Family medicine lures with variety, strong relationships, growing influence
During her third and fourth years of medical school, Robyn Dreibelbis, DO, fell for a succession of specialties. “I would finish a pediatrics rotation and say, ‘I’m definitely going to be a pediatrician.’ Then I’d go on a general surgery rotation and decide that I had to become a surgeon,” she remembers. “I loved absolutely everything.”
But when her time in medical school was running out and she had to figure out what to do with her life, she knew she had one clear choice. “Family medicine was the only field where I wouldn’t be limited,” says Dr. Dreibelbis, who has practiced in rural Oregon since 1998.
Family medicine entices those who thrive on variety. Most family physicians treat patients of all ages who have all manner of conditions.
“I might have a 12-year-old boy with strep throat in room 1, a person struggling with alcoholism in room 2, and someone with chest pain and anxiety because of an unfaithful spouse in room 3,” notes Kevin E. Lukenda, DO, a family physician in Linden, N.J. “The diversity is what attracted me to family medicine.”
Family physicians can choose from many different practice arrangements and settings. Keven de Regnier, DO, the vice president of the American College of Osteopathic Family Physicians (ACOFP), for one, enjoys the independence he has being in solo private practice with a couple of physician extenders. In contrast, ACOFP President-elect Carol L. Henwood, DO, likes the enhanced ability to coordinate care that comes from being part of a large multispecialty group practice.
While many physicians in family medicine practice primarily in an office or clinic but also make hospital rounds, some family physicians today are strictly hospitalists, while others are strictly office-based.
Whatever their practice model, family physicians can wear many different professional hats. They can serve as team physicians, medical directors of nursing homes and county medical examiners, for example.
“I tell students that in family medicine, you can tailor your practice to whatever you want,” says Nancy A. Bono, DO, who chairs the family medicine department at the New York Institute of Technology College of Osteopathic Medicine (NYITCOM) in Old Westbury. “In this profession, you don’t get bored because it incorporates so much.”
Although breadth is one of the field’s selling points, family physicians who wish to focus their practice on a specific population or service can do so, Dr. Bono notes. DOs in family medicine sometimes subspecialize in geriatrics, women’s health, hospice and palliative care, sports medicine, and other domains. Many osteopathic family physicians have become specialists in osteopathic manipulative medicine.
In rural areas, however, family physicians often perform a wide range of procedures, such as removing skin lesions and cysts, splinting fractures, injecting joints, suturing lacerations, and performing circumcisions, vasectomies, colposcopies, biopsies and emergency cricothyrotomies. In some locales, it is still common for family physicians to deliver babies.
“I’ve done every procedure under the sun that you can do in a clinic setting,” says Dr. Dreibelbis, the vice chairman of family medicine for the Western University of Health Sciences/College of Osteopathic Medicine of the Pacific—Northwest in Lebanon, Ore. “I also did obstetrics for a number of years, and I took care of neonates even if I wasn’t the obstetrical provider.”
When she referred patients who needed major surgeries, Dr. Dreibelbis would oversee their hospital care. “If one of my patients needed a joint replacement or a hysterectomy, for instance, I would scrub in for the surgery,” she says. “Family physicians provide continuity of care. And that continuity doesn’t stop at the operating room door.”
Indeed, the ability to establish long-term relationships with patients is what many family physicians relish most about their specialty. They often care for several generations of family members for many years.
“I find this field so rewarding because I treat entire families and get to know my patients very well,” says Jeremy J. Fischer, DO, who directs the AOA-approved family medicine residency at Henry Ford Macomb in Clinton Township, Mich.
Dr. Lukenda knew some of his patients even before he became a physician. “I grew up in Linden less than a mile from my practice,” he says. “So this is a dream come true. I always wanted to be a family doctor in my hometown.”
Previously known as general practice and family practice, family medicine has been the traditional strength of the osteopathic medical profession since its founding. It is the specialty that fits best with osteopathic medicine’s whole-patient approach to care, many osteopathic family physicians insist.
