Family Physicians are
in High Demand
In a difficult economic time when many people are searching in vain for work, family physicians can count on having a job.
Family physicians, general internists and general pediatricians are primary care physicians. Typically they are the first physicians who people consult when they are ill. Physicians who prefer to have long-term, meaningful relationships with their patients often choose primary care. Primary care doctors provide preventive services and can care for most of their patients’ problems. If they need to refer patients to sub-specialists, such as cardiologists or orthopedic surgeons, they help coordinate their patients’ care. Primary-care-oriented health systems around the world tend to have lower costs, better health outcomes, and greater health equity. Given the rising cost of health care and the lack of equitable care provided over the years to Native people, having primary care providers is especially important in Native communities.
All primary care physicians are needed in underserved areas, but family physicians are uniquely equipped, as they are the ones who are able to deal with a broad scope of problems and age groups. Pediatricians care for children and general internists care for adults. In contrast, Dr. Terry Maresca, Mohawk, says, “Family medicine spans the age range from very young infants and women who are pregnant to children, young adults, adults, and Elders. We care for the whole spectrum. Our training is broad enough that we can thrive within a rural community as well as in an urban underserved community.”
In contrast to most medical specialties and subspecialties, family physicians are taught to care for patients within the context of both the family and the community. This orientation fits well with Native communities.
The Need for Family Physicians
There is a critical and growing shortage of family physicians in the United States. Dr. Joy Dorscher, Turtle Mountain Band of Chippewa Indians, says that Indian communities are being hurt even more than non-Native communities. She points to the 18% vacancy rate for Indian Health Service physicians. Dr. Pat Rock, Leech Lake Band of Chippewa, agrees with Dorscher and adds that reservations have been hit even harder than urban American Indian communities, like the one he serves in Minneapolis.
Dr. Jack Colwill and his research team found that in less than 20 years, the U.S. could face a shortage of up to 44,000 family physicians and general internists.
Drs. Dorscher, Rock and Maresca, who are all family physicians, are eager to see more Native people enter family medicine and medicine in general. Dr. Rock says, “As with other ethnic and minority groups, Native physicians are more likely to return to their community or practice in another Native community.” Rock adds that even the Native physicians, who don’t work directly with Native communities, often serve Native people in some way.
Sharing a common heritage with their physician increases the likelihood that Native patients will share information that is vital to understanding their problems and providing care that will work for them. Rock says, “Because of our history, people have trouble with issues of trust. These barriers are difficult, no matter what. When you’re telling important personal things to another human being, you want to be able to trust them. I think those boundaries are able to melt away more quickly where there’s some commonality, like sharing a wholistic way of looking at the world, including spirituality. It’s easier to work with our own people.” Rock adds that he feels that Native physicians who choose to serve a broader community have a great deal of value to share with non-Native people. Dorscher and Maresca agree.
Unfortunately, however, the number of Native physicians might decrease. Since 2005 there has been a 14% decrease in the number of American Indians and Alaska Natives applying to medical school.
Part of a Family
Why should students consider a career in family medicine? According to Dorscher, “Physicians have a wonderful opportunity to touch the lives of the people around them. As physicians we touch our patients both literally and figuratively. I can’t think of any other occupation, career or calling that allows this kind of interface.”
Dorscher continues, “The biggest reward, which I think is unique to family practitioners, is that you are part of your community. This winter a young man came up to me in Target and presented his child to me saying, ‘You delivered him. He is such a wonderful gift.’ Who else gets that? It warms my heart.
“When I was a resident, I took care of four generations of a single family. What a phenomenal honor to care for multiple generations of a family. To be allowed to be part of a family in that way.
“If you’re a cardiologist, they remember you and they might say, ‘Thanks for saving my family member’s life. We’re forever in debt to you.’ But we have the honor of being able to have a close relationship with a family. I don’t think that’s a normal part of a sub-specialist’s practice.”
Dorscher also talks about the rewards of relationships that are continuous over time. Such relationships are personally satisfying but also make it possible for physicians to know their patients well enough to provide care that is tailored to their patients’ needs and resources. “You watch young women build their families and grow into beautiful mothers. You help them with that process. I’m not saying they’re good mothers because of me, but now with families being separated, some families need motherly support. You can provide that. You watch these beautiful children and you help get them ready for school. When they see you in the community, they say, ‘Dr. Joy. What are you doing here?’ Such an honor!
