Regarding the Duke Family Medicine Program: (Not written by me)
Posted: Fri Nov 11, 2005 11:16 pm Post subject: A Paradigm Conflict
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Stripping away all of the malignancy, what they have is a conflict of paradigms. The disgruntled residents, for the most part, signed on with the understanding that they would be doing a traditional hospital-based family practice residency.
Two years ago, almost out of nowhere (at least from the point of view of the residents) and with little or no input from any dissenters the program was switched to a community medicine-based program.
Community medicine sounds innocuous but in reality it is a capitualation to the perception that Family Medicine is a dying specialty and in order to survive it has to find a new mission. In our case, the new mission is to be the American equivalent of "barefoot doctors," that is, adequately trained health providers who will fan out among the poor to provide low-cost or free primary care for a low salary.
Because this is Duke with acccess to every sub-specialty known to man it is easy to believe this. In fact, at our clinic we pretty much punt every slightly complicated case to adult doctors. This allows our clinic to function with a full complement of PAs and NPs, many of whom are permitted to function as Family Medicine Physicians despite their lack of knowledge and training. In the new paradigm, knowledge and training are not required so much as a rolodex with the phone numbers of grown-up doctors.
How is this working? Well, because the program is affiliated with Duke and needs to maintain good standing with the ACGME, there is no way to prevent the residents from rotating on the big boy services. Not to mention that residents are cheap labor at the hospital and are in high demand by attendings who don't want to come in early and stay late. So we do get excellent training on almost every off-service rotation. On cardiology, for instance, our interns are fully functioning members of the cardiology service and have generally been treated no differently than any other resident.
The problem comes with the family practice elements of the curriculum.
Because Pickens runs a profit every year, the priority is production, not learning. The program is so weak and, let's face it, non-essential to the otherwise high-powered misssion of Duke that if it showed a loss that would probably be the end of it. For those of you new to medicine, you need to understand that when you are precepted, your preceptor bills for your time with the patient. They usually see the patient but only for a couple of minutes.
In a good program, the preceptor will take an adequate amount of time to let you present, propose a plan, and then discuss the patient. Profit, while never unimportant, is always secondary to teaching and most teaching hospitals understand this. At Duke, the clinic is incredibly fast paced and not in a good way. You future iterns need to know that after a couple of months your patient panel for your half-day clinic will be increased from three to five. Not a lot, it seems, but you will always feel rushed and almost never have time to think.
The rationale is that usually at least one of your patients will not show up. True, in some cases, but if your 8:15 patient doesn't show you still have four patients who are going to hit you starting at 9:00.
(to be continued)
Posted: Fri Nov 11, 2005 11:56 pm Post subject:
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(cont'd)
I understand perfectly that some clinics need to be fast-paced. Out-patient surgery clinics, for example, are incredibly focused and it is not unusual for one resident to see twenty patients in a long moring. I did that as an intern last year almost effortlessly. This is because a surgery clinic is ruthlessly "problem-focused" with one chief complaint. The history and physical exam needed to formulate a surgical plan is concise but brief. Not to mention things like routine wound checks which take five minutes.
Family medcine is not surgery. The patients are generally more involved in their work-ups and even if they are not, this is where the concept of health maintenance rears its ugly head. In other words, not only do we have to elicit a chief complaint and formulate a plan for that but at every visit we are expected to address every single health maintenance issue that applies to the patient. If someone comes in for a sprained wrist it is not enough that we get an xray and treat it (by sending it to ortho, ha ha) but we have to make sure the patient is up to date on their cholesterol, colon cancer screening, pap smears, prostate, vaccinations, mammograms and every other applicable screening. And we have to offer smoking cessation, harangue them about their weight, and make disapproving noises over their drinking.
Not too complicated on a 23-year-old healthy male but very time-consuming on a typical older patient.
Thus, there is no such thing as a simple visit. Nor do we dictate simple SOAP notes but must fit our note into a incredibly cumbersome template.
In a way, however, this is a problem for all of family medicine, that is, squeezing a comprehensive visit into the time only sufficient for a focused visit. It's just that at Duke you start out rushing and only learn to rush, not how to be efficient.
I just want to mention didactics or rather the lack of didactics. The conferences are incredibly weak and are usually on some completely useless subject like anger management or self esteem. Either that or some topic on community medicine which is often taught by a social worker or someone who's medical knowldge is irrelevent to their career.
Even when on a medical topic, a rare event, because the conference includes PAs, NPs, social workers, and nurses the content is either irrelevant to physicians in any but an incidental way or sufficiently dumbed down for the benefit of those without medical degrees.
In short, very few didactic sessions are worth attending.
It has been proposed by quite a few people that we need to have a protected block of time carved out every week (like they do in Emergency Medicine) which is to be used for grown-up education. The PAs and NPs can sit at the kiddy table if they like.
The resistance to this idea is intense. Of course it would be hard ot schedule but not impossible. Surely Duke will not lock its doors if a couple of FP interns are off the wardss fro three hours on a Tuesday afternoon.
(continued)
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Posted: Sat Nov 12, 2005 10:33 am Post subject: cont'd
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(cont'd)
You future interns also have to understand that six residents per class is not enuogh to run a primary care specialty program at a large insitution like Duke. Maybe it is at a small unopposed program but there are many service requirements at Duke which siphon off residents from things like an Inpatient Family Medicine Service which we no longer have.
Not ot mention that the reason the didactics suck is that we can seldom, it seems, get enough residents together to make a good showing for a guest lecturer.
Medicine grand rounds, on the other hand, are well attended and the conference center is usually packed. If you are a high-powered academic, where would you want to give a talk? To a standing-room-only crowd of residents and attendings or two a couple of bored FP residents and a bunch of PAs and LPNs who probably don't even understand what you are talking about.
Consequently, the conferences we do have are pretty thin gruel. I absolutely refuse now to go to any conference presented by a social worker, a midwife, a lactation consultant, or any other "physician extender" because there is nothing important in them that couldn't be jotted down on a business card and handed out in lieu of wasting an hour of my life.
Thin gruel. That pretty much sums up the whole community medicine experience. I don't see why it requires specialized training in a residency to learn how to pass out condoms at high schools, nag the poor to quit drinking, and agitate for even more social welfare. These are things which, if you believe in them you can pick up in about five minutes which is why the academic barriers to being a social worker are so low.
(cont'd)
