EDITOR’S NOTE: Dr. Jones is off this week; fortunately, we have this guest post by Tim Kreider, our science-based medical student. Enjoy!

My first clerkship of my third year of medical school was Family Medicine, and I had a great experience. After the first two years spent mostly with books and then a three-year interlude in a basic science lab, these past five weeks were my first extended foray into the world of patient care. I had a few lectures and seminars on campus, but most days were spent in a primary care office learning on the job. I was assigned to an office attached to a community hospital with a Family Medicine residency program, so I was able to work with both attending physicians and residents in training. I learned a lot and gained some much needed confidence regarding my clinical exam skills, which were rather rusty after grad school.

I have heard as a criticism of the SBM mission that practicing medicine “in the real world” is different from what evidence-obsessed, ivory tower dwellers think it should be. Therefore I approached my Family Medicine clerkship as my first chance to see the challenges and realities of practice outside the university setting. How would the practice of community-based physicians compare to the perhaps lofty ideals espoused by academics?

The faculty on my university campus taught us about the concept of the Patient Centered Medical Home, which is an ambitious model for how a primary care physician can coordinate care for all a patient’s acute, chronic, and preventative needs. At the office, the family docs used medical records software that interfaced with their hospital and emergency department, and every one of them had point-of-care EBM software (e.g.) on a PDA or smart phone. They worked closely with physical therapists, a smoking cessation center, and a diabetes education center; I spent an afternoon with the latter, working with a nurse and a dietitian to help patients understand their disease and create realistic, individualized plans for lifestyle changes. The family physicians actively managed their patients who were admitted to the hospital, in consultation with specialists. They even made home visits for long-time patients too disabled to come to the office! These docs were doing a great job caring for a patient population with, in general, more needs than resources.

I also was curious to read a family medicine textbook—I chose Essentials of Family Medicine by Sloane—and see if its tone reflected practice at my office. There are three types of chapter in Sloane: on an aspect of health maintenance and primary prevention (e.g., well-child visits, post-menopausal health), on a major disease (diabetes, asthma), or on a common complaint and its differential diagnosis (fatigue, dyspepsia). Recommendations are graded by Strength of Recommendation Taxonomy, diagnostics are assigned likelihood ratios, and interventions are given values for “number needed to treat.” These EBM-related topics were stressed not only in my campus lectures but also at the community practice. I had some terrific discussions with my preceptor about critically evaluating evidence and understanding such statistics; it turns out she loves to challenge drug reps by asking for the NNT when they give relative risk reduction (the latter often being more dramatic).

I noted in the editorial description of the 2007 edition of Sloane that the text “includes chapters on evidence-based medicine and complementary therapies.” SBM readers will be interested to know that in fact the text has a chapter devoted to EBM but none for CAM. Rather, the end of some disease/symptom chapters includes a brief subsection on “alternative and complementary therapies” that mostly discusses evidence for particular herbs, occasionally mentioning acupuncture or chiropractic where it is popular. Every herbal or other CAM therapy mentioned is graded by SORT just like other interventions, and often the discussion is brief because the evidence is judged negative or of limited quality. (Incidentally, lifestyle factors and interventions are presented each chapter in a seperate subsection, which is generally listed early in the chapter and sometimes is quite detailed.) I found a similar attitude regarding CAM at the family practice: little of the polarized attitudes that characterize online debate, but rather a pragmatic recognition that some patients like to take herbal supplements or see a chiropractor. Our patient population at this office was largely low-income and non-white, so the closest to CAM I usually saw was an immigrant family with cultural beliefs from home.

As always, my observations are limited by the paucity of my experiences this early in my career. One of my classmates followed a sports medicine specialist who integrates standard therapies with chiropractic practices, including cervical manipulation… I’m glad I was taught (and graded by) a skeptical physician this clerkship. More of our discussions involved being appropriately skeptical of drug rep claims than of alt med, but that’s understandable given that we had a lot of patients who needed statins and ACE-inhibitors.

Indeed, the biggest hurdles to appropriate care in this setting seemed to be financial. Every day I saw patients prescribed drugs that were not the physician’s first choice because the patient was restricted to the Walmart $4 formulary. I don’t wish to start a political fight here over reform, but I’m quite puzzled by the rhetoric lately warning of government rationing as if rationing were not already with us. Whether done in private by HMOs, systemically by socioeconomic inequities, or publicly by “death panels” and CER councils, rationing of some kind surely must be done since resources are finite. I doubt that single payer would be either hell or panacea, but I wish the reform debate would focus on substance and values rather than on demonizing opponents.

My overall impression of Family Medicine is that it is a noble calling with admirable practitioners facing daunting systemic challenges. The reimbursement structure creates unavoidable financial pressures that limit physicians’ ability to spend time with patients. Effective use of team-based approaches, such as educational centers staffed by mid-level providers, is one way that dedicated family physicians are trying to provide effective care for patients with chronic and preventative needs. Keeping up-to-date with evidence-based guidelines is a challenge, but many convenient resources exist to help the busy clinician with this vital task. Although I do not expect to become a family physician myself, I am grateful to have spent time with some terrific docs in this setting who taught me about the joys and challenges of primary care.



Posted by Tim Kreider

a med student blogging about integrative medicine on campus