“It’s fun to see the strengths of the families. Even the most dysfunctional families have strengths that they bring. That’s pretty cool.
“When very difficult times hit, people will ask you to help them with very difficult decisions. As difficult as that is, it’s an honor to be there in that way.”
Identifying with the Patient
Family physicians make a good living but typically don’t get paid as much as subspecialists. This doesn’t bother Rock who cares for patients at the Indian Health Board of Minneapolis where he also serves as medical director and CEO. “I guess I am a living testimony to the non-financial benefits of family medicine. This is my eleventh year, and I continue working here. I love the job as much as the first day I walked in here. It’s challenging and never dull.
“People are so grateful, like the single parent mother who’s appreciative that we saw her daughter quickly. She couldn’t get in anywhere else. And there’s the Elder who is grateful that we saw and treated her grandchildren.
“I’ve never doubted the value of my work here. It’s positive even when there are negative outcomes – things that break your heart. In fact negative outcomes cause me to put more energy into my work.
“Today I saw a 50-year old Native American man. He has no health insurance. He lost his job in manufacturing a few months ago. His wife was just diagnosed with pancreatic cancer. He was in tears in my office. I told him I had to send him to the hospital because he’s neglected his health for a long time, in part because he doesn’t have insurance and thought he didn’t have access to services. Today he was so sick he had to come in.
“I told him ‘I’m glad that you’re here today.’ He said, ‘I’m glad I’m here today too.’ I said, ‘If you come back to see me I’ll work hard for you to get you feeling better and work to give you the necessary help. Don’t give up yet.’
“I see this [type of situation] every day. I identify with the people I work with. I feel like I’m part of the community. I’m not an outsider coming in. It’s very rewarding.”
Dr. Maresca finds family medicine rewarding to people who enjoy people and their stories and value rich, long-term relationships. She also says it can be rewarding for people, like herself, who enjoy variety. “On a typical day I might see someone with an ingrown toenail, a person with a lung clot, a person with a new pacemaker, an Elder whose fractured hip was missed in the emergency room, and a child with BBs in his nose. I am never bored!”
Maresca also appreciates being able to practice in a variety of settings. “Family medicine is a flexible profession,” she says. “I’ve been in many different areas. I’ve worked in everything from urban underserved, to reservations with IHS, to tribally-based communities. I actually tried private practice for two years.
“Family medicine is intellectually stimulating. By the time that patients get to a specialist their problems are likely to be narrowed down. They might even already have a diagnosis. But since patients typically bring their problems first to a family doctor or another primary care provider, you get the first crack at trying to figure out what’s going on. That means you need to be a good puzzle solver and be persistent. But you don’t need to know everything. We have consultants. Help is available.”
Maresca continues: “We have opportunities to be able to change the health system. We advocate not only for our profession but also for patients who have less voice in the health systems that we serve. There’s a strong social justice piece in family medicine that is very satisfying to me.”
Characteristics Needed for Family Medicine
As Drs. Dorscher, Rock and Maresca implied, family physicians need to value people and their stories, be empathic and be good listeners. They need to be able to build and sustain trusting relationships with their patients, families, colleagues, and community members. They need to be intellectually curious, able to tackle and follow through on difficult issues, and enjoy problem solving. Because family medicine includes a broad scope of issues, family doctors need to be dedicated, life-long learners. Not only do they need to increase their medical knowledge and skills, but they also need to continue to grow as people so they have the self-comfort and knowledge that enables them to invite and help patients deal with tough problems, including sensitive personal issues.
Preparing to be a Family Physician
Drs. Dorscher, Maresca, and Rock recommend getting involved in a pre-med program, such those offered in conjunction with the Association of American Indian Physicians. They say that even if students who are interested in family medicine are not able to be involved in a structured program, they can do such things as search for information on the Internet, ask a local family doctor for permission to shadow him or her, and/or talk with a local family doctor about what it is like to be a family physician.
The article above was originally published in the Spring 2009 issue of Winds of Change. The cover artist is Joe Maktima, Laguna Pueblo/Hopi. This piece entitled "Chanting Wind" and the rest of his work is rooted in the culture of his pueblo ancestry. For more information visit the artist's website: joemaktima.com or email him at: firstname.lastname@example.org.