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Putting family first

Members of Geisel's Class of 2014 are helping fill the primary care gap by pursuing residencies in family medicine.

By Lori Ferguson

When Aaron Reinke started medical school, he was sure he'd pursue a career in emergency medicine. He had always wanted to work with underserved populations in an international setting, and he found the inherent chaos and variety of the ER both exciting and stimulating. But Reinke's experiences over the past five years, including a clinical elective in Papua New Guinea, gave him a new perspective. "I realized that all of the physicians doing the kind of work I hoped to do were family medicine docs, and it became clear to me that this specialty offered the best training I could get to pursue my goals," he says. "My time at Dartmouth allowed me to gain an appreciation of what a family medicine practice can be, and in the end, my decision to enter this specialty came down to who I wanted to be as a person. I realized that the people in family medicine were the kind of people I aspired to be, as a physician and as a person."

Lori Ferguson is a freelance writer in New Hampshire.

Reinke is one of seven members of the Class of 2014 at the Geisel School of Medicine who elected to enter family medicine residency training programs. Their backgrounds and experiences are incredibly diverse, but their driving passions are remarkably similar: they are all deeply committed to filling society's fundamental need for primary care, and they are passionate about doing so by building strong, long-term relationships with the patients they serve.

Addressing a crisis
Primary care is often referred to as frontline medicine—the first point of contact for those seeking medical care. But these days, the specialty is front and center for another reason as well. In 2012, the Annals of Family Medicine published research indicating that by 2025 the country will likely need almost 52,000 additional primary care physicians to meet burgeoning health-care utilization requirements, a demand heightened by the passage of the Patient Protection and Affordable Care Act (ACA). And while opinions on the cause of the shortage range from issues of physician distribution to deficiencies in training, reimbursement, and retention, everyone agrees on one point: Primary care physicians—particularly those in family medicine—play an integral role in our health-care system.

I've seen what a difference a trusting doctor-patient relationship can make in a patient's outcome.

Perhaps no one at the medical school is prouder of the group of recent graduates than Cathleen Morrow, vice chair and an associate professor of community and family medicine at Geisel and a veteran family physician. Over the past four years, she has been intimately involved with these students' development as doctors, advising and encouraging them throughout their educational journey. "On Match Day, when everyone learned where they were going, the news was so wonderful that I thought, 'Wow! I should just retire!'" Morrow says with a smile.

During students' time at Dartmouth, Morrow explains, she works very hard to provide them with positive role models and opportunities to experience the joys of family medicine. "The atmosphere at Geisel, especially in relation to The Dartmouth Institute, is one that's focused on high-value care, which really speaks to the concepts that are central to family medicine," she explains. "This specialty is all about cultivating long-term relationships with patients in the context of the entire life cycle, from infants to young adults to geriatric patients. When I do advising—and I do a lot for undifferentiated students—I tell students, 'If you want to practice family medicine, you should have a real interest in relationships as a component of medical care, you must be comfortable with uncertainty, you should have a genuine interest in team-based care, and you must love diversity, because your day may start with a well-baby check and end with a dying 92-year-old.'"

Morrow adds that family medicine education at Geisel encompasses a wide array of experiences. "As they pass through medical training, Geisel students are exposed to the spectrum of medical specialties and experience firsthand the joy and complexity of family medicine as practiced out in the community," she says. "But they are also grounded in the real crisis of our current health-care system and understand their responsibility to help solve it. I believe this is at the core of why primary care specialty matches are increasing here. Students say, 'I have a responsibility to contribute to the solutions to this problem—it's not simply about my salary and lifestyle.'"

The seven members of the Geisel Class of 2014 who chose to pursue residencies in family medicine are pictured here (with friends and family) at the 2013 Match Day Ceremony. Cathleen Morrow (kneeling, right), a family medicine physician who mentors many students interested in family medicine, was delighted by the Match results.

The seven students departing for their residencies echo this sentiment. "I really feel like we have a health-care crisis in this country," says Karl Dietrich, who is completing his residency at Memorial Hospital of Rhode Island, "and the only way to effect change is to deliver better primary care, so we have to increase the number of family medicine doctors available." Classmate Jody Epstein, who is now at the University of Wisconsin School of Medicine, concurs. "Over the course of the past four years, I've really learned a lot about the major gap in health-care providers," she says. "There's a fundamental need for primary care doctors, and I feel a responsibility to meet the call."

Building relationships
Despite the challenges, all seven embrace this responsibility with a heartening blend of idealism and enthusiasm. "I love the broad range of care that I'll be providing as a family medicine doctor," observes Tessa Reinke, who, like her husband Aaron is now a resident in family medicine at Texas A&M. "And I'm grateful that I'll be doing something to make a difference in my community."

