In November 2007 the department of family and community medicine celebrated the 35th anniversary of its residency program, one of the oldest in the country. As David L. Stewart, MD, MPH, chair of the department, and his colleagues looked back fondly at all their accomplishments over the years, they also shared their plan on how to reverse an alarming trend: for a variety of reasons, the number of medical students choosing family medicine residency training has been steadily declining in recent years.

“We’ve instituted some specific initiatives to help students who arrive at medical school with an interest in family medicine and primary care retain that interest,” explains Stewart, who officially became chair in December 2006 after three years as acting chair. Called the family-care track, this effort recruits first-year students with an interest in primary care. “Those who are accepted are linked with a faculty person in family medicine who becomes their mentor,” says Stewart. “We also have some early clinical contact designed for those students during the first year.”

This early contact is critical to getting and/or keeping medical students committed to practicing family medicine. According to the National Registry Matching Program (NRMP) website, in 2007 the department filled only two of its first-year residency spots via “The Match,” when in years past it had easily filled all eight. One reason why may be how medical school itself operates. “Most medical schools are tertiary clinical operations,” Stewart says. “So you may have someone who’s very interested in primary care or a general discipline who is put through this very intensive experience which is at the opposite end of the spectrum. That person needs a lot of support to maintain and retain his or her interest in a discipline like family medicine.”

One thing that does attract students is the opportunity to get direct clinical experience in the field. Like other departments, family medicine has a four-week clerkship for third year students, but theirs is a bit unique. “With that clerkship we keep about half the students here on campus, and half are put in offices of family practitioners throughout the Baltimore community,” Stewart explains. The department also has an in-patient service, where fourth-year medical students can do sub-internships, as well as electives in family medicine for all levels of students, although the majority who take advantage of those are third- and fourth-year students.

Clinical experience is imperative in a field where the physician often doesn’t know what kind of care might be called for. “Family medicine includes the whole gamut,” says Stewart. “We have a saying—‘from birth to earth.’” In other words, family medicine doctors can provide obstetrical care, pediatric care, adult primary care and geriatric care. “We also do a vast number of procedurally oriented things associated with primary care, including colposcopy, simple things like suturing and dermatological problems—removal of warts and things of that nature,” says Stewart. “There’s this whole gamut of procedural things that family doctors can do that don’t necessarily need referral to a sub-specialist.”

Emphasizing the range of care family medicine can provide is an important message to get across these days. “In our country, people believe that health care is about seeing the kind of doctors you want to see, when you want to see them,” explains Stewart. “Someone may want to see a dermatologist for a rash just because the patient doesn’t know that a primary care doctor might be able to address such issues.”

The External Forces
This increasing demand for specialists—and the higher reimbursements doctors can get for specialty care—explains why many of today’s aspiring doctors aren’t pursuing a general field such as family medicine. “There is so much that goes into who applies to medical school now,” explains Stewart. “It tends to be cyclical, as is the pipeline of who’s interested in science at a young age and who gets into the proper pipeline to eventually be a science major in college and then applies to medical school.”

There is also the issue of lifestyle. “At this medical school, and I believe in medicine in general, things are shifting from this being a very male-dominated career to more and more women entering the field,” says Stewart. “And women have specific ideas around what they want their life to be like, especially if having children is a consideration. What kind of disciplines are more conducive to lifestyle, schedule, that kind of thing, all come into play. How much you earn comes into play, too, especially when the cost of education is going up. There are just so many factors that go into it, and a lot of those factors have been forces that have not pushed people into the primary care discipline. I don’t think anyone has one answer; it becomes a very murky problem when you try to settle it.”

Complicating things even more is government bureaucracy. “I just read where they want to cut all physician reimbursement by a certain percent,” says C. Earl Hill, ’60, who is now retired after teaching for 23 years in the department. “Meanwhile, they’re adding more stringent requirements in terms of reporting. It’s an albatross around everyone’s neck. I wouldn’t want to be in practice these days because these people are really suffering. It’s not attractive to students who are coming out burdened with large educational debts. That’s the sad part. It’s really holding primary care back.”