“In family medicine, we take care of people rather than body parts,” Dr. Lukenda observes.
For many DOs in family medicine, the term osteopathic principles and practice means much more than a philosophic approach to care. Compared with other osteopathic physicians, except for those who specialize in neuromusculoskeletal medicine, DO family physicians are most likely to incorporate osteopathic manipulative treatment into their practices, Dr. Bono says. Accordingly, those who complete osteopathic training in this specialty and pass the AOA board-certification examination become certified in family medicine and OMT.
With 220 AOA-approved residencies in family medicine and OMT, this specialty is by far the profession’s largest.
In part because of surging student loan debts and reimbursement challenges for primary care physicians, interest in family medicine waned for more than a decade, as DO, as well as MD, graduates gravitated toward more lucrative specialties. But today, an increasing number of osteopathic medical students are pursuing family medicine as their first-choice specialty, residency directors report.
“Our program keeps getting more competitive,” says Dr. Fischer. “This year, we have 80 applications for four spots,”
Although not all AOA-approved family medicine residencies fill during the AOA Match in February, practically all of the positions fill after the National Resident Matching Program (NRMP) post-match period in March.
Growth in the number of osteopathic medical graduates is partly responsible for the increased interest in family medicine. The newest osteopathic medical schools all aim to recruit future family physicians and other primary care specialists who will alleviate the burgeoning primary care physician shortage.
But another important factor is family medicine’s rising cachet. Federal government initiatives emphasizing primary care have propelled family physicians to the forefront of medicine.
“You can’t turn on the television and not hear about health care reform in some shape or form,” says Dr. Dreibelbis, who directs the AOA-approved family medicine residency at Good Samaritan Regional Medical Center in Corvallis, Ore.
The Affordable Care Act champions the patient-centered medical home model of care, in which a primary care physician serves as the team leader and coordinates patient care with other specialists and nonphysician health professionals. Viewed as health system leaders, family physicians will have greater influence and prestige than they had previously, residency directors tend to agree.
This may be why some family medicine residencies are starting to see candidates with more competitive credentials.
“The biggest thing I’ve noticed this year compared to previous years is that overall my candidates’ board scores are a lot more impressive,” says J. Todd Weihl, DO, who directs the AOA-approved family medicine residency at Doctors Hospital OhioHealth in Columbus. “I think students are perceiving bigger and better opportunities in primary care.”
Similarly, Dr. Dreibelbis points out that two of her recent applicants scored in the high 700s on the Comprehensive Osteopathic Medical Licensing Examination of the United States (COMLEX-USA). During her residency’s initial years, the average COMLEX score for applicants was around 450, she says.
Still, stratospheric scores aren’t likely to become a requirement for family medicine, a field that places much weight on interpersonal skills.
Most directors of AOA-approved family medicine programs use board scores as a screening tool, preferring candidates who passed COMLEX Level 1 and Level 2, both the cognitive evaluation (CE) and the performance evaluation (PE), on the first attempt.
During the 2012 AOA Match, those who matched into family medicine as their first-choice specialty had average scores of 463 on Level 1 and 468 on Level 2-CE, according to a new report by the American Association of Colleges of Osteopathic Medicine. Of those residents, 81% passed Level 1 and 79% passed Level 2-CE on the first attempt.
The report shows that 97% of students matching into family medicine passed COMLEX Level 2-PE successfully on the first try, compared with 95.5% of all AOA Match participants.
“Normally we’re looking for candiates who’ve passed their boards. But if they’ve had a failure, we might consider interviewing them if they can satisfactorily explain what happened,” says Dr. Weihl, who received 70 applications this year for six openings.
Henry Ford Macomb’s Dr. Fischer expects candidates to have passed each COMLEX level, preferably with a score at least in the mid-400s. “I don’t consider anyone who has failed the performance evaluation portion,” he adds.
“In family medicine, you can tailor your practice to whatever you want.”
