their cheap help pulled for one afternoon a week but part of leadership is looking after your own troops and having the nuts to tell the other services to pound sand.

This suggestion, like most suggestions, went nowhere. It was probably because of the complexity of scheduling but it is also likely that having all of the residents in one spot at one time receiving specialized training would emphasize the distinction between physicians and mid-level providers when the goal of the program seems to be to erase this distinction.

The Empire Strikes Back

Parsing carefully the chairman’s statement detailing the reasons why the Family Medicine residency program was closed, we find the curious assertion that clinic patients were receiving inconsistent care. Apparently the insanity had gone on long enough and it was time to stop the madness before those darned residents killed someone.

Even in defeat the first instinct was to blame the residents which is typical of the program. Although every other program at Duke has continuity clinics where the patients receive the same kind of “inconsistent” care from residents who have large blocks of their time dedicated to inpatient rotations, this is apparently only a problem at Family Medicine.

Obviously someone didn’t get the memo that the purpose of a teaching hospital is to train physicians and this is done by allowing residents to see patients. I’ll be the first to admit that an intern is not usually a model of efficiency with all the answers at his finger tips. On the other hand the patients accept this and are usually pretty tolerant. Many actually prefer residents because what we may lack in experience we make up for in our genuine interest in their condition and in the amount of time we spend with them, usually considerably more than the five minutes or so you can expect in private practice.

I suspect that one of the reasons the residency program was closed was because it was interfering with clinic operations. Duke Family Medicine, as I was told on many occasions, is a money-making enterprise. Nothing wrong with this of course but I also suspect that because there is not much love for the family medicine residency program at Duke, the positive cash flow provided the only leverage to keep it going. Delivering health care through interns and residents is unavoidably inefficient and this probably was hurting the bottom line.

You will note that Duke Family Medicine is not closing. It will continue as a faculty-run clinic staffed by attendings and the usual assortment of mid-level providers. (The Sports Medicine fellowship is not effected by the closure of the residency program, by the way, and the plan is to expand the fellowship offerings.)

Out of Control Bureaucracy

Let us recap. Until a few years ago, Duke Family Medicine was a well respected program which, although effected by the general decline in popularity of Family Medicine, always managed to fill its quota in the match (although to be fair the program was shrinking, going from 18 residents per class in the seventies to six when I signed on). It was the implementation the chairman’s vision of Community Medicine which sank the program, beginning several years ago when almost a third of the residents either quit in disgust or were driven away after their concerns over the effect of this on education and training were dismissed.

You’d think that this would have given someone pause but apparently the reaction was “good riddance” and the program continued towards the iceberg which it hit two weeks ago. And, to continue the metaphor, the deck chairs were being re-arranged while the program sank as numerous Task Forces, working groups, and committees were set up to explore such life or death questions like a new form to evaluate the preceptors and all other manner of things which may be important but which don’t really require this kind of frenzied activity. None-the-less, several bureaucrats from the department’s extensive stable were delegated to solve the program’s problems, one evaluation form at a time. If they could only get a handle on “metrics,” if only cultural competency could be more adroitly addressed, and if only the residents would get on board and sing the praises of the Five Year Plan things were going to be all right.

Paradoxically, for a program that was very intolerant of dissenting voices they made something of a fetish about soliciting input from the residents. The process is the thing, you see. As long as we ask for your opinion we can get all warm and fuzzy about how much of a team we are without actually taking you seriously. To this end there was a constant demand for evaluations and they were deadly earnest about them.

The expectation that the house staff are responsible for solving a program’s problems of which the constant demand for evaluations is one symptom can be demoralizing as it sometimes indicates a lack of leadership. Everyone likes to be consulted and good programs listen to reasoned criticism from their residents and take appropriate actions to correct problems. Still, it is not necessary to get resident buy-in on every decision. Those who are in a position of leadership need to lead and eschew the SWOT groups and Task Forces which dilute responsibility under the guise of gaining consensus.

Consensus is great but as the program was run in a top-down authoritarian style rather than a consensus-building team approach the attempts at collective decision making had something of a politburo flavor as there is definitely a party line to which we must adhere.

Don’t get me wrong, as a former Marine I am all for the authoritarian style of leadership in which responsibility and authority are clearly delineated and all suggestions and orders flow through a well-defined command structure. I just think that asking for our input and then either ignoring it or harassing the critic confuses the house staff and leads to unnecessary friction. Better to just proclaim the policy, offer the door to those who don’t like it, and soldier on. This is under the theory that acting boldly on a mediocre plan (and community medicine is definitely a mediocre plan) is better than vacillating and wringing one’s hands while trying to think up a perfect plan.

What we had, I repeat, was a failure of leadership. I think the program’s problems were obvious. Surely everybody in authority must have known what they were. But instead of stepping up and owning up to some bad decisions the defense mechanism was to spread the blame by making everyone, through the polite fiction of evaluations and task forces, responsible for the eventual outcome.

