It was my pleasure to spend time with a good friend and former medical student yesterday. I have not had contact with him in over 4 years. In the past we have had the chance to share much about life and medicine over free dinners and laundry (at my house and my expense). Since he is a chief resident in surgery this year, we discussed the problems of general surgery and the match. This year his program did well but last year was a real challenge. With only 2 residents per level it is particularly critical for their program to make every year count. I was impressed with his personal growth and maturity in the past years. I was particularly proud that he had chosen a job that would fit his spouse and past commitments better even though he could have had made nearly 3 times more in a different location. He credited his surgical mentors with his education and the ability to confront him regularly when he was off base. This year as chief he had hoped to prepare the residents better than they ever had been prepared. Unfortunately one of the residents is not coming along well. This resident had some of the highest board scores ever, but he just is not making it. The chief has strained himself to his limit in one on one efforts, to no avail. The problem resident focuses his attention on other areas, including his family, but I get the impression that he is not motivated. Apparently he likes the intellectual learning, but is not willing to spend the time to get the experience. Because the surgical program is so dependent on residents at each level, probation was not an option.
Surgery is indeed more than a medical approach, it is a lifestyle. This lifestyle includes a significant service component. It is learning by doing, by being put in situations where decisions are made. Attracting students with service-orientated lifestyle is a key issue for general surgery, as it is for us in Family Medicine, especially underserved Family Medicine. It also was more apparent to me that in this small general surgery program, the learning process was much different than the usual process in medical schools. The learning was often one on one. Surgeons in training had constant exposure to mentorship and small group education. Does medical school education contain enough of these elements so that students are at least comfortable with this "alternative approach?" How does this impact medical student selections? Do we in Family Medicine have enough of these experiences so that our own residents and faculty understand these and other important issues?
Later I had a chance to review the latest Family Medicine journal and reviewed a few more emails about the RTT match (or lack thereof) on the rural list serve. The same elements were present. The programs needed students with service-orientation and they needed familiarity with the process of education in smaller and more personal settings. Are students willing to trust that one or a few faculty can meet their needs over a prolonged period of time? My mentorship experiences have been some of the most rewarding of my career, but how do I translate that in a significant way to current students and will they understand enough to feel attracted to this?
My teens have also taught me much about this area. My daughter has had significant problems with attachment. She went to a Christian facility for a few years where the rule of the day was tough love. She made great progress in this system. She had a big sister who had two littles to supervise, my daughter and one other. My daughter also worked with a counselor and a teacher. The key supervisor was the house director, in charge of the big sisters. On the surface this is not too much different than other situations, except for the smaller ratio of supervision. The history and development is quite different. The leader of the organization began efforts to disciple young men over a decade ago. A young woman also felt a call to be a part of the efforts. The leader resisted on the basis of same sex considerations. Then the group had a challenging circumstance. One of his key supporters had a challenging daughter. They group needed a discipling female to be able to help with this teen. The success with this teen led to more teens and a house and counselors and two locations with directors. Later the ministry added a summer component working with youth sponsored by inner city churches so that disciples and discipled could both serve and learn together. The approach fit many needs. The teen needed supervision and direction. The big sisters and brothers needed a way to practice their training and learn about service. The Christian example of Jesus and the disciples provided excellent direction, but it wasn’t enough to study the Bible. They needed to practice what was being preached. A key element was the selection of the bigs. After all, this kind of labor was quite demanding, with late and irregular hours. The teens were often more than two experienced and dedicated parents could handle. How could the bigs cope, especially when few if any had ever had kids?
The solution was to select based on willingness to serve. At this facility and its sister facility, the bigs basically volunteered a year and did another one or two years if they continued as house directors. Occasionally some bigs do not work out. The program continues because of service and commitment and dedication on the part of the others. While it is true that many considered this an important step to becoming counselors or teachers or ministers, such training could have occurred on the job with pay rather than taking a year off.
Programs such as this one are natural feeders for the kind of students and residents that we need in Family Medicine. Family Medicine requires mature learners with life experiences. What better choices than those who have been counselors and teachers and leaders? Who can best advise parents and community leaders regarding some of the most challenging situations that we have? Service-learning is another area where similar concepts come into play. Americorps volunteers, former Scouts, and Peace Corps volunteers should be at the top of admissions lists. Peace Corps volunteers interested in medical school face some interesting challenges getting applications, MCATs and other routine items done in a timely fashion. Strong Christians such as the ones who worked with my daughter also face extra scrutiny during medical school admissions. Most of the service-oriented folks, especially those who have spent a year or more away from books and college and academics are somehow felt to be at more academic risk by admissions committees. Our medical schools and perhaps our entire society with its focus on the intellectual are missing out on the importance of people and institutions that value relationships. It is no surprise that our discipline is suffering and with it our society. Clearly
1. A discipline based on service needs servants. Rural Interested Students Service Orientation
2. Servanthood is a matter of choice and dedication and lifestyle rather than training. Richard is Gone Mother Theresa Servant to the Underserved
3. Academic medical centers are losing the service component and with it the disciplines who place a higher priority on service. Family Medicine is not immune to this see The Academization of Family Medicine
One of the most neglected components of American Institutions is the potential to accomplish significant change in some of the difficult situations faced by many of our citizens. In Family Medicine we have always been in a position to effect change. Our practitioners have been making a difference for decades. The major limitation for a discipline of service is disciples. What better material to work with than those dedicated to service?
Robert C. Bowman, M.D. rcbowman@atsu.edu