But program director Jennifer Zweig, DO, says that outstanding performance on a rotation can make up for a board exam failure or mediocre grades. “If we have seen that a candidate is a hard worker, teachable and easy to get along with, failing one board exam once or not having the greatest grades becomes less important,” says Dr. Zweig, who directs the family medicine residency at Pacific Hospital of Long Beach in California. “However, if applicants we don’t know have failed their boards, we’re very unlikely to take them on as residents.”
Overall in family medicine, serving an audition rotation with the targeted AOA-approved residency is desirable but not as critical as in many other specialties. Nevertheless, most residency directors recommend that students spend time at prospective sites to see which programs would be the best fit.
“In deciding whom to interview, we give the biggest preference to those who have rotated with us and those we know,” Dr. Fischer says.
For Dr. Dreibelbis, whether someone served an audition rotation with her program is a key component in assigning an applicant an A, B or C rating. “An audition rotation is like a monthlong interview,” she says. “It gives us an opportunity to understand how the person thinks and works with patients. We get to assess firsthand the applicant’s knowledge base.”
Similarly, serving an elective rotation at Truman Medical Centers in Kansas City, Mo., is advantageous for anyone applying to Truman’s dually accredited family medicine residency. “We take four to six students each month, limiting the electives to people who are very interested in family medicine,” says program director Laura K. Hempstead, DO. “For anyone applying to our program, rotating with us is a big plus.”
“It’s important to me that candidates at least see what our program is about,” adds George J. Scott, DPM, DO, who directs the AOA-approved family medicine residency associated with the Rowan University School of Osteopathic Medicine (RowanSOM) in Stratford, N.J. Residents in his program split their time between Kennedy University Hospital in Stratford and the larger, more urban Our Lady of Lourdes Medical Center in Camden, N.J.
“I would’t want to accept someone and then have them come here and be unhappy,” Dr. Scott says.
Although all osteopathic family medicine residencies meet the same basic standards, the programs vary widely. Some are more hospital-focused, while others emphasize outpatient care.
One AOA-approved family medicine residency that launched this year is completely different from most others. A partnership between the Wright Center for Graduate Medical Education in Scranton, Pa., and the A.T. Still University-School of Osteopathic Medicine in Arizona in Mesa, the program has 22 residents training at six community health center sites around the country.
“We are orienting our residents to be very strong in primary care and serve the underserved,” says program director Richard S. Dobrusin, DO, who is based in Mesa. “We hope they will practice at and eventually run community health centers after they finish residency.”
“The ability to be a leader—to manage nurses and physician assistants and work with other physicians in a group—is extremely important today.”
Dr. Lukenda, the program director of a new AOA-approved family medicine residency launching next July, places a lot of weight on the difficulty of the electives and selectives completed by his candidates.
“I like to see an applicant who has completed more challenging electives,” says Dr. Lukenda, whose program at St. Barnabas Medical Center in Livingston, N.J., will accept two residents a year. “I especially like to see rotations that gave candidates a lot of responsibility in supervising patients.”
To winnow their candidate lists, family medicine residencies also scrutinize deans’ letters for indications of each applicant’s leadership ability and for red flags. “Although these letters often follow a template, if a student stood out for a positive or negative reason, that would be highlighted,” Dr. Dreibelbis says.
Like many family medicine residency directors, Dr. Fischer says he is impressed by candidates who’ve been student leaders, such as Student Government Association presidents and national officers of the Student Osteopathic Medical Association.
“The ability to be a leader—to manage nurses and physician assistants and work with other physicians in a group—is extremely important today,” says Dr. Hempstead, whose program accepts two DOs a year through the AOA Match and 12 physicians, a mix of DOs and MDs, through the NRMP Match. “Because medicine is moving toward the patient-centered medical home, we value candidates who have the skills to educate and motivate patients to make changes in their lives.”
