"The Generalist": An Essay by UCSD Combined Chief Dr. Ryan Shackelford
Friday, October 8, 2010 at 10:26AM The Generalist
by Ryan Shackelford, MD, UCSD Combined Program Chief Resident
As I reflect on four years of medical school and five years of residency all focused on providing care to the underserved it has become clear that there is no easy fix to our nationʼs healthcare crisis. However, on a most pragmatic level, in my mind there are a few simple ways to mend our broken system and one of them is to produce many more quality family doctors. As my father recently so succinctly put it, “we need to train more quarterbacks”. Family medicine is the workhorse of the medical engine. As such, we work hard but we are not just brawn. What we are is difficult to summarize. We are the true coordinators of care, the friend, the stern parent, the supportive parent, the teacher, the listener, the spiritual supporter, the one person whoʼs job it is to step back and put the whole picture together when others focus continually narrows...in short, we are the quarterback.
Last year the American Academy of Family Medicine rejoiced in the “highest percentage match ever”. No matter that the absolute number was still below what it was a decade ago. No matter that the only reason the percentage was so high was that the total number of offered positions had plummeted by more than 500! The program here at UCSD, one of the best public medical schools in the country, with over 100 talented medical student graduates per year contributed a disappointing and dismal 5 family medicine matches in 2010. I hate to say it, but at times like these it seems undeniable: specialty practice has become the pinnacle of modern medicine.
How did we get here? Iʼm baffled. How did this happen? Iʼm angry. The family doctor I always envisioned and was hoping to emulate has disappeared. How did this art full of renaissance men and women taking care of entire villages of families from cradle to grave, making house calls, and being paid in harvested goods turn in to the fallback option for those who canʼt “specialize”?
I recently appeared on a panel at a family medicine interest group for medical students. The first things out of the panelists mouth were not pride- filled statements about our livelihood. Instead what those few students, whom we desperately need, got from us were tired excuses and defensive explanations about our lack of pay and respect. Sure we donʼt make a lot but we get to connect with people. True we arenʼt at the cutting edge of medicine where the advancements are made but we get to manage chronic conditions and help people move at a glacial pace towards healthy lifestyle change. Not very appealing.
Perhaps it really is just all in a name. Maybe we should just join the bandwagon and masquerade ourselves as specialists to boost our own lowly self-esteem. In the past decade weʼve added a slew of fellowships that amount to areas of medicine we were already responsible for but now feel inadequate to practice including ob, geriatrics, and adolescent medicine. Or maybe we need to conform to the real movers of medicine, the billing gods. If we just focus on increased documentation, up- coding, more procedures and asking about smoking as we walk away texting on our iphones we could raise our income to a respectable level.
No, hiding behind superficial titles and boosting our toe-nail removal rate will not fix our fractured egos. To get to the heart of why specialty care has rapidly risen in prominence we need to look at how we train young physicians. Medicine in America is a pyramid with community clinics at the bottom spread out all over the country and large academic centers with highly specialized clinics and physicians in few select areas. Most of these medical behemoths have an affiliated medical school which raises their prestige while providing the necessary exposure to all specialty areas for the trainees. As we have gotten farther away from community based training programs and more academic center focused the doctors coming into practice now, including myself, have no conception of what a true family medicine doctor can do for a town. They have been blinded by the glorious light of treating obscure neurologic syndromes and removing once inoperable tumors that affect a fraction of a percent of the population. Certainly it is admirable to apply yourself to these highly challenging fields but it in no way should diminish the incredible import of working with patients on depression, weight and high blood pressure where the public impact can really be felt.
How do we take back our glory. How do we reverse the trend toward specialization. My vote is to re- create our own brand, the notion of generalization. What is more difficult, to specialize in knowing the anatomy of your hand or to be held responsible for being competent in all branches of medicine. What is more admirable, to create a drug that is a near replica of the drug you came up with 7years prior and then prove its efficacy against placebo or to struggle in partnership for years of monthly visits against diabetes and thereby delaying your patientʼs kidney failure by years affording them more time with their loved ones. We need to take the offensive. We need to stand up and be the true quarterbacks we used to be. We need to show our pride to the next generation of doctors. We need to generalize!
