Nebraska,28 Marshall University,29 and the University of Tennessee–Memphis 30 have summarized their experiences with the accelerated residency program and rural training tracks have done the same. These programs have recognized the need to train our future teachers and role models broadly, combating the “learned helplessness” that too often characterizes our training environments when we leave this teaching to subspecialists.
Meeting the needs of a rural practice
Some physicians with a more limited scope of practice appear threatened by proceduralists. While there is room for everyone in the big tent of family medicine, if our specialty is to survive and be credible, we must seek to meet the needs of our patients and our students. In most urban areas, family medicine has abandoned large parts of our patients’ care to the specialties of emergency medicine and obstetrics/gynecology.
From the rural perspective, it is impractical or fiscally impossible to recruit and maintain platoons of obstetricians and board-certified emergency medicine specialists to counties not located near a metropolitan area.31,32 Family physicians, if properly trained, are the ideal physicians for nonmetropolitan practice.
Moreover, the current practice management curriculum in most family practice residencies is a do-it-yourself suicide kit where few physicians understand accountability measures for billing, collections, equipment, and human resources. They may have memorized the entire amino acid sequence for the human genome, but they don’t have the time to understand billing for Medicaid or the impact of providing a full range of services to their patients. What’s wrong with this picture?
FPs must adapt to serve their patients
The net result of the production of our graduates lacking technical skills is an overstocked urban job pool and a shortage of rural physicians. There are few 9-to-5 family practice jobs available in urban areas like Nashville and Memphis for limited generalists. On the other hand, there are jobs for every family physician willing to work after 5 P.M. This includes continuing care, urgent care, and middle-of-the-night hospital care. Procedural skills and hospital service predictably require “extra effort” and extra risk. Reimbursement policies continue to favor those physicians who assume these risks and provide these services.33.34
Another result of following the path of least resistance (as reflected in nonprocedural family medicine is the decreasing student interest in family medicine.35
Responsibility also rests with unskilled faculty who will not perform a broader scope of practice within the medical specialty of family medicine. There is personal risk for “being there” at the critical moment of procedural decisions. Students do not automatically shun this risk, but family medicine may be self-selecting for those who do.
Family physicians practicing in diverse geographic, social, and political environments will naturally adopt various diagnostic and therapeutic modalities in the service of their patients. It is not up to us to judge the appropriateness of those modalities except by the ultimate yardstick of the quality of the end result.
We are not advocating the addition of laparoscopic cholecystectomy to the “required” family medicine curriculum. However, we support the right of John Haynes to practice this skill and to teach it to others to the benefit of patients. The specialty that cannot provide training and credentials for its own members has been reproductively sterilized.36,37 This is a unique market niche ideally suited for family medicine.38,39
Procedurally trained family physicians represent the cutting edge of an emerging paradigm of care that includes ambulatory surgery, maternity care, cesarean section, and laparoscopy, particularly for patients in smaller communities and developing nations. We salute John Haynes and his co-authors for taking “the road less traveled.”
Corresponding author
Wm. MacMillan Rodney, MD, 6575 Black Thorne Cove, Memphis, TN 38119. E-mail: Wmrodney@aol.com.