Nature vs Nurture: What matters more for student interest in Family Medicine?

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At a recent conference for medical educators by the Society of Teachers of Family Medicine, Wanda Filer, a past president of the American Academy of Family Physicians asked how many of us in the room had been told we were “too smart for Family Medicine”? At a conference of close to 600 people, a little over half of the participants in the room raised their hands. Which leads me to ask, what are we, as a profession, doing to either bolster or harm the reputation of primary care among students?

Many medical students begin medical school interested in Family Medicine. It is not unreasonable that once exposed to the breadth of options in medicine they might choose another specialty, but how can we best nurture that interest?

We train in this highly populated valley, but we serve a much wider region given that so much of our state is geographically rural and less densely populated. Is there more we can be doing to serve the entire state’s needs? You might expect our school to turn out a high number of Family Physicians given that we are abysmally low at 49th in the nation for lowest primary care physician‐per‐ 100,000 population ratio by the AAMC. However, last year, the percentage of the class that matched in Family Medicine was 10%, and this year we were at 12%.

The medical school with the highest rate of graduates going into Family Medicine, based on three years of data, is at 20%. In a time when projections for primary care are dire, what are we doing to improve our numbers? What is it that pushes a student to choose Family Medicine?

In the last two years, our clerkship was expanded from four weeks to six; this change was driven by student interest. This has given us an opportunity to really showcase our specialty. In addition, many students are choosing to experience a rural practice for three weeks and a more urban experience for the other three weeks, further emphasizing the incredible breadth in our profession. Evaluations have been positive with students appreciative of the flexibility of this option.

Providing students experience through activities sponsored by the Family Medicine Interest group is another way to nurture a budding interest. For our program, this is another way for medical students to be exposed to our awesome residents. Becoming acquainted with residents, so close to their own experience as medical students, allows students to more realistically see what their future as a Family Physician could be.

I would be remiss if I did not mention those practicing Family Physicians that have influenced all of us. We all have those amazing mentors, inspiring leaders that rejuvenate us and remind us why we do what we do. For me, it was Heidi Shields.  When I was a third-year medical student, she showed me that a Family Physician can do it all – deliver babies, deliver excellent patient care both inpatient and outpatient as well as have a family. I will never forget going with her to the wedding of one of her patients in the hospital chapel as the woman was dying from cancer. This woman was emphatic that both of us attend, as we had seen her daily for the last few weeks in the hospital while we worked to manage her symptoms. I will never forget watching this patient stand as tall as she could, Foley catheter bag full of urine covered by the folds of her dress, her eyes fluid-filled as she walked proudly down the aisle. Throughout my powerful learning experience with Dr. Shields, she shone as an example of what I hoped to become. Each of us has the opportunity to be one of those influential people for a student and nurture this interest.

Rather than lament our own past experiences, it is time to move forward and truly spotlight Family Medicine. Let us stand up for what we do and what we believe in: caring for all people through all phases of their lives. I am lucky to be a part of an awesome team in medical student education at the University of Utah; our mission statement encapsulates a goal for us all, let’s “inspire and mentor students to champion Family Medicine”.

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Karly Pippitt, MD, FAAFP is the Director of Medical Student Education and an Assistant Professor (Clinical) in the Department of Family & Preventive Medicine at the University of Utah.

 

One in Five

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By Vanessa Galli, MD

Nearly one in five women have reported experiencing rape in their lifetime according to the most recent data from the CDC. Statistics never mean as much to the reader as an “n of one” or a personal testimony. I myself am the one in five, a survivor of rape. That is not the point of this article, but rather serves as a context for a larger conversation.

I bring this all up at the beginning of this article because it shouldn’t be any different than talking about any other part of one’s life story. The shame and the embarrassment that these events are shrouded in stops us from having open conversations and prevents survivors from seeking the help that they need. I also bring this up to challenge your stereotypes about rape trauma survivors and for any of you reading this who share my experience to remind you that you are not alone in this journey. One in five means that many of you reading this unfortunately share this part of my life’s story.

Sexual assault can come in so many forms, both big and small. I have always been aware of gender biases in conversation, although have become increasingly aware of these throughout medical training. Each time I was called “Sweetie”, “Honey”, and “Angel” and told that I “looked like a Barbie Doll” by patients, it became harder to just shake it off and walk away. I attempted gentle correction, changing the subject and removing myself from the conversation. I never found a “good” solution and was left feeling guilty on some level. I found myself asking the question, “What did I do to bring this on?” I was experiencing some form of survivor’s guilt.

I also began see how often we do this to one another in the work environment. I began to notice that my female colleagues are frequently addressed collectively as “ladies” or automatically by their first name in conversation, while their male colleague sitting next to them may be addressed in the same breath as doctor. In the hospital setting, I have overheard staff complementing male providers for their “bluntness” and female providers with a similar communication style accused of being “harsh and unapproachable.” We live in a world of micro-assaults that are committed innocently in the work place every day.