Dr. Lukenda also prioritizes leadership skills when he evaluates candidates. “What I’m looking for is not someone who just wants to sit in the office all day and see patients,” he says. “I’m looking for those who want to get involved in their community and their medical society—those who will rise up and not only take care of the patient but also proactively coordinate all aspects of a patient’s care with other doctors and health professionals.
“I’m looking for someone who will be a future leader as the medical field shifts more toward primary care and primary care physicians become quarterbacks of the medical home.”
Identifying genuine interest
Perhaps more than in other specialties, family medicine residency directors look carefully at applicants’ personal statements for evidence of sincere interest in the field. Just about every candidate includes an anecdote about being inspired by a particular family doctor to pursue family medicine. More convincing, say some program directors, are applicants who reveal a deep understanding of the role family physicians play today and commitment to evidence-based practice and the medical home model of care.
Because some ostensibly enthusiastic applicants actually view family medicine as a fallback specialty or a field of last resort, residency directors check personal statements for subtle signs of apathy or deception.
“In addition to correct spelling and grammar—which trips people up amazingly often—I look for evidence that an applicant is being honest and straightforward,” Dr. Fischer says. “Some personal statements are written in bombastic language. I appreciate personal statements that are genuine and that have some humor in them as well.”
To weed out applicants who are feigning interest in family medicine and really hope to match into a more competitive specialty, RowanSOM’s Dr. Scott looks closely at the clubs and activities they’ve been involved in.
“If someone says he has always wanted to be a family doctor but he has been a member of the surgery club and not a member of the student chapter of the ACOFP, that certainly raises doubts,” Dr. Scott says.
But impostors aren’t always screened out. Dr. Zweig, who has five annual openings in her southern California residency, notes that practically every year she inadvertently takes on one resident who isn’t really committed to family medicine.
“It is not uncommon for someone to swear, for example, that even though she applied to obstetrics and gynecology residencies, she was on the borderline and wanted to do family medicine all along,” Dr. Zweig says. “Then while in my program, she will reapply to OB-GYN programs.
“In deciding whom to interview, we give the biggest preference to those who have rotated with us and those we know.”
“Since family medicine is a less competitive specialty, we just accept this to a large extent. Some people will leave our program to do what they’ve always wanted to do.”
Because a fairly large number of family medicine residents leave their residencies after the first year to pursue other specialties, many programs regularly have openings in postgraduate year 2. As a result, it is often possible to match into AOA-approved family medicine residencies from traditional rotating internships and to transfer from one family medicine residency to another.
Life experience counts
When reviewing applications, residency program directors also pay attention to candidates’ work experience, volunteer experience, fluency in a foreign language, and passion for travel and other cultures.
“I look for experience outside of medicine,” Dr. Fischer says. “Applicants who’ve had jobs in customer service or other positions where they’ve interacted with the public tend to have the people skills that are so important in family medicine.”
“One of the main things we look for is life experience,” echoes OhioHealth’s Dr. Weihl. “We’re looking for that person who is well-rounded.”
Many family medicine candidates have volunteered in their communities or served on medical missions abroad. The nature and extent of their humanitarian service can make a difference to some residency programs.
“For our community health center sites, we want to find people who’ve demonstrated the spirit and commitment to work with the underserved,” Dr. Dobrusin says. He also looks favorably on candidates who are fluent in Spanish and who show interest in global health care.
Location, location, location
Some family medicine residencies place considerable weight on candidates’ ties to a region or state.
“We want to know that our applicants have some sort of linkage to the Pacific Northwest,” says Oregon’s Dr. Dreibelbis. “Did they go to school here? Did they grow up here? Do they have family here? If they have some connection, that means they are much more likely to practice medicine in the Pacific Northwest, which is our goal.”
North Jersey’s Dr. Lukenda generally looks less favorably on applicants from the West Coast than the East Coast, preferring candidates who are from or went to school in New Jersey or New York. “I give the most credit to local applicants who want to remain here after residency and make an impact on our community,” he says.
