Increasing Student Interest in Family Medicine and Urban Health Care The Family Care Tract

Increasing Student Interest in Family Medicine and Urban Health Care: The Family Care Tract Richard Colgan, M.D., Caitlin E Iafolla, Yvette Rooks, M.D., and David L Stewart, M.D., M.P.H Abstract Throughout the last decade, general interest in primary care has drastically decreased While medical students collectively show a high awareness for the significance of primary care during their first two years of medical school, this enthusiasm wanes for many as they complete their clinical years As a result, fewer students enter into this concentration each year In an attempt to mediate this changing interest, the University of Maryland School of Medicine Department of Family and Community Medicine has implemented the Family Care Track (FCT) This longitudinal experience spans the first two years of medical school and allows for mentorship by family medicine faculty, while also providing students the opportunity to learn via the formation of long-term relationships with patients Development of a FCT at other urban academic medical centers may be beneficial in allowing students who have expressed an early interest in primary care to better understand the implications of their career aspirations, especially regarding care of underserved populations This discussion includes the rationale for the development of such a special tract in family medicine, examines other implemented efforts to maintain student interest in primary care, and elucidates the benefits of developing an intensive longitudinal curriculum in family medicine for preclinical students Introduction In order to better identify the University of Maryland Department of Family Medicine’s role in community education, research, and clinical care, the department purposefully expanded its name to the Department of Family and Community Medicine We simultaneously reinstituted the Family Care Track in an effort to maintain the first year medical student’s enthusiasm for gaining experience with family medicine in an urban setting At the University of Maryland School of Medicine (UMSOM), the FCT provides an inspiring and life-changing experience for many students Our goal is to expose interested students to these educational and life experiences, and ultimately increase the number of fourth-year medical students that enter into their medical careers with aims to help acknowledge and alleviate health disparities There exists a nationally recognized shortage of primary care physicians This unfortunately holds true in the state of Maryland and particularly in Baltimore City—home to the state’s only public medical school In accord with the reasons behind general health care disparities, the shortage of physicians entering into primary care is multi-factorial in its origins Fewer doctors pursuing primary care translates into fewer physicians to serve inner city populations Ultimately, these populations—which disproportionately consist of minorities and those of low socioeconomic status—are denied proper access to health care At the UMSOM Department of Family and Community Medicine we created the Family Care Tract for the entering freshmen class of 2011 This was thoughtfully done in an effort to expose these budding physicians to the many educational and personal opportunities that come with practicing primary care medicine in an urban location; moreover, we provided this program with the hope that unique clinical and community experiences will ignite their enthusiasm toward family medicine and serving those less fortunate Our intention was to see a greater number of students become interested in primary care medicine, especially practice that serves those in urban settings Our belief is that having a greater number of medical students with specific medical and professional knowledge about the delivery of primary care in Baltimore city will yield a greater number of doctors familiar with taking care of an urban population, particularly those who suffer from disparities in health care and improper access to preventative and medical treatments The University of Maryland School of Medicine Family Care Tract Medical Students’ Waning Interest in Primary Care The number of medical students choosing family medicine peaked in 1996 This coincided with the federal government’s encouragement that all Americans have a primary care physician to function as the gatekeeper for their health related issues According to the American Academy of Family Physicians, the number of fourth-year medical students going into family medicine has halved in the ten years since its pinnacle1 During the same time period the selection of other primary care specialties by fourth year medical students has also diminished significantly Student interest in primary care medicine has always existed throughout The Department of Family Medicine’s thirty five year history at the UMSOM However, much like other academic medical centers in the northeastern United States, the number of fourth-year UMSOM medical students choosing family medicine as a residency has typically been below the national average (Table 1) It is this dwindling interest that has been addressed by re-implementation of our Family Care Tract The Resurrection of the UMDSOM Family Care Tract Upon entering medical schools, many students identify primary care specialties as potential career choices For many, this interest wanes as they complete their four years It seems that most often students lose their enthusiasm for primary care during the third year The reasons for this loss are not entirely clear, and although they are certainly unique to each student, there exist some general notions among today’s medical students Two often heard sentiments are 1) the perception that primary care does not fit with the type of life style for which many students are looking and 2) the perception of a lower income for those in primary care The rationale for the development of the Family Care Tract (FCT) at UMSOM in 1988 was the belief that if students who express an interest in family medicine were mentored by a family physician from the beginning and throughout the course of their medical school experience then they would be more likely to pursue family medicine as a career In addition, the programs expressed goal was to focus on the care of the urban poor Funding was provided by the United States Department of Health and Human Services A detailed listing of the FCT’s goal and objectives can be found in Table The inaugural FCT ran from 1988 until 1993 Many students in the program chose to pursue family medicine as a career; moreover, a significant number focused on practice with underserved populations Others followed primary care career paths in academia and public health The statistical likelihood of a student ultimately pursuing a