So what exactly do we do about this? I do not believe in being overlying politically correct as that doesn’t further the conversation and leads only to frustration and tip-toeing around the true issues at hand. I believe in being direct and open in communication, a style that was born from my Northeast roots. So on that note, I challenge each person reading this to question your own preconceived notions and stereotypes. We are in a line of work that relies on solid skills in pattern recognition and judgement, although sometimes we need to leave that judgement at the door. We need to have open conversations with each other. We need to feel comfortable and safe correcting one another, whether it be a patient or a co-worker. Only then, will we create a work environment and a patient care environment that is safe for everyone.

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 Vanessa Galli, MD is a Chief Resident in the Family Medicine Residency Program in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.

 

Choosing Gratitude

By Kara Frame, MD

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I don’t remember the exact lecture or rotation, but somewhere along the course of my medical school education, I was taught this powerful lesson: a person is capable of changing how she thinks.  Of course, people have natural tendencies- leaning more positive or tending toward a more pessimistic outlook- but to some degree these preferences are pliable rather than fixed.

 

In a very rudimentary way, it can be explained like this: our brains are facile, constantly remodeling themselves.  And, if a thought becomes repetitive, it reinforces the nerve pathway that it triggers, essentially making the pathway stronger. The reverse can also be true, if we de-emphasize a certain pathway (thought process) it may become less prominent. This lesson resonated with me and the concept seems to resurface in my conscious at different intervals in my life.

 

As a family doctor, the idea has helped me offer hope to patients, many of whom, unfortunately, struggle with depression and anxiety.  Of course, I would never mean to suggest to them or to you that their disease can just be willed away, that simply reframing their thinking will make all of their problems disappear.  That way of thinking suggests the disease is completely within their control, something they might have caused or are responsible for, which is grossly false and is partly responsible for the stigma they often feel when it comes to mental health conditions. It minimizes their experiences.  However, when I talk about the multi-pronged treatment that I often recommend for depression or anxiety, it typically includes medication, good therapy, and lifestyle interventions.  The last part can be overwhelming but it can also be empowering.  When you are battling depression and/or anxiety, so much feels out of control.  You might feel at times as if you are “going crazy” or losing your mind.  It often comes with a sense of hopelessness.  So, the idea that there may be things within your control can be uplifting.

 

Eating well, being physically active, being rested, generally taking care of ourselves: these are the pillars of health that can be difficult to maintain even when we are not depressed, so trying to do this under the weight of depression can become impossible.  Therefore, I encourage my patients to start very small.  To choose one thing to focus on first and then we build over time from there.  Still, just wanting to exercise more or eat “better” doesn’t often get the desired results, so we often have to back up a few steps.

 

No one can make a change until she understands what is stopping her in the first place.  And, for many of us, that something that is in the way is often our own thinking.  “I am so out of shape, what’s the point?” “I can’t even walk to the mailbox-there’s no way I can run.” “I have already eaten half the bag, what difference does it make if I eat the whole thing now?”  These are all paraphrased examples of the negative self-talk, I have heard from patients.  When they start to think about change, some version of these negative thoughts will run through their heads. And, once these negative thoughts are recognized, the work of re-framing them can begin.  If we recognize the repetitive thinking as it begins, we can then stop it and shift to something different, replacing the negative with more positive and actionable thoughts.

 

As for us doctors, we are not above the negativity.  In fact, we are often more susceptible. It is generally accepted that doctors have a higher rate of burnout than the general public, and we certainly are at risk for depression.  People talk about the jadedness that often envelops physicians somewhere along their training- people who began a profession with total optimism and a desire to help too often becoming filled with negativity and, sometimes, contempt.  I have seen this in residents, young doctors going through the gauntlet that is residency.  There are times when it can become overwhelming and even the most positive can begin to falter.  And, I have seen this in seasoned physicians with many years of practice under their belts.

 

For my own part, I have been pretty fortunate.  I have been lucky to train, both in medical school and in residency, at places that were very supportive.  And now, I work in a program that places a very high value on personal wellness.  And yet, there have been times when I found myself slipping into negativity, too.  Something I subconsciously considered myself to be above happening to me, just as I had witnessed in other friends, colleagues, and learners.  I have always considered myself to be a positive person, so don’t like it when this new pessimism starts slithering in.  I try to practice what I preach and make an effort to change.  By consciously focusing on the countless things I am grateful for, at least once each day, there is less time for the negative chatter.  When I start this practice, sometimes it is hard to think of much, but as I become more practiced, numerous things pop into my head each day.  By choosing gratitude I also shift back toward optimism.
As I am writing this, I recognize that I am vastly oversimplifying a very complicated process, a process that often has many starts and stops, times of progression and regression.  Yet, in a time where there is a lot of uncertainty, when many feel lost and as if there is nothing in their control, I find it comforting to be reminded that we can do something pretty big: we have the power to change the way we think.

Frame

Kara Frame, MD is an Assistant Professor (Clinical) in the Department of Family & Preventive Medicine at the University of Utah School of Medicine.