Similarly, Dr. Weihl favors candidates with Ohio roots. “We feel that correlates with whether they want to come to our residency and stay here to practice,” he says.
But not all family medicine residencies prioritize geographic ties.
“We’ve had people in our program from nearly every osteopathic school in the country,” says Dr. Scott, whose South Jersey residency receives more than 100 applications a year for seven positions.
Far-flung applicants are attracted to this residency in part because of RowanSOM’s three AOA-approved fellowships for family physicians: geriatrics, OMM and palliative care. Students who intend to subspecialize often pursue residencies at institutions with the desired fellowship.
Make or break
AOA-approved family medicine residencies typically interview many applicants and weight interview performance very highly.
“Once we bring applicants in for the interview, that’s what really sells us,” says Dr. Scott, whose program interviews 50 candidates each year. A committee of eight to 10 people reviews the applications and participates in the interviews.
Read more about specialties
This is the 20th and final article in a series profiling medical specialties. The others focused on the following:
- Emergency medicine
- General surgery
- Internal medicine
- Occupational and preventive medicine
- Osteopathic manipulative medicine
- Physical medicine and rehabilitation
- Proctology, urology
“Our interview format is kind of like speed dating,” Dr. Scott says. “Each member of our interview team is in a different room. The candidates spend 15 minutes with each interviewer one-on-one.”
At the end of the process, each interviewer’s assessment of a candidate receives equal consideration.
“We look at each person as a whole,” Dr. Scott says. “How did the person present himself or herself during the interview? Is he or she really interested in primary care, family medicine and our program?”
Dr. Hempstead receives approximately 600 applications for 14 positions, about 90 of which target the two AOA-approved spots. Due to its location in Missouri, which has two osteopathic medical schools, two-thirds of Truman’s family medicine residents are DOs. Most osteopathic physicians enter the Kansas City program through the NRMP Match.
Each year, says Dr. Hempstead, Truman interviews 100 candidates, 20 of whom applied for the osteopathic spots. Dr. Hempstead, other residency faculty and residents make up the interview team.
The night before interview day, Truman candidates have dinner with two residents. The next day, each prospective resident interviews with four people in the morning and four people during lunch. The interview team members then fill out an evaluation form for each candidate.
“Those evaluations receive the highest weight in our resident selection process,” Dr. Hempstead says. “At the end, we bring all the interviewers together for a PowerPoint presentation and lively discussion on each candidate.”
Each interviewee’s picture and school information is displayed, and everyone has a chance to voice their views. “Someone may say, ‘I think this candidate is really strong, and I’ll rank him in the top third,’ ” Dr. Hempstead explains. “Regarding a different candidate, another interviewer may say, ‘I worked with her when she was on rotation, and she was awesome.’ The next candidate may be less popular. Someone may say, ‘I worked with him and he was lazy. We shouldn’t rank him.’ ”
“The residents play a really big role in how we rank applicants,” Dr. Hempstead adds. “They are the ones who will be working with the candidates every day.”
Given the spotlight on primary care, this is an excellent time to enter the specialty of family medicine, residency directors agree.
In high demand, family physicians have numerous job opportunities, whether they choose to become employed physicians, start their own practices, enter academia or become medical directors of health care organizations.
Those who practice in medically underserved areas can often take advantage of loan repayment programs offered through hospitals, states and the National Health Service Corps.
To reduce their tuition costs, students who know from the outset that they want to be family physicians can consider three-year accelerated tracks at NYITCOM and the Lake Erie College of Osteopathic Medicine in Erie, Pa. Other schools may have tuition-reduction options and even full scholarships for students who commit to practicing family medicine in underserved rural or inner-city areas.
“Family medicine has always been a wonderful profession,” says NYITCOM’s Dr. Bono. “It’s all about taking care of everyone and knowing what your limits are, knowing when to refer.
“But this is such a great time to enter the field. Because there is a huge need for primary care physicians today, osteopathic family physicians are getting more opportunities and more recognition.”