career in family medicine, following participation in the FCT, has not been studied against a control group However, the clear increase in maintained interest, as indicated by a recognizable portion of students choosing primary care careers, fulfills the objectives of the current FCT experience Like many academic family medicine residency programs we have seen a steady decline in the number of residents we train, from a maximum of fifteen residents per year at the initiation of our training program to our current level of eight residents per year The decline in the number of residents is often associated with a decrease in the number of full time faculty to teach in a residency training program Further, declines in the number of teaching faculty have resulted in fewer mentors available to participate in the FCT program Unfortunately, the decrease in the number of available faculty mentors became the single greatest factor for the dissolution of the initial FCT in 1993 With much effort and consideration, we reinstituted the FCT in 2007 and once again offered the experience to entering freshmen We selected individuals in the medical student class of 2011 Interested students were required to apply by submitting an essay describing their interest in family medicine Twenty-five students applied to this program and 21 were accepted Four students could not participate; two due to academic difficulties and two because they had already chosen a similar psychiatry elective Based upon a review of the students’ applications and expressed interests, they were matched with a faculty member with expertise in such areas as sports medicine, obstetrics, and research Expectations for students participating in the FCT include: Working with their mentor at a minimum of one half day per month in the family health center; Attending a monthly brown bag luncheon lecture series on common topics that relate to the primary care of the urban patient, Participating in an intensive 80-hour clinical immersion experience with their mentor during their first summer, Completing a project prior to advancing into their third year; and Following an obstetrical patient from time of diagnosis to delivery Options for the FCT project include: a) a community health project; b) a research project or c) a quality improvement initiative under the guidance of their mentor As the current FCT student moves into his or her second year, he or she will continue working with their mentor in the office, be paired with a family physician instructor for the second year course in Physical Diagnosis, as well as continue to follow their assigned obstetrical patient In the third year the FCT student will be paired with family medicine faculty members for their required clerkship experience and finally in their fourth year they will have the opportunity for a sub-internship on our inpatient family medicine teaching service We expect that FCT students will have a firm understanding of family medicine by the time they reach the clinical years The students’ preparation will give them the ability to rely on their own observations and experiences in family medicine if confronted by false, negative or discouraging comments from peers and others during their third and fourth-year clinical experiences The FCT experience will also generate a greater awareness of service to the urban poor in Baltimore City Students also acquire an understanding of the role of The Maryland Academy of Family Physicians Foundation (MAFP-F); the state chapter of the American Academy of Family Physicians, with whom we partnered in this effort The MAFP-F has undertaken an aggressive fund raising effort, including a call for donations from all members of the MAFP state chapter to help underwrite the financial cost of supporting the FCT students during their mandatory eighty hour clinical rotations Each student will receive a financial stipend of at least two hundred and fifty dollars to defray their living expenses as they stay in the Baltimore area over the summer This is an important practical component of the program, as many students must take up summer employment to support themselves between years one and two of medical school We did not want to deny this exposure to family medicine to interested students who otherwise would not be able to participate because of financial need Our goal is that students who experience this intense immersion into family medicine in their preclinical years will be more likely to enter into a primary care specialty We expect that even if FCT students not chose a primary care specialty, they will be more knowledgeable about family medicine, and the role family physicians play in the delivery of health care Further, we hope that no matter where their careers take them, students who have completed the FCT will find it a valuable and rewarding experience—one that will positively contribute to their medicalprofessional lives Discussion Numerous studies have revealed a shortage of primary care physicians nationwide Barbara Starfield, M.D has shown that increasing the number of primary care physicians is positively associated with improved health outcomes for the general patient population while increasing the number of specialists appears to have the opposite effect Dr Starfield’s work has also shown that a 20 percent increase in the number of primary care physicians is associated with a percent decrease in mortality.2 Furthermore, she describes that “by every accepted epidemiological measure: birth weight, infant mortality, life expectancy, to name a few, primary care-oriented health systems are associated with healthier populations that live longer.” This strengthens the notion that increasing the number of physicians dedicated to family and primary care has positive implications for the general population; moreover, programs that fuel interest in this field provide parallel benefits to society It is possible to evaluate whether an FCT student is more likely to pursue a residency in family medicine, as well as aspire to serve an urban population compared to other members of his or her class A similar two-year, longitudinal mentor-mentee track program in family medicine at the New York College of Osteopathic Medicine provides data that looks at residency specialty choice of matriculating students.3 David Yens, Ph.D notes a significant increase in family medicine residency selection amongst those medical students who completed a longitudinal track in family medicine compared with those who did not participate (20.5 v 11.7 percent) If it can be shown that students who participate in an intensive exposure to family medicine early in their medical curriculum results in a higher likelihood of entry into family or primary care medicine— particularly to an underserved population—such evidence would support justification for expansion of similar