Recent opinion pieces in Family Practice Management have painted a fairly depressing picture of the state of our specialty. With all of the economic, social and political challenges in the medical marketplace, who in their right mind would want to go into family medicine anymore? Quite simply, the same people who have been going into it for the right reasons all along.

Raise your hand if you went into family medicine for financial security. Sure, medical education debt is a huge burden. But how many of us really entertained the idea of becoming, say, urologists because that career choice would bail us out of debt more quickly?

Raise your hand if you went into family medicine for peer recognition. I'm betting that you chose family medicine despite peer opinion, not because of it. While serving as a “tater” (the term of endearment some of my IM colleagues bestowed on those of us from other disciplines rotating off-service), I witnessed a cardiologist threaten to demote an IM intern to family medicine for a deficiency in his knowledge of myocardial minutia. (Don't misunderstand; my residency was not three years of nonstop insult and abuse. I just mean to say that in 1994, family medicine was not the discipline of choice if one was seeking instant awe and admiration.)

In my mind's eye, I'm not seeing many hands. Yet these are among the reasons the academicians in family medicine cite for the declining interest in our specialty: no money, no respect. Are the students of today so different from us? I would argue that the right students are not at all different from those of us who care enough to wring our hands about our future.

The right people

To survive, we have to get the right people into the specialty and get the wrong people out. The right people are the students who clearly display and communicate their passion for taking care of families – nothing more, nothing less. If a student meets this criterion, he or she belongs somewhere in family medicine. The right place might be a community-based residency; it might be in a large city; it might be at a teaching hospital. I'm not ignoring competence. But a student who lacks passion, no matter how gifted, credentialed or, dare I say it, politically connected, should not be part of our specialty.

Is this how we currently approach the residency selection process? I'm skeptical. If it were, wouldn't we interview all applicants? How can one identify the passion factor except by meeting the student? Would we define success in the residency match as filling our slots? Or would we define it as having only the right people in our incoming intern class – even if that class is half full?

I understand that having warm bodies to fill our programs is beneficial in the short term. But every time we let the wrong student in – the one who is driven ultimately by something other than the passion to care for families -we give the right people a dangerously false impression of what our core identity truly is. In the process, we turn the right people away, which is something we absolutely cannot afford. Maintaining our core identity as doctors who care for families is the only way to ensure that the right people identify and connect with our discipline.

The right training

James Glazer, MD, in a provocative FPM opinion piece, focused on another potential threat to our core identity: certificates of added qualification and how we use them.¹ When medical students encounter family physicians whom we as a discipline designate as “specialists,” what are we saying to them? That we are passionate about caring for families? Or that they needn't worry if they're not really interested in caring for families, because we'll let them specialize, too! Treating our core identity like a ball of clay that we can remold on a whim to look like someone else's will kill our discipline, not save it.

However, I was troubled by Glazer's intimation that “real” family medicine is defined by providing care in the broadest possible array of medical settings. I vehemently disagree. Being a real family doctor is not employing the technical skill set to provide one-stop medical shopping from birth to death. Being a real family doctor is being passionate about taking care of families, however one chooses to manifest that passion. When we define family medicine simply as the overwhelming combination of IM-Peds-OB-Gyn-Psych-Surgery-Ortho, whom do we attract? Indecisive students? Most certainly. Students who enjoy one of these specialty components and see family medicine as an easier training prospect? This I've seen firsthand. Does this definition attract the right people? I suspect not.

And even if the right person blunders into one of our residency slots, then what? Once we have a passionate resident who has a clear vision of what his or her family medicine practice will entail – in 2007, likely a result of good luck rather than good recruitment systems – should we say, “So, you don't think you want to do OB or hospital work or (insert your pet procedure here)? Why? Don't you want to be a real doctor?” When the resident brings up the issue of his or her educational debt, should our response be, “Boy, I'm glad I'm not in your shoes! Good luck paying that off”? It seems to me that attitudes like this would eventually result in a cohort of family doctors who are uncertain of their professional identities and overwhelmed by the financial burden and complexity of medical practice. Come to think of it, that cohort sounds oddly familiar. Could it be that we have created our own crisis? I wonder.

If we want the right students to come to us and stay with us, family medicine residency cannot be an enterprise designed to coerce trainees into doing things they're neither interested in nor comfortable with just so they can call themselves “real doctors.” It also cannot ignore the financial burdens that our future colleagues carry. To attract and keep the right people, we need to create a residency paradigm that accomplishes the following:

• Exposes our future colleagues to the breadth of family medicine and ensures a recognized minimum level of competence in the scope of our medical care as family doctors;

• Cultivates and hones the technical skills that each resident sees as important to his or her individual vision of family medicine;

• Prepares our residents for the economic and management realities they will face in practice.

Expose, cultivate, prepare. This should be the mantra for all family medicine residencies. I don't know about yours, but my residency was great at No. 1, fair at No. 2 and poor at No. 3. We need to make the commitment to our future colleagues that we will not only ensure basic competence but also train them to be the family doctors they want to be. We should sit down with residents midway through their training, listen to their visions of their future practices and customize the latter half of residency to meet their needs.

We must also pledge to help them navigate the choppy economic waters ahead. We should incorporate intensive orientation to employment contracts, malpractice insurance, third-party payer negotiations, loan forgiveness programs and practice finances in the third-year core curriculum. Such a financial/management rotation would have been much more valuable to me than my month in the NICU. In 10 years of rural family medicine, I have never been asked to inspect the gastric aspirate of a 28-week premie. I sure have inspected a lot of balance sheets, though.

If we could make these changes as a discipline, I think we would see something amazing: Family medicine would attract more and more of the right people. Instead of cruising deserted medical streets searching in vain for passengers (all the while asking yourself if the passenger you find in a dark alley is one you should pick up in the first place), you'd start seeing lines form at the bus stop on Main Street.

I realize this proposition is fraught with logistical obstacles. It doesn't matter. To survive, family medicine must grow and become better than it has ever been. To survive, we need to shift our training, selection and focus. The alternative is for our discipline to become a shadow of its former self. If it survives at all, that is.