Re: Wide Gap between Preparation and Scope of Practice of Early Career Family Physicians

To the Editor: Peterson et al.¹ have published a stimulating piece that leaves the reader wanting more analysis, which will probably show up in future articles. For all the years since residency education began, a family medicine residency graduate faces a “buyers' market” relative to job opportunities that match one's desired practice. With appropriate guidance from teachers and mentors, residents should be able to clearly write down the values that are important to them, the type of community in which they would hope to practice, and the nature of the patients for whom they would like to care. I have a letter that I wrote in the fall of 1972 with those items and have referred to it as my career has gone along.

This report in the journal raises the issue of the early differentiation of residents in their desired scope of practice. Instead of a “generic stem cell” graduate, we have seen an increase in early choice making, almost immediately after the match has happened. One of the purposes of residency education is to expose residents to patients and communities and practice styles of colleagues that will influence their thinking about future choices. Deciding too early risks closing off learning.

If, however, the problem is, in part, corporate medicine in large cities deciding that fragmented care is what it wants to deliver, those systems should be confronted with the analyses and data that show that family doctors can and will provide comprehensive and integrated care at lower cost and higher quality. In the end, if large systems cannot figure out how to let family doctors “practice at the top of their degree,” then graduates can walk away, organize efforts to demand changes in their organization, or find another health system that will. Like unions in the early 20th century that demanded working conditions that met their needs, family doctors can collectively confront organizations that will not let us practice in the ways we are trained. But that discussion needs to happen among family doctors of all ages and generations. Solidarity is power.

My concern is that self-differentiation, economic and family issues, and what is portrayed as a comfortable life may influence choice. Variety is not only the spice of life, it has been shown to positively affect physician happiness. We do not want to see a dissatisfied generation of family doctors stuck in monotonous care systems. If large systems that respect diversity of practice and clinical autonomy and encourage innovation are featured and celebrated by graduates, the industrialized health systems will have to change toward that model of care if they want to recruit new family doctors. Word has a way of getting out.