tracks at other institutions It is also important to consider the positive implications for those students who participate in longitudinal primary care tracks, yet not pursue a primary care specialty No matter which career choices they make, these students will have been exposed to principals of primary care and how to provide care for an underserved population Such exposure will lead to greater sensitivity, humanity and a greater call to service in clinicians regardless of the type of clinical specialty Even though specialized, these future physicians will hopefully retain the primary care values to consider the patient as more than their biological and disease components, but to always see them for the people they are—with lives outside of the clinic and family that are equally as affected by their illness The ultimate outcome should have a positive effect on the inequality of health care experienced by many in this country, and alleviate the resultant disparities in individual and community health care Students who participate in the FCT will benefit from a greater appreciation for family medicine, primary care, the care of the underserved and how they, as physicians, have the power to make a difference in their communities The classroom for the FCT student is each exam room in the mentor’s office Within those walls students see and hear the stories of those who have such nationally problematic illnesses as hypertension, diabetes, or chronic pain They are exposed to a spectrum of common and extraordinary conditions In addition, they see and hear how each person deals with illness in the context of poverty, real or apparent differences in culture, ethnicity, health insurance, socioeconomic status, and education level In addition to seeing patients at our family practice center, students are given the opportunity to travel on house calls and see patients at Health Care for the Homeless We are eager to introduce the FCT students to the faces, people and families that represent the numbers behind the statistics of those suffering from health disparities Many students have learned that approximately 15 percent of Americans not have health insurance, and therefore not receive the same care as those who have insurance We believe a more powerful lesson is to encounter and serve these patients, while learning of their stories, and how each patient and their family must cope with illness while facing extreme adversity Such educational experiences become life experiences not likely to be forgotten Conclusion Society is challenged to provide greater healthcare access for underserved populations Simply put, more doctors are needed to serve in these urban areas Primary care practitioners disproportionately serve more patients in underserved areas then specialists Efforts to explore means which support an increased number of medical students choosing primary care specialties are important and necessary to improve healthcare nationwide A recent statewide taskforce that examined physician manpower in the state of Maryland once again confirmed a present and future shortage of physicians serving areas of our state, including Baltimore City, Western Maryland and the Eastern Shore It is also known that students from more affluent backgrounds and from areas with greater socioeconomic resources are more likely to return to these same areas to practice a non-primary care specialty However, it is our hope that by teaching students from a diversity of economic, social and cultural backgrounds and providing them unique and significant educational, career and life experiences, they may see the value in the challenges and rewards of serving an inner city population Furthermore it is our hope that in doing so we may see an increased number of students choosing specialties in primary care and focusing on practice in underserved communities Doctors Richard Colgan and David L Stewart are Associate Professors, Dr Yvette Rooks is an Assistant Professor in the Department of Family and Community Medicine; Caitlin Iafolla is a second year student at the University of Maryland School of Medicine For a complete list of references contact Sraskin@montgomerymedicine.org or the authors References: Comparison of Primary Care Positions Filled with US Seniors in March: 1996-2007 [Online] Accessed October 29, 2008 Starfield B, Shi L, Macinko J Contribution of Primary Care to Health Systems and Health Milbank Q 2005; 83:457-502 Yens D., Outcomes of a MS1 and MS2 Clinical Mentorship Program Society of Teachers of Family Medicine Annual Report Poster Presentation 2006-2007 Baltimore, Maryland TABLES Table 1: Comparison of US and UMSOM Fourth-Year Medical Students Pursuing Family Medicine Residency Table 2: Family Care Tract Goals and Objectives Continuity of Clinical Experiences: To provide students with ongoing clinical contact with a constant set of families throughout their training Skill Acquisition: Students will acquire the specialized skills necessary to function as effective members of the health care team, particularly in an urban center Psychosocial Influences: Students will learn to recognize the symptoms and signs of both familial and intrapersonal dysfunction and how these dysfunctional patterns relate to the onset and course of various diseases Socio-Economic Influences: Students will become familiar with the impact that social economic cultural and political, spheres play in promoting health and well being in the urban poor family Comprehensive Health Care Delivery Students will develop the role of “patient advocate” in the acquisition and efficient utilization of community resources promoting comprehensive health care 6 Case Management Skills: Students will develop the skills necessary to be the “case manager” including working with and communicating between consultants and community agencies Ethical and Professional Standards: Students will become comfortable with the ethical and professional standards which respect the dignity, self determination, and civil rights of their patients and families Self- Awareness Students will become aware of personal attitudes, beliefs, values or feeling that may either directly or indirectly influence their delivery of effective health care services to the urban poor ... preventative and medical treatments The University of Maryland School of Medicine Family Care Tract Medical Students’ Waning Interest in Primary Care The number of medical students choosing family medicine. .. understanding of family medicine by the time they reach the clinical years The students’ preparation will give them the ability to rely on their own observations and experiences in family medicine. .. for those in primary care The rationale for the development of the Family Care Tract (FCT) at UMSOM in 1988 was the belief that if students who express an interest in family medicine were mentored