Introductions

Plan for the Presentation

        About Current Medical Education

        What was Medical Education like when teaching was the priority?

         How has that impacted training for the underserved?

Talk

Small groups by level and concerns

Stick around for continual dialog or find a mentor

Assumptions for this talk about your choices thus far in your career

1. You chose medicine to care for people
2. You are interested in family medicine because you want to make a difference, you want more than just treatment of disease
3. You are interested in caring for people who need help, not the worried well or those with access to care
4. You have chosen rural medicine because you want to serve, you want to give more of yourself than most in your profession

I have some pointed questions for you to consider. Take some time to think about these:

• If you chose medicine for intellectual challenge, why are you here? Serving the underserved takes some intellectual ability, but it is more important to have emotional intelligence, understanding, dedication, willingness to learn in multiple dimensions and solve in multiple dimensions. Don’t mix up intellectual challenge with complex problem solving and service.
• If you chose family medicine for other reasons besides caring and making a difference, please go elsewhere. We would rather have less family physicians that more that did not understand what family medicine is about.
• Are you making your own choices and growing stronger and more confident in your career decisions, or are you relying on others around, peers, faculty, etc? I allowed myself to be influenced by others. I allowed myself to compare what I was making and should have been making. I allowed myself dissatisfaction in many former jobs before I make the decision change me rather than whine about those around me. What is your decision?

My task today is not to make your life more difficult. I do not want to drive you away from your spouse or family. But I do not think that a career in rural medicine excludes other activities.

My primary task today is to motivate you to resist as much compromise as possible. There will be many constant challenges to your career decision pipeline on the way to any practice, particularly rural practice. I want you to finish your medical career proud that you accomplished what you set out to do, what you were called to do, what the country needs, what your patients need.

What I do not want is for you to give a lukewarm commitment to serving the underserved. Underserved rural and urban communities can ill afford to pay your way and your salary, if you will only be there a few years. It costs practices or the community a quarter of a million dollars to replace you. If you want to change jobs through convenience or flexibility, please choose someone with deep pockets, not those in need.

Medicine and medical schools today are about vain attempts to cure disease. We fill your heads with information about disease and pathology and treatments, but we fail to mention the fact that all of these advances have failed to reduce overall cancer deaths. The only thing that has done so is successful efforts to decrease smoking.

The sooner you discover that medicine is about caring for people and populations and not just disease, the sooner you are ready to move on to what is needed: complex problem solving.

Medical Education Needs Major Reform – It has lost touch

Sir William Osler is widely regarded as one of the greatest academic physicians

It is much more important to know what sort of patient

has a disease than what sort of disease a patient has.

The deans of medical schools for the first half of the twentieth century noted that the best doctors were needed for rural practice.

Flexner is the Father of Modern Medical Education, this is what he said:

"The small town needs the best and not the worst doctor procurable. For the country doctor has only himself to rely on: he cannot in every pinch hail specialist, expert, and nurse. On his own skill, knowledge, resourcefulness, the welfare of his patient altogether depends. The rural district is therefore entitled to the best trained physician that can be induced to go there." p. 44

Abraham Flexner, 1925 "The student is to collect and evaluate facts. The facts are locked up in the patient. To the patient, therefore, he must go. Waiving the personal factor, always important, that method of clinical teaching will be excellent which brings the student into close and active relation with the patient: close, by removing all hindrance to immediate investigation; active, in the sense, not merely of offering opportunities, but of imposing responsibilities." Contributor: Huth, Edward J.Source: Flexner, Abraham. Medical Education: A Comparative Study. New York: Macmillan; 1925 [As cited in Wartman W. Medical Teaching in Western Civilization: A History Prepared from the Writings of Ancient and Modern Authors. Chicago: Year Book Medical Publishers; 1961, pp. 227-8].

If medical experts said it, what happened. It has taken a couple of generations of distraction, but Medical Education has forgotten about people, service, and involvement. Your task, if you choose it, is to help medicine remember.

Family medicine is in a unique position. We are the ones that are in medicine, far enough to be considered part (although very new) but new enough not to be completely distorted. Where medicine deals with individuals one at a time, we consider the family and community. We have insulated medical schools from the ire of society a long time, but we will likely not be able to save it from accountability for costs, quality, and general ignorance of societal need.

Medicine education is about specialization. You will be rewarded and bound and restricted by that specialization. Family medicine is about helping you find your specific niche, your purpose, your talent, for caring for patients.