"I knew from the outset that I wanted to pursue a specialty that involved a strong service aspect and entailed meeting people where they were at," Epstein notes. "The social justice piece was critical to me—I wanted it to be a part of my specialty and family medicine gives me that."

"The opportunity to build long-term relationships with patients is part of what makes the work so rewarding, but I also wanted service to be a big component of my career through involvement in local public health organizations and community initiatives, and family medicine is a specialty that's uniquely situated for doing that," says Karl Dietrich.

Sean Uiterwyk, a family physician at White River Family Practice in White River Jct., Vt., and an instructor in Geisel's On Doctoring program, echoes this sentiment. "It's a privilege to take care of patients throughout their life cycle," Uiterwyk observes, "but I also encourage students to think about their roles as leaders in initiatives to improve health care at the local, regional, and national levels."

Another aspect of the specialty that appeals to these students is the chance to be a patient's first, and continuing, point of contact with the medical community. "I love being the first access that a patient has to the health-care system," Emma Wright confesses. Prior to attending medical school, Wright served in the Peace Corps in Mali and ultimately hopes to practice in a rural environment. She will have ample opportunity to hone her skillset while doing her residency at the University of Montana, in one of the most medically underserved states in the nation. "It's intellectually challenging and rewarding to see undifferentiated patients," Wright says. "I enjoy the close personal interactions and the opportunity to build long-term relationships with my patients—it's inspirational and a huge motivator for me."

Sean Uiterwyk, a physician at White River Family Practice, works with students through Geisel's On Doctoring program.

"I feel family medicine is a specialty that will work very well with my life and personality," Ben Colby observes. "My training will be broad enough to grow with me; depending on my circumstances, I can treat a broad range of patients or have the flexibility to narrow my focus to something like sports medicine or geriatrics." Colby will be staying in the Northeast, completing his three-year residency at the Maine-Dartmouth Family Medicine program. "I'm also excited about the idea of building longitudinal relationships with my patients. I've seen what a difference a trusting doctor-patient relationship can make in a patient's outcome. It's a partnership—it won't do me any good to prescribe a medication or a treatment if I don't know whether the patient is receptive to that approach."

"Building relationships with patients involves a certain amount of intimacy, trust, and continuity—people are often sharing things with you that they'd share with no one else—and having a contextual understanding of their lives can have a huge impact on treatment," Aaron Reinke asserts. "When you have a long-term relationship with a patient, you're aware of the physical and emotional factors that are contributing to their situation, and it informs your approach to treatment."

Stephen Genereaux ('87), a family physician at Little Rivers Health Care in Wells River, Vt., underscores this level of intimacy and continuity to the medical students doing clerkships in his practice. "I encourage students to think of the practice of family medicine as an embedded model," Genereaux says. "We live in the community with the people we take care of—they teach our children, they fix our cars, they run the local businesses. This familiarity adds a dimension of continuity and responsibility that makes us better family doctors, but it also blurs the line between one's personal and professional lives. It's important for students considering a career in family medicine to see that and put their own personal Geiger counter on the experience. They need to ask themselves, 'Is this level of interaction for me or not?'"

Stephen Genereaux ('87), a family physician at Little Rivers Health Care in Wells River, Vt., pauses before meeting with a patient. Many Geisel medical students spend time working with Genereaux at Little Rivers, which is a federally qualified health center that provides care to many low-income patients.

Louis Kazal, a family physician who practices at Dartmouth-Hitchcock's Heater Road facility, teaches first-year students in Geisel's "On Doctoring" program and also works with students in their third-year clinical rotations in family medicine. Exposing students to the importance of forging a strong doctor-patient relationship is one of the aspects of his work he takes most seriously. "Over the past soon-to-be 12 years at Dartmouth, I've developed significant meaningful relationships with many patients. These relationships are essential for helping patients achieve health," Kazal observes. "When students are working with me, they have a chance to see firsthand how these relationships are the joy of family medicine, a byproduct of the privilege we have in being an important part of the patient's life and family circle. I try to highlight for them how therapeutic relationships are developed and cultivated over time and demonstrate the important leverage they provide to positively influence a patient's health. It is vital that students understand that practicing family medicine successfully involves more than book knowledge, making a diagnosis, and prescribing medication. Patients are complex creatures with unique life stories that are relevant to their health and cannot be understood outside the context of family and their community."

Facing reality
The variety of patients and fluctuating mix of inpatient and outpatient care that are part and parcel of family medicine do have a flip side, these young doctors admit. "The scope of knowledge I'm responsible for mastering is both overwhelming and terrifying," Aaron Reinke says. "You have to come to terms with the fact that you'll always be learning; you have to step up and stay on your game, but you also have to recognize when to say when and refer out."

