Every Match Day, a number of medical schools claim that far greater numbers of students are going into primary care than actually are because the schools’ calculations don’t account for the many who match into internal medicine that will ultimately subspecialize and never practice primary care. Still, some schools are truly training large numbers of primary care doctors, and here one professor explains how.
By Jim Boulger, Ph.D.
Like many schools, the Duluth campus of the University of Minnesota Medical School states within its mission statement that our goal is to train excellent family physicians that will serve rural and Native American populations. Unlike many schools, we are very successful at these tasks. Why?
It begins, as we all would expect, with selection. If the wrong folks come in, the wrong folks go out. We actively select applicants who are from smaller communities – typically about 85 percent of the class of 60 comes from small towns – and who have a demonstrated interest in family medicine, have been academically successful and hold decent MCAT scores. When we interview these folks, we try to be as holistic as possible, respecting their uniqueness but always with the institutional mission “fit” in mind. They are plenty smart enough with an average GPA of about 3.7 and MCATs of about 28.5, and our Step I Board scores are typically at or above the national average.
Duluth medical students – all of them – are required to participate in our Rural Medical Scholars Program – spending about five and a half weeks in smaller communities, some as far as 300 miles away, over the first two years of medical school. While in these communities, the great majority, particularly those in the smallest towns, literally move in with the family physician and his or her family. They are required to perform community assessments, of course, but the majority of their time is spent seeing patients with their family practice role model and her or his partners. Additionally, in the first year they also spend seven mornings or afternoons in the offices of family doctors in the Duluth area.
Many of the students – about 20 in a typical year – also select the Rural Physician Associate Program, which places them in a smaller community for nine months of their third year of medical school.
Teasing apart the potency of the various components, i.e. admissions, curricular emphases, etc., is very difficult, but I do think that it is clear that the combination
really works well. Of course, not all students elect family medicine as a specialty or rural or Native American practice sites. Education should – and does – change us. So students may come in on the family or rural medicine track, but that doesn’t guarantee they will all leave that way. But we can certainly boast that we are wonderfully successful.
In the 2013 match, for example, 44 percent of the May graduates who matriculated in Duluth four years ago, or 26 of 59 students, selected family medicine residencies. An additional five of the nine who selected internal medicine or med/peds chose residencies which typically foster generalist internal medicine, and I would predict that two of the four who selected peds will stay with general peds. If these projections hold true, the actual rate of entry to primary care for this group would be about 56 percent. Of the 1,748 students who have matriculated in Duluth since 1976, 836 have selected family medicine as their specialty. Forty-four percent of those in practice are in communities of 20,000 or less.
Many will protest that this cannot be done elsewhere. But I usually try to distinguish between what can be done and what we really want to have happen. Our behavior is more important than our pledges. If we wish to change the mix at the end of medical school, at Match time, we have to change what happens at admissions and during the medical school years. Doing the same thing again and again, but expecting different results, is one definition of psychopathology. We know that if we want to see real change in our patients’ health, we must expect – demand – to see changes in their lifestyle. If we want to see change in who populates our practices of medicine in the future, we must also demand changes in how we function in academia. The same old stuff will not work.
Our nation needs change from us. We can make the changes necessary. But do we have the will to act? I don’t think we can wait much longer for the answer.
Jim Boulger, Ph.D., is a professor in the department of biobehavioral health and population sciences and the department of family medicine and community health on the Duluth campus of the University of Minnesota Medical School. He has been involved with the teaching of medical students in various roles for the past 44 years.