June 24, 1999
In the past, Tulane trained its medical students to hear zebras. Rick Streiffer wants them to hear the horses, too. Streiffer, professor and chair of Tulane's new Department of Family and Community Medicine, says teaching medical students in the university hospital, usually occupied by the sickest patients or those with the rarest illnesses, prepares them to expect the unusual.
"In other words, if you hear hoof beats, you are trained in the specialized world of academic medical centers to think they are caused by zebras, which are rare," he says. "Most of the time, however, out in the community, hoof beats are caused by horses."
Thirty students got to see a stampede of horses over the last school year as they volunteered to spend one month in the office of a family medicine physician in the Gulf South region. This pilot program added a family medicine clerkship to the established third-year "rotations" in general internal medicine, surgery, pediatrics, psychiatry and neurology, and obstetrics and gynecology.
Over the next two years, the school will phase in the clerkship to become a two-month requirement for all third-year students. The goals of the program are not only to graduate more students who choose to go into family medicine, but also to give those students who go into medical specialties an appreciation of the primary-care generalist.
"Even if our students become neurosurgeons or another type of very subspecialized physicians, this will expose them to where their patients come from, to the community perspective," Streiffer says.
Rich Levine can tell you from experience that family medicine is, to use the definition of the American Academy of Family Physicians (AAFP), the medical "specialty of breadth." During his stay in the clinic of Ponchatoula, La., family practitioner Mark Tilyou, Levine saw patients with diabetes, hypertension and heart problems. He witnessed acute asthma attacks and saw kids with colds and sundry viruses. He got to suture cuts, perform skin biopsies and remove warts.
He watched as Tilyou performed diagnostic procedures to detect colon and cervical conditions. He woke up at dawn for hospital rounds and collapsed into bed after a full day in the clinic. In short, Levine experienced life as a family physician. "It was exciting," Levine says. "It was what I came to medical school to do." Family medicine is actually a fairly new term used to describe an old discipline.
Before there were cardiologists and gastroenterologists, general practitioners delivered babies, treated colds, set broken arms and served as the family's expert on health and medical matters. Typified by television's kindly Marcus Welby, the general practitioner gradually has given way to medical specialists over the past few decades.
"After World War II, there became fewer and fewer doctors who looked after whole people," Streiffer says. "You had the expert on the heart and the expert on the skin, but who knew anything about the whole person?" The whole person--head to toe, from infancy through the last years of life--figures into the AAFP's definition of family practice.
The organization defines family practice as the medical specialty that provides continuing health care for the individual and family, integrating the biological, clinical and behavioral sciences. Its scope encompasses all ages, both genders, each organ system and every disease. The American Medical Association recognized family medicine as an official specialty in 1969. Streiffer likens the family practitioner to a general contractor in construction.
"Can you imagine building a house without having a general contractor? The electrical system wouldn't coordinate with the plumbing. "Sometimes you need specialty contractors to come in, but you still need a general contractor to take care of the project, manage most aspects of the job directly, and make sure it's organized."
With the growth of managed health care in the 1980s and '90s, health maintenance organizations helped bring back the primary-care generalist as a physician who knows and understands the patient and who can coordinate care effectively, perhaps avoiding unnecessary tests and trips to specialists.
Currently, 54,183 board-certified family physicians practice across the country, nearly 600 of them in Louisiana. Medical schools scrambled to set up family medicine departments starting in the 1970s and early '80s, Streiffer says, with public schools leading the way in response to pressures from state legislators. Private, research-oriented schools such as Tulane--which were accustomed to graduating specialists--followed shortly with their own programs.
In July 1998, Tulane University Medical Center formed its Department of Family and Community Medicine, building on groundwork laid by the decades' old Program in Community Medicine led by J.T. Hamrick, now professor and vice chair of the department. Streiffer, who received his bachelor's in mathematics from Tulane in 1973 and a medical degree from Louisiana State University in 1977, made expanding the community-medicine elective into a full-fledged family medicine clerkship one of his first projects.
Clinical clerkships are a turning point in medical school. After the first two years--spent primarily in the classroom, in the gross anatomy lab or behind the pages of a thick textbook--medical students begin the third and fourth "clinical years." During this time, they encounter actual patients together with other medical students under the tutelage of an "attending" physician and perhaps a resident who is performing advanced training in a specialty.
At Tulane, students perform the majority of their clerkships in the university's own hospital and outpatient clinics and other hospitals and clinics in New Orleans. At the start of the third year, students are eager to see, talk to and assess real patients. Although they've practiced clinical procedures with Tulane staff members who act as patients in the school's standardized patient program, interacting with an actual patient brings the medical students one step closer to becoming doctors.
"At the beginning of the third year, you're very excited to see patients by yourself," says clerkship pilot participant Rich Levine, who enters his fourth year of medical school this fall. Levine says one of the reasons he volunteered for the clerkship was to have closer relationships with patients and his physician-teacher, who program organizers call a preceptor.
"I really wanted to do a one-on-one with a doctor," he says. "I was looking for more of a mentorship than being one of a bunch of students and residents with an attending."
