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Who’s Going to Take Care of the Folks?

Whitcomb, Michael E. MD

From the Editor

One of the things I like most about my job is that each year I have the opportunity to visit a number of medical schools to work with deans, members of their staffs, and key faculty as they strive to improve the education of their students. I always return from those visits very optimistic about the future of medical education. But I also come away impressed by the seemingly intractable nature of some of the challenges schools are trying to address. And it never fails that at some time during each visit, someone will ask a question (often a rhetorical one!) that prompts me to rethink whether our efforts to improve the education of medical students are properly focused.

For example, during a recent visit, a member of the school’s leadership team described enthusiastically the efforts under way to improve his school’s educational program. And he added that while he was excited by the curriculum reform efforts occurring at his school and at schools across the country, he was nonetheless very worried about the future. And after a short pause, he looked at me and asked, “Who’s going to take care of the folks?”

He was referring, of course, to the alarming decline in students’ interest in careers as generalist physicians. And his point was that while a great deal is being done to improve the education of medical students, fewer and fewer of them want to be generalists who will spend their careers taking care of the folks (as he put it). And I am sure that underlying his concern is the belief that not enough is being done to create educational experiences that will attract students into generalist careers.

This issue of the journal contains several reports on factors influencing medical students’ specialty choices. Two of these reports show that students are increasingly choosing specialties that have higher incomes; three indicate that students are favoring specialties that allow practitioners more control over the time they devote to their practices. It is widely believed that these two factors are largely responsible for much of the decline in students’ interest in pursuing careers in the generalist specialties of family medicine, pediatrics, and general internal medicine. And it is interesting that while many assume that the rising importance of controllable lifestyle in specialty choice reflects the increasing number of women in medicine, two of the studies in this issue demonstrate convincingly that this is not true. Regardless, there are many who believe that students will not pursue careers as generalists in adequate numbers unless something is done to increase the earnings of physicians in the generalist disciplines and to allow them to control their lifestyles.

But this month’s journal also contains a report that suggests that students’ career choices can be influenced by the nature of the educational programs they experience. Ko and colleagues show that the clinical experiences provided by the UCLA/Drew program have had an effect on students’ decisions about practicing in underserved communities. This observation is similar to those from reports (such as those published in last month’s issue) that document the impact that rural tracks have on the decisions of students to practice in rural communities. Taken together, they suggest that it may be possible to increase the number of students choosing careers as generalists by providing educational experiences specifically designed to attract students to those careers.

Now, some will argue that the favorable results achieved by the UCLA/Drew program and by rural tracks simply reflect the fact that students inclined to particular career paths preferentially select educational programs that provide experiences aligned with their career interests. In other words, the favorable outcomes of the programs are simply the result of preselection bias. And for some students this may be the case. But so what! The key finding of the study by Ko and colleagues is that among the UCLA students who were initially inclined to practice in underserved communities, the nature of the clinical education they experienced appears to have influenced the career goals they held at graduation. Specifically, those UCLA students who experienced clinical rotations in the inner-city environment provided by the Drew program were much more likely to maintain their inclination to practice in an underserved community than were the UCLA students enrolled in the traditional clerkships. If so, what does this tell us about how we might increase the number of students committed to generalist careers?

I think it means that we need to do a better job than we now do in exposing students to the challenges and rewards of generalist careers. And we need to learn from the Drew experience and the rural track experiences as we think about how we might do this. Jordan Cohen, MD, the AAMC’s president, and I have suggested that schools need to carefully design educational experiences that will allow students to appreciate fully the challenges and rewards of being a generalist.1 And given the fact that not all students who enter medical school are inclined to generalist careers, the Drew and rural track experiences suggest that schools should establish tracks specifically designed for those students who do have an initial generalist inclination, to help them maintain it. And to reinforce those efforts, internal medicine and family medicine residency programs must be redesigned so that students interested in careers as generalists are convinced that the programs will prepare them for such careers.2

We have been working toward these objectives at the AAMC. Since the care of patients with chronic illness is an increasingly important aspect of generalist practice, we convened a group of individuals holding leadership roles in family medicine and internal medicine to discuss what might be done to improve the education of residents in both disciplines about the care of those patients. That group—the Education for Chronic Illness Care Roundtable—has concluded that dramatic changes are needed in those programs if we hope to accomplish that. And we are now working on a project funded by a grant from the Josiah Macy, Jr. Foundation that will lead to innovative approaches for integrating education for chronic illness care into medical school curricula and into internal medicine and family medicine residency programs.

As I noted above, there are those who are quite skeptical about all of this. In their view, we should work toward increasing the incomes of generalists and redesigning generalist practices so that future generalists will have more controllable lifestyles. I am not opposed to those objectives, but that is not work for the medical education community to focus on. Medical educators need to accept the responsibility to create undergraduate and graduate medical education programs that will affect positively students’ attitudes about generalist practice. It is, in my view, irresponsible for medical educators to sit by until someone figures out how to change the country’s health care system along the lines many recommend.

Finally, I suggest that we stop referring to generalists as primary care physicians. I believe this term has a negative connotation for students. During the past decade, it was common to define the role of primary care physicians as gatekeepers (triage specialists) and as practitioners who could be replaced by nonphysician health care providers. In my view, the practice of generalist medicine is the most challenging of all forms of medical practice, and it grows more so each year as the population ages and the number of persons afflicted with chronic diseases increases. So I suggest that the term specialists in comprehensive medicine should be used to refer to those practicing generalist medicine. If you were a student, would you be more inclined to pursue a career as a primary care practitioner or as a practitioner of comprehensive medicine?

So my answer to the question posed on my recent visit is this: I hope the folks are going to be cared for by specialists in comprehensive medicine. Our challenge is to figure out how to make that happen as we continue to strive to improve the medical school curriculum!

Michael E. Whitcomb, MD

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1 Whitcomb ME, Cohen JJ. The future of primary care medicine. N Engl J Med. 2004;351:710–12.
2 Arora V, Guardiano S, Donaldson D, Storch I, Hemstreet P. Closing the gap between internal medicine training and practice: recommendations from recent graduates. Amer J Med. 2005;118:680–87.

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© 2005 Association of American Medical Colleges