"The breadth of the specialty certainly presents challenges," Matt Mackey cheerfully acknowledges, "But I want to be a life-long learner, so family medicine suits me." Mackey, who took a year off between his third and fourth years to earn a master's in public health at The Dartmouth Institute, is now at the Group Health Cooperative in Seattle.

Mackey's classmates agree. "There's a tremendous amount of information available, and you can only learn so much about each topic," Epstein points out, "so to some degree you need to be comfortable with not knowing."

Medical students get many chances to hone their basic medical skills. Here, Emily Harding-Theobald ('16) works with Dartmouth-Hitchcock family physician Cathy Pipas to close a wound.

"As a family medicine doctor, there's so much to know that you simply can't be an expert in every subject," Emma Wright observes. "Given those inherent limitations, my goal is to be an expert on my patients."

Despite the acknowledged need for primary care providers, family medicine has historically suffered from a tacit lack of support in many medical schools. Some faculty and advisors question the wisdom of entering a specialty that is known for overwhelming workloads, lower compensation, and, in the eyes of some, a lack of prestige and intellectual stimulation.

In light of these perceived negatives, some might question why students would elect to pursue a career in family medicine, especially at Geisel, which does not offer a family medicine residency. Yet the recent graduates say that they received tremendous support for their decisions and perhaps gained a broader understanding of the truly rich spectrum of care that family medicine represents than students at other medical schools. Faculty, they say, have been very encouraging, particularly Morrow, whom all of the students cite as a source of inspiration. "Dr. Morrow is incredibly intelligent, encouraging, and engaged," Jody Epstein asserts. "There's a bias in some places that people go into family medicine because they can't get into another specialty, but I never encountered that at Dartmouth. Instead I've heard comments like, 'Oh, I could never absorb all that information or I couldn't see so many patients a day, but I know you'll do a great job!'"

"I'm sure all seven of us have heard some variation of 'You're so smart—why are you going into primary care?'" Aaron Reinke says. "A lot of people have a negative stereotype of the specialty—they think that you only enter family medicine if you're not a strong student. But given what you have to know, I think only the best of the best should go into family medicine."

Although students can't complete a family medicine residency at Dartmouth, all seven students note that the school has afforded them ample opportunity to explore the full spectrum of family medicine through off-campus rotations and research projects. "Most medical students don't leave their cities or medical schools during training, but Dartmouth makes a concerted effort to enable students to engage in research projects and rotations all over the place," Aaron Reinke remarks. Reinke's experiences included a rotation on the Navajo reservation in Fort Defiance, Ariz., and a research project working with traditional healers in Tanzania.

The scope of knowledge I'm responsible for mastering is both overwhelming and terrifying.

"The school is completely open to getting you the kind of experience you want to have," Karl Dietrich confirms. Like Aaron Reinke, Dietrich completed an elective on the Indian reservation in Arizona and also spent time with Genereaux in Vermont. "Working with Dr. Genereaux and seeing how you can practice family medicine really cemented my decision to pursue this specialty," Dietrich says.

Tessa Reinke, who is interested in practicing in a rural environment, completed rotations in primary care practices as far flung as Valdez, Alas., and Wichita, Kans. "I got to do everything from delivering babies to working in the ER and assisting with colonoscopies," Reinke notes. "I just loved the variety—I could see kids and adults and OB patients, all within a 24-hour time period. You see how much you're needed within a community and it feels great to be able to make a difference."

Gift opens doors to family medicine

Nearly all Geisel students graduate with debt—on average, about $140,000. Although well below the national average for medical schools, this level of educational debt can be crushing for graduates, especially those who want to practice family medicine, one of the lowest paying but most-needed specialties. A generous gift from Herbert and Patricia Prem will now help ease that burden by providing scholarships to third- and fourth-year medical students at Geisel who have a strong interest in becoming family medicine physicians. By establishing a scholarship endowment, the Prems know that the impact of their gift will continue to grow and be felt by students—and those they will care for—for decades to come.

Making a difference
"When I first came to Geisel, I heard an upper-level student who was going into a family medicine residency talking about the need to be authentic and true to your calling," Epstein observes, "and that really resonated with me."

"I remember hearing Dr. James Weinstein, the CEO and President of the Dartmouth-Hitchcock health system and an orthopaedist, speaking about the importance of patient-centered care and the value of helping patients make informed decisions," Mackey recalls. "I thought, 'Here's a practicing physician who's interested in making a systemic difference in health care.' His message really stuck with me.

"Family medicine is the specialty of 'Yes!'" Mackey concludes. "Yes, I can help you resolve your problem, or at least get you started on the path to recovery and refer you to a specialist who can help further. I find that incredibly appealing."

If you'd like to offer feedback about this article, we'd welcome getting your comments at DartMed@Dartmouth.edu.

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