His mentor came in the form of family practitioner Mark Tilyou, an 18-year veteran of a bustling practice of six doctors in the small town of Ponchatoula, about an hour-and-a-half's drive from New Orleans. During the first few days of his month in Ponchatoula, Levine observed Tilyou as he talked to patients and assessed their problems. Eventually he began to see patients by himself, reporting to Tilyou his diagnosis and thoughts on treatment.
Doctor and student then saw the patient together, with the final diagnosis and treatment plan falling to the more experienced clinician. Getting to the heart of a patient's problem was a challenge for Levine in the beginning. "When you talk to a patient, you're definitely slow at first," he says. "You don't know all the questions to ask and you ask more questions than you need to. I definitely saw an improvement in the month on how I could become more focused."
Levine, who had completed a three-month clerkship in surgery prior to his family medicine clerkship, says the experience underscored for him the importance of the community physician's personal relationship with his or her patients. "Dr. Tilyou had these patients for so long that he could just walk into a room and automatically know if they're looking well or not," he says. With so much of modern medicine seeming high-tech and impersonal, Levine says he witnessed a side of medical care that stressed attentive and caring interactions.
"Out of 15 minutes with a patient, maybe five minutes would be on their health problems and the other 10 minutes would be about fishing or what crop they just grew, things totally unrelated to medicine," he says. "He knew about their whole lives and enjoyed talking like this. It was definitely a different feel from the hospital in the big city."
Streiffer calls this type of practice "medicine in the context of community." "Family medicine is about learning the context, the community, the family, the values," he says. The context also relates to the actual experience of illness in a given community, where the overwhelming need is for general, rather than specialized, care.
Streiffer likes to illustrate the importance of general, community-based education with a classic 1961 study called "The Ecology of Medical Care." The study's authors found that in a population of 1,000 adults, about three-quarters will report some sort of injury or illness and about 250 people will see a physician. Of this group, nine will be admitted to a hospital and only one will end up at an academic medical center.
"The diseases that you see in a university hospital like Tulane do not resemble what you see in a community," he says. While the hospital setting remains an essential part of medical students' training, getting them into the community where the majority of medical care occurs is just as important, Streiffer says. In fact, the government's Council on Graduate Medical Education issued a report in March recommending that students receive clinical training in community settings as well as in traditional teaching hospitals.
"As the quintessential generalists, our role is the general medical education of students," he says. "You cannot provide optimal generalist education in the traditional medical school setting."
Far from the typical medical school setting is a clinic in a tiny southwestern Mississippi hamlet. On the border of the Homochitto National Forest, the area boasts a population of about 1,300, the majority of whom are African American. The region is fairly rural and fairly poor. Forestry is the main industry.
Last spring, Tulane student Elaine Roe clerked in this rural area, where she witnessed everything from prenatal to geriatric care, emergency-room duty to regular medical check-ups. She even had the opportunity to see patients at a local prison. Community doctors in settings like this are the cornerstone of the clerkship, says Hope Ewing, associate professor and director of predoctoral education in the family and community medicine department.
Ewing and Winkie King, senior program coordinator, scour the Gulf South region for family practitioners willing to take in students. "We look for board-certified family physicians who are good role models and interested in teaching," Ewing says. A commitment to teaching is paramount, she adds, for the doctors receive no compensation for their participation. "Their services are donated to the university," Ewing says. "It's a big contribution."
In return, Tulane trains the doctors in office-based teaching and offers them continuing medical-education credits, which often are required for licensure in hospitals and certification by medical organizations. Currently, almost 100 physicians are signed up as teachers in the program. Their locations range from the Gulf Shores of Mississippi to the piney woods of Alexandria, La.
Finding the right doctors, matching them with students and locating housing in the community is a logistical challenge, Ewing says. "It's a serious and thoughtful process. We try to use our intuition as well as our brains." Matching students and doctors with common interests helps foster the relationship.
"Some students, for some reason, like to go to doctors who are also coroners, which is common in these little towns." Ewing says. "Others are interested in sports and want to work with doctors who serve as physicians for their high schools' sports teams." While a few physicians put the students up in their own homes, finding housing for students during their clerkship remains a formidable task, Ewing says.
"Many of the students stay in hospital rooms," she says. "At one site, they stay in an old dentist's office." Ewing's dream? To find Tulane alumni in each community who have an extra room to spare for a hard-working medical student in training.
During her month in rural Mississippi, student Elaine Roe stayed in a patient room in Field Memorial Hospital in nearby Centreville, Miss., founded by surgeon Richard Field (A&S '47, M '49). "Living in a hospital was certainly interesting, but I was so busy that I didn't even have time to really think about it," Roe says. To start her day, Roe only had to walk out the door of her room and onto hospital rounds with her preceptor, who usually had patients in the small, 35-bed facility.
They then drove the 15 miles to Gloster and saw patients all day, ranging from children to the elderly and including expecting mothers. Roe worked in one of the few family practices that included obstetrics. One of Roe's goals for the month was to improve her ability to perform medical procedures such as drawing blood, giving shots and taking blood-pressure readings. The greatest accomplishment, however, was triumphing over her personal demon, the ophthalmoscope.