Hill says change may be on the horizon, though. “There is a project that is being put together with the ‘family’ of family practice, seven organizations that make up the academic and certification board and what have you,” he explains. “They’re looking into the future of family practice and the things that need to be done. This is being done at the Robert Graham Center in Washington, DC, and some really strong ideas are coming out of that group that may get the attention of the government.”
In the meantime, the medical school is luring many potential family medicine providers, not only with its clinical programs but also with its location. “We certainly attract residents who are interested in providing primary care to urban families or who have an interest in the health care problems of urban people,” Stewart says. “We don’t make any special effort to advertise ourselves as an urban residency. Some of it is based on our location here in Baltimore, certainly—we’re in the heart of the city. As a result of that, we’ve acquired faculty who have an interest in urban problems. So their research and academic interests tend to be around the problems of urban minority people—such things as teen pregnancy, hypertension and diabetes.”

Research Focusing on Behavior
A recent change in the name of the department—from the department of family medicine to the department of family and community medicine—reflects its dedication to Baltimore’s urban population. “As family physicians, we believe that a lot of what needs to be done to support health or change behaviors that affect health has to occur in the community setting rather than in an office with the patient,” admits Stewart.

So the research being done within the department focuses less on basic science and more on basic behaviors. “We have Project Bridges, an effort headed by Dr. Elizabeth Barnet,” details Stewart. “Her interest is in teen pregnancy, and the parents of those teens and the needs that have to be met for them to become better mothers and fathers. Her research has been community based, reaching out to people in their communities and helping support them in their role as parents. She examines the issue of the male in those families, as well as the needs of the female. More recently she’s found that there’s a major problem with depression among both men and women in that group. How that affects their ability to parent is one of the things she’s studying. It is very cutting-edge research that sheds a lot of light on how we look at teen pregnancy and what might be some of the things we need to do to address it, especially if the goal is to interrupt recurrent pregnancies.”

Vivienne Rose, ’92, and Verlyn Warrington, ’92, are also tackling the issue of teen parenting. “We found parents needed a lot of support in just learning how to be parents to their kids,” says Stewart. “And kids needed other mentoring relationships within the communities that we serve. So now kids are coming in weekly—they actually use our conference room on Saturday mornings, and they go through things like increasing self esteem and the mentoring process. Some of it’s done through sports; some of it’s done through group activities. They bring their parents in, too; so the parents have interactions about the challenges they face with their children. Again, all of these things are related to improving health, but they’re done at the community level, rather than the individual level.”

The department is also finding partners within local communities to help spread the word about better health. “We have an extensive ongoing program with hypertension and cardiovascular disease in West Baltimore, working with the state and the CHAMP (Community Health Awareness and Monitoring Program) organization,” Stewart explains. “It revolves around early detection of hypertension and changing the lifestyle behaviors of individuals who live in those communities to address hypertension, cardiovascular disease and diabetes. A lot of that work is done through churches, but it’s not limited to churches; some of it is also done through community organizations in the neighborhoods. I think all of that helps us live up to our name.”

As the department grows its reputation, its patient base also continues to grow. “We had been averaging around 100 or so new patients a month, without us doing a bunch of advertising. Then last month it jumped to 200 people,” reveals Stewart. “We have around 40,000 visits a year. So it’s a very busy, very vibrant practice, to say the least.”

As for the makeup of these patients, “they’re people from all over,” Stewart says. “People on campus are coming in. (The family medicine clinic is the student health site for the campus and the employee health site for the medical school and a number of other related entities.) Changes are going on with housing downtown, and those people are trying to access us. I was just supervising one of the residents, and a new patient came in with a cycling injury, and he said he wanted to come here because he thought it was a good place to get quality care. People are just looking for good doctors. And we have those.”

In order to keep turning those out, however, help is needed. “We’re aggressively working on developing philanthropic support for primary care,” Stewart admits. “If people come in to get a kidney transplant, it’s very easy for them to decide, ‘Oh, I’d like to give the transplant program a gift.’ Primary care is a bit different, but we believe that developing that kind of philanthropic support for what we do is important. And we’ve had some success.”

This success has come from showing people that family medicine is more than just seeing patients. “The type of education we provide is needed no matter what discipline you go into,” says Stewart. “Some of what we do as far as educating medical students—teaching about interacting with other physicians and interacting with the public, about professionalism—are things we can do very well because we’re generalists. I think people are appreciating now that this is unique and should be supported. It’s a real challenge for us, but something we will be improving over the coming years.”

Looking Back at Family Medicine's History