Why Family Medicine?
A Couple Chooses to Work with Those in Need and to Treat Patients from "Mind to Toe"
Rebecca Ryan and Jason Kurland met as students at the University of Rochester School of Medicine and Dentistry. They married in November. Rebecca and Jason, members of the Class of 2010, chose family medicine for a career and will begin a residency at the University of New Mexico School of Medicine in Albuquerque. They each explain their choice.
At the start of medical school I had a specific, though somewhat idealized, vision of my future medical career: I was going to study infectious disease, discover new treatments for old diseases that plague the developing world, and be on the frontlines of disease outbreaks. My progression through medical school quickly began to alter my vision as I learned about the realities of actual patient needs, psychosocial determinants of health, and the preponderance of morbidity and mortality secondary to chronic diseases.
Prior to my journey into medicine, I was a Peace Corps volunteer doing community health and HIV prevention in rural West Africa. I worked in a clinic where I saw patients with malaria, diarrhea, tuberculosis, and other infectious diseases. I began to note a close association between limited availability of health care, poor nutrition, and disease among these patients, as well as among my friends and neighbors. It wasn't until I started my medical training that I truly internalized the idea that though infectious diseases do ravage poverty stricken areas, the underlying causes of morbidity in these vulnerable populations are social determinants of health, limited education, and health care provider shortages.
"At the start of medical school I had a specific, though somewhat idealized, vision of my future medical career: I was going to study infectious disease, discover new treatments for old diseases that plague the developing world, and be on the frontlines of disease outbreaks."
More profound for me was the epiphany that resource limitations, poverty and poor health outcomes are not phenomena unique to the developing world. I was naively surprised to see these same disparities in my own neighborhood in Rochester and in pockets throughout the United States.
I had the opportunity to volunteer at URWell, the student-run clinic for people with no health insurance in Rochester. I was surprised to meet patients with serious medical problems who were denied care at other institutions and who had no access to a primary care physician on a regular basis. I heard the stories of our patients—of everyday people struggling with chronic diseases. I listened and learned from my patients and truly saw that health is related to employment, home life, family history, stresses and other psychosocial elements far more complicated than a simple disease diagnosis. Every patient has a rich story that informs who they are and how they approach their health. In order to help them be well, we need to know their stories and tap into our patients' strengths and world view.
After third year, I took a year out from medical school to work with underserved communities to study the relationship between primary care and public health and to learn about medical practice in resource poor settings. My mentors during this year—at Planned Parenthood in inner-city Rochester, in rural Alaska, in colonias along the Mexican-American border, and on the Navajo Reservation in New Mexico—were primary health care professionals and community health workers who are dedicated to decreasing barriers to health care and improving individual and community health. They taught me valuable lessons about patient care, cultural sensitivity, decision making in resource-poor settings and the true nature of integrative family medicine. I was exhilarated by these models of care based on a knowledge and interest in the patient's story and using that knowledge to improve the delivery of complete patient care.
In the end, family medicine was the most logical choice for me. I came away from Africa with a sense of solidarity with and personal responsibility towards the underserved. In medical school, I developed a more practical and focused outlet for this sense of purpose through a passion for rural primary care and developing personal relationships with patients. I studied with primary care providers who inspired me to embrace the family medicine model of providing patient-centered, prevention-focused care that empowers patients to achieve wellness for themselves and their families. I think I can best meet my goals of working and empowering underserved populations and approaching care in an integrated fashion through family medicine.
My husband and I are interested in developing our careers in such a way that will allow us to work with underserved populations and to provide support, services, and empowerment to those in need. As rural family medicine doctors, we will work to reshape the traditional structure of medical practice to empower those who are frequently overlooked and to realize the basic human right to accessible and affordable medical care. We both chose family medicine because it offered the best way to truly meet patient needs through integrative biopsychosocial care, while also being a resource, an anchor, and a teacher.
When I tell fellow medical students that I'm going into family medicine, their reactions vary. Yet almost inevitably, their response contains elements of two themes: "Why would you do that?" and "How noble!"
No one in medicine is unaware of the trifecta of long-hours, lower-pay and limited-prestige that characterizes the primary care specialties. Medical students love mnemonics such that even advice on choice of specialty has been distilled into a memorable phrase: "Stay on the ROAD." The best specialties, or so the conventional wisdom goes, are Radiology, Ophthalmology Anesthesiology and Dermatology. These and related fields are held to offer the best "lifestyle," itself a kind of shorthand for an optimal combination of income, work hours, and status. In this view, family medicine isn't merely off the road, it's off the map.
Although I'd like to claim a noble madness led me astray, I chose family medicine for the same reasons most of us choose a specialty: the opportunity to help people coupled with the potential for professional satisfaction.
The critical need for more primary care providers, particularly in rural and poor urban areas, is well established. On the macro level, I am pleased that my choice of specialty can contribute to meeting this need. On the level of the individual patient, I am convinced that high-quality primary care has the potential to do incredible good for people. The benefits of good primary care can be substantial, at the individual and population levels, but tend to be more difficult to recognize, quantify and reward than the benefits of acute dramatic interventions, such as placement of a coronary artery stent. The value of a stent seems obvious, direct and immediate; the value of preventive care and early intervention may show up only as an absence, as the need for one less stent.
Yet a good primary care physician can provide much more than screening and preventive services. Unfortunately, our clinical training, weighted as it is toward the inpatient setting with only sporadic outpatient exposures, tends to dramatically downplay the potential benefits and satisfactions to be found in primary care.
"When I tell fellow medical students that I'm going into family medicine, their reactions vary. Yet almost inevitably, their response contains elements of two themes: 'Why would you do that?' and 'How noble!'"
When we do see outpatients, it is exceedingly rare to see the same patient twice. What I caught only glimpses of in medical school—but was lucky to experience prior to matriculation—is the power of continuity in the doctor-patient relationship. As a medical assistant working with one doctor over extended periods, I observed patients' almost universal need to feel known and understood as people, above and beyond any particular diagnosis or subset of problems. Specialists can and should offer the very latest thinking on diseases of the skin, kidney or lung. The primary care physician is uniquely situated, both within the health care system and within the patient-physician relationship, to integrate all aspects of a person's health into a coherent picture, taking into account not just the patient's current problem list but their personhood before and beyond illness.
While I expect that much of my satisfaction as a family physician will derive from relationships, the specialty's audacious, even intimidating, breadth of scope suits my personality. While I have great respect for the intellectual and practical rewards of detail work, it is the big picture patterns that truly excite me—and I like continuities more than I do boundaries.
During third year clinical clerkships, I was frequently frustrated by the distinct, sometimes counter-intuitive, boundaries between specialties. For instance, on obstetrics clerkship, I spent hours monitoring the minute-to-minute status of a laboring woman’s fetus only to immediately turn the newborn girl over to another specialty once she had traversed the birth canal. Passing into this world, she passed out of our scope of practice with no hope of returning to it until she herself needed obstetric or gynecological care years from now.
No doubt the ability to recognize and the humility to acknowledge the limits of one's own expertise are crucial to providing good care, primary or otherwise. Mindful of this fact, I am nonetheless excited at the prospect of following a heterogeneous panel of patients, assessing and addressing their health issues from mind to toe, ever balancing the care I can provide myself with that I can obtain for them from my colleagues, both those on the ROAD and those drawn away from it.
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