The instrument, which focuses a narrow beam of light on the interior structures of the eye, allows clinicians to examine a patient's eyesight. Using it properly takes practice, something Roe had little of in her previous medical training. "We got very little training in using the ophthalmoscope in the second year and it's not something you use a lot in the hospital," she says. "I did eye exams on many of the patients and by the end of the month I felt comfortable doing them."
Roe saw a unique part of medical care while accompanying her preceptor during his weekly clinics in a state prison in Woodville, Miss. Three times a week for five hours, she saw about 40 inmates who requested medical attention. "We got to see a lot of interesting things," Roe says. "Some of the guys had pneumonia or interesting rashes or had been in a fight and needed to see a surgeon."
The experience drove home the importance of asking the right questions and quickly zeroing in on the problem, she says. Roe learned the benefits of a focused exam, "because there were so many patients," she says. "Also, some of the guys were there just to get out of their cells for awhile so we had to see who had problems and who didn't."
Family physician Mark Tilyou also wants his students to see where primary care fits into the health-care structure, particularly if they plan to become specialists. "We're on the front line. We see people coming in with everything," Tilyou says. "I like the students to see what it's like to make a referral to a specialist and get a good letter back and be part of a team. A lot of times you'll send patients to a specialist and you'll never hear a word. That's not good for patient care."
Witnessing the continuity of care in the clinics was new to many of the students in the program. Student Susan Farrar, who clerked in the office of Marrero, La., physician Jim Theis, had the opportunity to see the results of a prescribed treatment and even developed relationships with patients. "It was nice working in his office for a month," Farrar says.
"I saw a lot of patients come back again. I could follow up with them and I even got to know some of them." Levine agrees. "When you do your rotations at Tulane and Charity [New Orleans Medical Center], you give them a diagnosis and a treatment and then you're gone by the time they follow up in three weeks," he says. "At Dr. Tilyou's, I got to see the patients again and see if the treatment did work or didn't work."
Another benefit of patient continuity is the opportunity to provide meaningful education to patients on a long-term basis. As Streiffer points out: "So much of what we do is lifestyle education and education about medications. It's part of our values." It's no wonder that educational materials topped the list of the research projects required of students after their one-month clerkship. Students devised materials to help patients manage diabetes, lose weight and manage high blood pressure.
Other research projects included a survey of the prevalence of depression in one primary-care practice, a study of a doctor and his relationship with three nursing home patients, and an analysis of setting up a solo family practice. The clerkship also requires the students to spend a day in the business office of the family practice.
Here, they see how the physicians and their staffs work with insurance and managed-care companies, learn about medical coding and billing, and observe the particulars of running an office--practical stuff rarely covered in the typical medical school curriculum. In the community with their mentors, students experience more than just the doctor's clinic. They see all aspects of life as a family doctor.
"The students also get to see some of the personal aspects of being a doctor: managing their time, balancing family life with work, the professional stresses of running the business and other things that doctors do besides see patients," Streiffer says.
Daniel Jens (M '78) is one of only a handful of family doctors involved in the clerkship who graduated from Tulane. At his practice in Mandeville, La., Jens has served as an adviser to Tulane students who formed a Family Medicine Interest Group a few years ago. Jens says he was thrilled that Tulane formed the new family and community medicine department and looks forward to serving as a mentor to students interested in the field.
"There were no role models in family medicine when I went to Tulane," Jens says. "I hope to motivate people to go into family medicine or at least provide students with a good experience in the setting where 90 percent of medical care takes place."
Streiffer stresses that the primary goal of the clerkship is to expose Tulane students to family medicine no matter what type of medicine they choose to practice. If his past experience as the director of a similar clerkship at Louisiana State University is any measure, however, the introduction to the field should increase the number of students who become family practitioners.
Three years after he started the LSU clerkship in 1990, the percentage of students entering family medicine residencies jumped from 3.1 percent to 17.6 percent, and has remained fairly steady ever since. The percentage of Tulane students entering family medicine clerkships has averaged about 7 percent over the past five years. While the clerkship confirmed Levine's and Roe's interest in family medicine as a career, Farrar says the experience led her to choose obstetrics and gynecology as a specialty focus.
"Personally, I find family medicine is very overwhelming because you have to know a lot about a very big field," Farrar says. "I don't necessarily feel that comfortable pursuing it, although I think family practice is a great field and I think students definitely need exposure to it in the third year." Students who choose family medicine as a specialty can anticipate a healthy job market, Streiffer says. "Family physicians are being sought after everywhere, particularly in rural areas and in the inner city, but also across the country in any community."
After her clerkship in rural, small-town Mississippi, Elaine Roe says she's more convinced than ever that family medicine is the choice for her. "I like that you get to see all types of medical problems," Roe says. "My preceptor was really good about managing a huge amount of material and he managed to do that in a rural area without a great library down the street. If he can do it, then, hopefully, I can do it."
Judith Zwolak is managing editor of Tulane's faculty-staff newspaper, Inside Tulane, and a frequent contributor to Tulanian.
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