Many talk about specialists and hospitals using family medicine doctors to fuel their health systems. What I see in practice and for the future is much different. Homer Flora began practice in 1954 in Nowata OK. I started practice in Nowata in 1983, fresh out of the Waco FP residency. Homer and I did not always see eye to eye on politics, but he was a far better physician and I learned much from him. I have never seen someone work a consultant or specialist as well for information as he did. He would wait till the end of the talk, and then ask specific questions about specific patients that he had. He was constantly pushing out the cutting edge of his learning so he could serve patients more effectively.

Homer used the specialists, not vice versa. He constantly reminded them that it was there duty to serve. Each of you has a choice to compromise on education and service, or you can push your own boundaries back.    

The Academization of Family Medicine

Don’t believe this isolated academic medical "experts" who do not understand comprehensive patient care needs and are devoting their lives to the lost cause of curing all disease. Don’t believe them when they say:

1. You are wasting your time in family practice, rural practice, etc. – You decide how to spend your time. How can it be a waste for you to invest the time to master medicine and then move beyond it to more complex problem solving touching on legal, ethical, religious, social, cultural. Even your peers graduating from medical schools recognize that medical school education has little training in these areas that are greatly needed to be able to deliver health care to people, especially the neediest ones.
2. You will never have time for yourself – You already know the answer to that question because you have already made decisions in that area for years. Before high school, during college, in your summers and school years preparing for medicine, during medical school, and throughout residency, you have already had to decide between medicine and self and family and others. You decided how to spend your time. A choice of dermatology does not dictate how you will spend your life, neither does a choice of rural family medicine control what you are about and what choices you make.
3. You will not make as much money as you should. Money and wealth are not a problem for doctors. Spending money is a different matter. If spending is a problem for you now, going in to medicine will not help you with this problem. If money is your reason for going into medicine, please leave quickly. Consider Wall Street, Dot Com, or some other profession please. It will be costly in the short term, but we may have to buy you out in the future, if medicine does not improve its care of patients.
4. How can I practice medicine in a small town where everyone has access to me. Care is personal, not anonymous. My experiences in small towns taught me that caring for people was personal and involved, not distant.

I just delivered a baby yesterday. Even though I was at and urban academic hospital, the delivery seemed rural to me. I knew the family well. I was delivering her fourth child, I also delivered her third. I also knew the nurse well as I had delivered her baby a year ago. The birth father was present and helpful. He was raised on a reservation. He is a farmer and we had constant conversations back and forth comparing deliveries of cows and humans.

As a rural medical educator, I have done interviews and surveys of rural docs, some still doing deliveries. One noted, "Why do I let 30 people control my life, my vacation, etc.?"

I can tell you why. Because this doctor and other rural doctors and other family practice doctors love people. I still do OB because there are few medical experiences like it. When the baby took a dive under the pelvic brim and went from –4 to delivery it was exciting, just like last time. When the baby was the first girl after 3 boys, the father’s rejoicing is etched in my brain. I continue to learn from the quiet strength of the mom who cares now for 4 kids under 5 years old.

I happen to love movies where people grow up, especially men. But none of them compare to becoming a part of a developing family as your care for a pregnant young girl in her 20’s as she grows and matures and becomes a woman. True life is better than movies, drama, comedy, tragedy, soap operas. You can choose to embrace it, or you can compromise. You can become involved and risk it, or you can insulate yourself in a specialty or behind caring nurses or techs. You can do this in OB, in trying to get patients to give up alcohol, in working with old folks in declining health dealing with major family issues, etc.

You can also worry whether this will impact your family. Will it warp you kids and marriage if you get so involved with your practice? Again this is a matter of your personal choices. Will it actually help your family more if you spend more time with them? If you do have the time, will you give it to them or will you simply use the time on yourself? Will you set a better example by giving your kid everything that they want or sending them off on multiple athletic or other endeavors? Or will you teach them best by showing them what personal sacrifice and caring are all about?

Well I did sacrifice much in rural practice and in academics. My family does feel these effects, but these effects are because of my choices, and not rural practice or addiction to making a difference. I also have spend much time isolating myself in the basement running a guppy farm, watching movies and doing complex problem solving on landscaping and video games, instead of my family. My kids have ADHD and learning disabilities, they are adopted and therefore part of them is not from me, but much of them bad and good is from me. My selfishness is in them and it nearly did in my wife. This is the most difficult thing that we continue to deal with. But they also have the caring nature of myself and my wife. My 16 year old son is often my best friend, and sometimes my worst nightmare. My daughter and I are renewing a relationship that has often been distant.

I have chosen to accept this challenge. I still have to choose it every day. There is a synergy and resonance between serving your practice, your family, and your community. Family medicine has been a vehicle for me to do all of these things and more. Rural medicine was the best learning and the best way to put all of these together.

Choose well. Decide for yourself what you yourself want. Do not compromise on things that really matter like career and family and caring for people.

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