A Sense of Impending Doom

Did the emphasis on community medicine hurt me? Not really. I was an intern and consequently spent most of my time rotating off-service. Some people are surprised to learn that Family Medicine residents rotate on general surgery, medicine, and MICU. These plus inpatient and outpatient pediatrics, cardiology, obstetrics, gynecology, and a few weeks of urology and otolaryngology make for a very busy and somewhat traditional intern year of the kind suffered through by the majority of residents in almost every specialty. I had a half day clinic every week (which was very well precepted I have to add) and I kept my head down and did my job. I attended a few of our program’s conferences but as they were usually pretty weak and there was no requirement that interns attend I was happy enough to sit in on my host service’s didactic sessions.

So I got pretty good training. Other than that as I was somewhat preoccupied with the match I had a few more important things to worry about than bureaucratic in-fighting. Remember that by switching specialties I had committed myself to moving my wife, three kids, and five dogs for the second time in a year. Not to mention the struggle to interview around a rather inflexible schedule.

Still, it was hard not to get the sense that things were falling apart at the program. Every time I went there people seemed on edge and disgruntled. Nobody made eye contact, if you understand what I mean. Did this bother me? Not particularly because as an intern you are always rotating off-service and have your own set of problems and challenges keeping you occupied. Time flies like you wouldn’t believe. You put your head down on the first rotation of the year and when you come up for air it’s October. Then you blink and it’s February. Additionally the call schedules and work requirements of the interns are so erratic that it’s difficult to get all of them together to build camaraderie.

So before I knew it match day had rolled around and after a tense week of nail-biting I found that I had matched. After that it just didn’t matter. In no way did I drop my pack and I think everyone on every service where I rotated would report that I was gung ho and as bushy-tailed as possible for an intern. That’s just the kind of guy I am. I will confess thought that I have been dragging for the last couple of weeks. My only clinical duties have been a few clinics and other than that I have been definitely smelling the greener pastures.

I have also avoided any criticism of the program until now so as not to hurt their chances in the match but it doesn’t matter anymore. You may view this article, long-suffering reader, as either a cautionary tale, gossip, muckraking, or just something interesting about the medical profession.

Whistling Past the Graveyard

Family Medicine as a specialty, for various reasons, is not doing well and seems to be headed for extinction. In it’s place is a new model of care in which a highly trained physician is both uneconomical and unnecessary. The Chairman of the Department of Community and Family Medicine admits as much in his rational for closing the residency program. His vision is to have an army of low-skilled providers fan out into the hinterlands like so many Chinese barefoot doctors. Of course, he doesn’t say it quite like that but whether he is bowing to the inevitable or he sincerely believes it, he doesn’t think the physician is important enough in the specialty to support a residency program.

I received a letter today from the North Carolina Academy of Family Physicians calling attention to the closure of the Duke Family Medicine residency program. The money statement was this: “The Academy leadership does not believe Duke or any other university can implement these new models of care by eliminating family physician training and only relying on mid-level providers.”

Well, that’s sort of the point. Whether the academy leadership believes it or not, the “new model of care”is being implemented without Family Medicine physicians. It’s almost a done deal.

A Few Closing Thoughts

1. Family Medicine is declining in popularity among American medical student. Short of socializing medicine and forcing people to work where they don’t want to, I can see no encouraging trend indicating that students will slap themselves on the head and say, “Eureka! I want to spend my career working like a dog for low pay in Corn Hollow, Nebraska nagging my patients about their weight while referring out all of the interesting cases.”  It just ain’t going to happen. There is a genuine demand for family practice physicians but other specialties are in even greater demand. I also don’t see salaries rising to meet the demand so the demand my be over-stated.

2. Increased empathy will not compensate for decreased knowledge. In other words, spending time on empathy training, cultural competence, and all of the fuzzy things is fine except that it might take away from the serious study of medicine. Most of the fuzzy things don’t need to be taught to most people anyways. What usually ends up being the case is that these topics become a sounding board for the political views of organization doing the teaching. I happen to believe, for example, that personal responsibility is an ideal towards which every social program should be aimed. Mention personal responsibility at Duke Family Medicine and you are asking for a reprimand or an attempt at re-education.

It’s just a philosophical difference. The program can point to countless patients who even I will admit are incapable of doing anything for themselves. On the other hand I can say, with some justification, that it is the very social programs advocated by the program which contribute to this state of affairs and make it unlikely that anything will ever change.

3. I’m just one guy, the lowest guy on the totem pole at Duke, and these are strictly my opinions. You may have different opinions which I am perfectly willing to consider. If you are offended by my opinions then you have the entire internet on which to associate with people who can reinforce what you believe and there is no need for you to trouble yourself over my small corner it.