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Steering Med Students into General Practice
|By David Ollier Weber||October 23, 2012|
Medical schools are working against cultural currents and engineering a new strain of broad-spectrum doctors.
Gowned and bored, cooling my heels in pre-op, I struck up a conversation with the anesthesiologist who'd ducked through the curtain to probe me with a stethoscope. He'd gone through the checklist of routine questions in anticipation of my outpatient procedure. After quantifying my alcohol consumption for him, I bantered that, from his accent and the name on his badge, I surmised that he came from a culture known for knocking back a vodka or two.
He was Russian, he affirmed, originally from Siberia — born and raised in one of the special "science towns” set up under Stalin to house the cream of the Soviet Union's physicists, chemists, mathematicians, biologists and the like. His father was part of the support infrastructure, a blacksmith.
But everyone who lived there — Akademgorodok ("Academy City”), near Novosibirsk — enjoyed salary bonuses; access to scarce foodstuffs and otherwise hard-to-get commodities; comfortable accommodations; and plenty of fresh, clean air to keep elite brains functioning at maximum efficiency. He grew up cross-country skiing through the endless pine forests that surround the city. He went to the local university. He decided to become a doctor.
When he told his family his career plan, his working-class father frowned, shook his head and demanded, "But how will you support yourself?”
It was not as odd a question as it might seem. In the Russia of his youth, the anesthesiologist explained, physicians were very poorly paid. "It was a calling" he said. "You did it out of idealism. You knew it would be a sacrifice.” He chuckled. "Becoming a physician was kind of like becoming a monk.”
He chose pediatrics. For four hours a day he saw patients in the clinic; afternoons and evenings were spent on house calls. He could observe firsthand the conditions under which children were being raised, and firmly instruct a parent who filled the room with cigarette smoke, for example, that the atmosphere was unhealthy for the family.
"You can make a big impact on children's lives that way" he said. He found the work rewarding, albeit hard and unremunerative.
"In Odessa the doctors took bribes" he said. "They argued that since they weren't making any money, it was justified. In my area that was frowned on.”
Eventually he emigrated to the United States. And here he chose to do a residency in a different specialty — one of the most highly paid in medicine, anesthesiology. Pediatrics, among all the traditionally bottom-of-the-pay-scale primary care specialties, is the lowest. But no worried father in America would ever ask a prospective MD or DO the question usually posed to wayward progeny majoring in the arts or journalism.
A medical diploma, no matter how it's put to use, is universally understood to be an express ticket to financial success. But that's not the end of the story.
Each year, the Association of American Medical Colleges surveys the new class of matriculating students nationwide on a variety of subjects, including what influenced them in their decisions to become doctors. In 2011 — the most recent survey — four in seven cited as a positive motivation "anticipated salary.”
To be fair, the remainder said money was not a lure, and many more — almost 80 percent — declared that the "competitiveness/challenge” of medicine had been a major attractant. (The listed career influences were not mutually exclusive.) Besides, says Tonya Fancher, M.D., of the University of California Davis School of Medicine, the lucrative options in business and finance available to the kind of top academic performers who opt for medical schools suggest that, "If your goal is to make a lot of money, medicine is not really the way to go.”
Fancher, a primary general internist and educator herself, knows whereof she speaks. And she has a strong reason for hoping her students aren't just motivated by the big bucks. She directs the Transforming Education and Community Health for Medical Students program at Davis, whose focus is expanding medical student interest and involvement in serving inner-city populations. She's also the associate director for curriculum for the UC Merced San Joaquin Valley PRIME program, which is similarly oriented toward encouraging primary care careers in rural areas.
Davis has long been a medical school with an emphasis on graduating primary care physicians. But efforts to steer more students into primary care — internal medicine, family medicine, pediatrics or obstetrics/gynecology — despite the allure of such better paid specialties as neurosurgery, cardiology or urology, are in full swing across the country, according to Carol Aschenbrener, chief medical education officer at the AAMC in Washington, DC.
Clinical experience in primary care and ambulatory settings is now a requirement at all U.S. schools, she points out. Eighty of them have clinical campuses in smaller cities where students can gain exposure to the relationship-based satisfactions of primary care — as opposed, she notes, to the usually briefer, shallower and more intermittent patient contacts that characterize most specialty practices.
Columbia University's College of Physicians and Surgeons in New York City, for example, offers about two dozen volunteer medical students the chance to spend a year earning primary care chops at clinics operated by 180-bed Bassett Medical Center in the upstate village of Cooperstown, population 1,800. As a sweetener, the students pocket $30,000 in scholarship money offered by a private donor.
The University of Nevada, East Tennessee State University, Michigan State University and the University of Washington, Aschenbrener notes, are among schools that support outlying clinical campuses in remote areas where medical students shadow primary care physicians. Duke University and the University of Illinois offer undergraduate medical experience in inner city clinics where, she says, "they're making a real difference in people's lives.”
