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All in the Family: A Profile of Family Medicine

Central to the skillset of every physician is the differential diagnosis; this is the process by which new patients are evaluated to establish the most likely diagnosis. Similarly, the first clinical year of medical school is like a differential for each student, except instead of a medical diagnosis, students are seeking to determine which specialty they will choose. This column explores this differential: experiences from each rotation by a current third-year student.
My first day on Family Medicine might be the best depiction of the specialty: my clinical preceptor and I moved between our three clinic rooms, barely able to keep up with the 20+ patients that had appointments. We saw a patient following up on depression with new-onset low back pain; a middle-aged woman with a classic urinary tract infection; a husband and wife geriatric wellness visit; an adult woman with diabetes; a 9-year-old with strep throat; and a few cases of sinus infection to round out the day. By the end, I was exhausted and wondered how I would ever learn everything that my preceptor knew about such a wide variety of disease processes and patients. By the end of the rotation, I was still nowhere near his level or my other professors’ – years of residency and clinical experience still separate us – but had at least developed a sense of how to manage many of the common illnesses, and feel that I have a good understand of the breadth and variety of family medicine.
It is common for those not in medicine to ask medical students if they will specialize, rather than in what they will specialize. This language is left over from an era when not all medical doctors chose a specialty but remained generalists or general practitioners – that is, maintained general skills in all aspects of medicine. Historically, these doctors completed 4 years of medical and then an intern year and were then free to practice general medicine, either as a hospitalist or in a clinic setting. With the exception of some military positions (e.g. flight surgeons), this system is no longer in practice; instead, every student chooses a specialty, but the closest thing to a generalist remains a family physician. (Note: in other parts of the world, general practitioner or “GP” remains the official title.)
As a specialty, family medicine is unique in that it focuses on care of the whole person for their whole life, from “cradle to grave” or “womb to tomb.” Family doctors receive training in all areas of medicine, which gives them the ability to manage many different medical problems. Along with pediatrics and internal medicine, FM is considered a “primary care” specialty. This means that family doctors tend to be the first point of contact for patients with medical questions or health concerns. It also means they play a major role in education and prevention; many argue that this is the most important function of the family physician. Because of this, family doctors must be knowledgeable in preventive medicine, and knowledge of public health is also helpful.
As noted, variety is the rule for family doctors, which makes it a compelling choice for students who are struggling to choose a specialty. Many family doctors, when discussing their specialty choice, report that they loved all of their clerkships during medical school, and family medicine allowed them to “not give anything up.” There is a sense of not knowing what will come through the door, and being able to work on a wide range of problems with a wide range of patients is challenging and rewarding. From one room to the next, the family doctor might have to function as a psychiatrist, an infectious disease specialist, and a gynecologist. Family doctors can do more than this, as well, especially when functioning in a more rural setting – they can assist in surgery, deliver babies, take call in the emergency room, work as a hospitalist, and offer palliative care.
The broad nature of the specialty does not necessarily mean a shallow knowledge of everything; it often means that family doctors must be able to recognize and solve a variety of mysteries. This may mean referral to a specialist, but depending on their level of comfort, family doctors can provide much of the care themselves. Either way, they have an important role in recognizing which patients may be at risk, which need more intervention, testing, workup, and which ones need better education about disease processes, medications, or simply the importance of general health. Because of their role as primary care doctors, family doctors also tend to manage chronic diseases – common ones include hypertension, high cholesterol, diabetes, and osteoarthritis.
Family medicine has the most residency spots available, which makes it a generally less competitive specialty. It is a three-year residency program, and most graduates plan to pursue a career in outpatient primary care. However, there are several fellowship options available: these include Addiction Medicine, Adolescent Medicine, Geriatrics, Hospice & Palliative Care, Preventive Medicine, Sports Medicine, and Urgent Care. There are also combined programs that can give family doctors more flexible career opportunities; these include FM/Psychiatry, FM/Internal Medicine, and FM/Preventive Medicine.
From a medical student standpoint, this clerkship was an excellent experience for many reasons. As my course director said during orientation, “This is what you came to medical school to do – to learn how to be a good doctor.” This was a major component of the clerkship – hands-on experience talking to patients, taking a thorough history, formulating a differential diagnosis, deciding on lab tests or imaging, explaining your reasoning and findings to the patient, and creating a treatment plan. The differential diagnosis was, of course, central to this: figuring out what was causing the patient’s symptoms, with a high suspicion for both common and serious causes that needed ruling out. In this sense, the clerkship was also excellent practice for the USMLE Step 2 CS – the clinical skills portion which requires medical students to do exactly that for 12 patients. Though it will still be a few months before I take that exam, I feel sharpened on my abilities in all of those aspects. Further, I valued the opportunity to work with a volunteer faculty member, who sees patients in a smaller community and has developed long-standing relationships with many of his patients. It was rewarding to see this side of medicine, which has not always been present in medical education. I am grateful for all the skills I’ve learned here, and look forward to applying them to the rest of this year – and the rest of my career.
Brent Schnipke is a third year medical student at Wright State University Boonshoft School of Medicine in Beavercreek, OH. He is a graduate of Mount Vernon Nazarene University with a degree in Biology. His interests include medical education, writing, medical humanities, and bioethics. Brent is also active on social media and can be reached on Twitter @brentschnipke.