The importance of mentors in family medicine

Saying that my medical alma mater, NYU School of Medicine, isn't known as a school that produces family physicians is a gross understatement. Actually, it routinely ranks last in the nation in the number of students matching to Family Medicine residency programs. My class of 2001, which sent 4 students to such programs, was a one-time aberration.

So how did I get started in family medicine? I give a great deal of credit to the Reading Hospital and Medical Center, which allowed me to do an elective rotation in their residency program from June through July 2000. But what inspired me to look into family medicine rotations in the first place? I recently came across a 13-year old letter I wrote to my cousin's husband (then a family medicine resident training in Minnesota) that gives part of the answer, and speaks to the vital importance of finding mentors for medical students who are interested in primary care careers.

**

November 15, 1998

Dear Daniel,

I hope that life in Minnesota has been treating you well! So far I have been enjoying the second year of medical school at NYU. The classes have been much more interesting than last year’s, and while I still have a long way to go, I’m slowly beginning to believe that I might someday know enough to take care of patients.

Last month we had a speaker come to talk about rotations and residencies in Family Medicine, and that made me wonder how you were doing. Is this the first or second year of residency? How do you like it? How many years are left to go? Where (geographically and what kind of community) do you plan on practicing after it’s over?

Since I haven’t even started my clerkships, I don’t really know which field interests me most, but since NYU doesn’t have a Department of Family Medicine, I thought it might be a good idea to gather information from outside sources that I know I can trust. I’ve spent several summers working with children, so the natural choice would seem to be pediatrics, but I would love to hear your perspectives on taking care of families while raising one of your own.

Have a wonderful holiday season, and best wishes to you and the kids.

**

Thank you, Dan.

Malpractice reform: unfinished business

In this week's Journal of the American Medical Association, cardiologist Peter Kowey, MD describes a case in which a young athlete sees him for a second opinion after a single episode of presyncope. Despite extensive cardiovascular testing that found no evidence to suggest that this young man had an increased risk of sudden cardiac death, another cardiologist had nonetheless recommended the implantation of a defibrillator. Why the overly aggressive recommendation? Dr. Kowey discovers that his colleague, who had endured a lawsuit about a patient with similar circumstances, was practicing "defensive medicine." He goes on to observe:

Defensive medicine is pervasive and takes many forms. It extends from ordering too many tests all the way to performing unnecessary surgical procedures. Lung nodules that used to be followed end up in a specimen jar in the pathology laboratory. Subcritical coronary artery lesions are dilated and stented. And the contamination is not just at the individual physician level. Practice guidelines are formulated by colleagues who hear the wolf at the door. In the absence of definitive data, wouldn't it be logical that recommendations about the frequency of prostate biopsy in patients with abnormal PSAs would be on the more frequent side for safety's sake? And once those guidelines are published, physicians who ignore them do so at their peril.

Indeed, malpractice reform is the "unfinished business" of the 2010 health reform legislation, which included few serious initiatives to address what physicians universally regard as a huge problem. Recent estimates that defensive medicine accounts for only a small fraction of excess health care costs are limited by the design of the studies, which typically compare costs in areas of the U.S. with malpractice award "caps" to those with no caps - thus ignoring the baseline ordering of unnecessary tests or procedures by physicians who are motivated to avoid being sued regardless of limits on individual awards.

Here's what I wrote in a post about this issue in September of 2009:

Tort reform is a good idea, whether it saves money or not. It is ridiculous that the only way that a patient (or grieving family member) can obtain money to provide for someone crippled by a bad health outcome is to sue the doctor, whether or not the doctor was "at fault" or not. As a result, the vast majority (greater than 90 percent) of patients who probably deserve compensation for medical errors never see a dime, and those who do receive compensation after years of litigation end up giving much of what they win to their lawyers.

Health reform would benefit greatly from including tort reforms modeled on existing no-fault compensation programs, such as the National Vaccine Injury Compensation Program or the Virginia Birth-Related Neurological Injury Compensation Program.

It's still absolutely true.

The Common Sense Family Doctor speaks

Since I began blogging at Common Sense Family Doctor in July 2009, its posts have been featured in widely read blogs such as KevinMD.com and Gary Schwitzer's HealthNewsReview, as well as the websites of major national newspapers such as the New York Times, the Wall Street Journal, and the Boston Globe. I have also written the consumer health blog Healthcare Headaches for U.S. News and World Report since August 2010.

Like the vast majority of physicians who blog, I write in my spare time. I have never accepted advertising or paid web links on Common Sense Family Doctor, and the choices of topics for posts are my own and not influenced by financial or other conflicts of interest. In order to support the time I devote to blogging, and to encourage high-quality medical writing and clinical practice, I give lectures and workshops to medical and non-medical audiences on a variety of topics. These include the uses of social media tools in medicine and education, developing and implementing medical guidelines, and the evidence supporting specific prevention recommendations. If you or your organization would like to invite me to speak about any of these topics, please e-mail me at linkenny@hotmail.com or KWL4@georgetown.edu.

Upcoming events:

Overdiagnosed and Over-Prevented: Making People Sick in the Pursuit of Health
- William J. Bicknell Lecture (panelist)
- Boston University School of Public Health
October 28, 2011

Past events:

Don't Do It! Preventive Health Services That Harm More Than They Help
- District of Columbia Academy of Family Physicians

Using the Medical Literature to Make Decisions About Preventive Health Services
- Medical Librarians Association

Medical Blogging and Other Professional Uses of Social Media
- Virginia Commonwealth University Medical Center

Spilling Ink: An Expert's Guide to Getting Your Work Published
- Society of Teachers of Family Medicine

Health Promotion and Disease Prevention in Clinical and Community Settings
- Uniformed Services University of the Health Sciences

The Value of Preventive Health Services
- Employees of MetLife

COPD Update: A Prevention Perspective
- Maryland Academy of Family Physicians