The University of Massachusetts, under a new state program, will forgive a med school student's entire tuition if he or she spends four years in primary care in Massachusetts after graduation. Texas Tech University now is offering to shave a full year off the traditional four-year path to a medical degree for students willing to devote three intense years to a course in family medicine.
"There are powerful forces in our culture that work against selecting primary care" explains Aschenbrener. "We're fighting an uphill battle.”
Consider the context in which students choose a career path, she amplifies. "We glorify technology. We judge people by their income and their social standing. Look at the current TV shows. If they feature doctors, they won't be family physicians. The show won't be about vaccinations and prenatal care for poor people.”
Given the influences permeating their entire lives, she suggests, students who opt to practice general primary care are making a decision that's "almost countercultural.”
Fully 38 percent of the incoming class of medical students nationwide last year — the class of 2015 — say they intend to practice primary care medicine. The number at Davis is considerably higher, says Fancher; nevertheless, she adds, "when students get to school there are so many stresses and financial pressures and disincentives to stick with lofty, admirable goals [the average allopathic medical school graduate emerges with $162,000 in student loan debt, the AAMC reports] that many more students plan primary care careers than will graduate into primary care.”
Whatever the specialty they choose, about a quarter of all students in the class of 2015 plan to practice in an underserved area — a third of them in rural communities, two-thirds in inner-city neighborhoods. Only 16 percent expect to work primarily with minority patients, but that is up from 11 percent only a dozen years ago.
Women now constitute almost half of any medical school class — 48 percent for the last several years. More than four out of five students are 25 or younger when they matriculate. Seventy-two percent identify themselves as white, which is proportionate to the racial makeup of the general population. Eight percent are Hispanic, 7 percent black — both underrepresentations. Seven percent are Asian or Pacific Islanders, an overrepresentation. Forty-three percent come from a two-earner family bringing home between $100,000 and $250,000 a year. Almost 80 percent have spoken English as their first language since infancy.
Which places Leopoldine Matialeu in the minority on virtually every count.
Until the age of 18, Matialeu lived with her father in the small village of Bandja, in the West African nation of Cameroon. She spoke only French and her native tongue, Fefe. Then in 2005, seizing the opportunity to "find a better future" she completed the necessary paperwork to join her emigree mother in San Jose, Calif.
Matialeu enrolled at a local junior college and applied herself to learning English. "My desire to pursue a higher education was a priceless gift that my dad instilled in me" she told an interviewer. "Growing up, I was taught to value religion, education and hard work.”
Those values were hard tested when, only a few months after Matialeu's arrival, her mother lost her job — and, not long afterward, her house. Matialeu, her 7-year-old half-sister, and their mother moved in with friends then into transient motels then into their car and finally shuttled through a series of homeless shelters.
"It was a very difficult time, emotionally and financially" she admits, "very stressful.” But she stuck to her English lessons and her pre-med courses. In 2008 she graduated with honors from Ca?ada College in Redwood City and was named class valedictorian. She received a prestigious Regents scholarship to attend UC Davis, where she earned a degree in biochemistry in 2010. After a year of work and Medical College Admissions Test preparation, she applied to 14 schools; this year she received acceptance letters from four. ("I know some people who applied to 30" she laughs; each year more than 5,000 would-be California med students vie for 1,000 in-state slots, notes Fancher.)
In July, white-coated and beaming as an emblematic stethoscope was placed around her neck, Leopoldine Matialeu was ritually inducted into the 109-member UC Davis School of Medicine Class of 2016.
She's still in the adjustment period, early in her first year, but Matialeu is loving the whirl. "It's great!” she exclaims in her lilting, vestigial French accent. "It's amazing! I'm a little bit overwhelmed, but I expected that. It's normal.”
In her spare time as an undergraduate, Matialeu raised funds to send medical supplies to Sudan through the international nonprofit organization Doctors Without Borders. She volunteered at a community clinic staffed by UC Davis undergraduates, providing free nonemergency health care to uninsured African-American patients in a black neighborhood of Sacramento. Now she's one of seven students enrolled in a special Rural-PRIME honors curriculum at UC Davis, developed to attract and prepare future physicians for careers in medically underserved communities around the state.
"I think most of my fellow students are idealistic" she declares. "That's what makes UC Davis special.”
To be sure, she acknowledges, "I'm still exploring specialties. If I stay and practice here, my focus will be on an underserved area. But my long-term goal is to work on the international level maybe for Doctors Without Borders. Although that's a long shot" she adds modestly.
"I'd like to go back to Cameroon" she muses, "because I know how dire the situation is there, health care-wise. [One hospital and two doctors serve 100,000 residents in Bandja, malaria and AIDS are rampant, poverty and corruption are endemic, she recalls.] Actually, I kind of want to do half and half if that's possible.”
Given her history, it's hard to imagine that anything's impossible for Leopoldine Matialeu. Or for the new generation of medical students she represents, among whom high-mindedness seems heartwarmingly far from moribund.
David Ollier Weber is a principal of The Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.
The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association.