Part 7: Family Medicine at Duke - Family Medicine Today

August 17, 2016

According to the article “Trends in Career Choice by U.S. Medical School Graduates,” published Sept. 3, 2004, in the Journal of the American Medical Association, a dramatic shift had taken place in the late 1980s in the number of medical school graduates entering primary care residencies. Interest in family medicine fell from 12.7 percent in 1987 to 10.6 percent in 1991. Interest rose and peaked in 1998 at 16 percent, but fell again by 2002 to 10.4 percent.

Kathryn M. Andolsek, M.D., MPH, professor of community and family medicine and assistant dean of premedical education in the Duke University School of Medicine, said that as a result, the Duke Family Medicine Residency Program voluntarily began decreasing its size in the late 1990s. She said that with a smaller residency, the standards could be kept higher. Allocating resident time to the inpatient service at Duke University Hospital then became difficult, she said.

“It was hard to justify having spent this number of months in the inpatient service just to keep an inpatient service that had residents on it,” said Andolsek, who stepped down as residency program director in 1998.

She said more faculty began treating patients on the inpatient service at Duke University Hospital, but that fewer family medicine patients were being hospitalized; more were being seen in the outpatient setting. Also at this time, the Department of Community and Family Medicine had begun working more closely with communities to prevent disease before hospitalization was necessary. Thus, the family medicine inpatient service had dwindled.

After a decades-long fight for acceptance at the medical center, J. Lloyd Michener, M.D., chair of the Department of Community and Family Medicine, opted to shut down the department’s inpatient service at Duke University Hospital in the early 2000s. He said the service didn’t make sense anymore.

“Why are we running an inpatient service taking care of transplant patients and sickle cell patients?” Michener remembered asking himself. “Makes no sense. So we decided to close the inpatient service because it wasn’t relevant anymore.”

Michener said there was a storm of protests because he was giving up the privileges that others had fought so hard for.

“My argument was … we wanted to … keep people healthy, rather than take care of patients, especially on an ICU, when they’re sick,” Michener said. “We were doing interventions around, ‘How do we keep people healthier so they don’t need to be admitted?’ ”

Joseph Greenfield Jr., M.D., James B. Duke Professor of Medicine and former chair of the Department of Medicine, said in a recent interview that he was upset when Michener shut down the family medicine inpatient service, because he felt very strongly that for family medicine to have a real presence at Duke University Medical Center, it should have admitting privileges and beds in the hospital.

“It upset me because I had worked really hard to try to help them,” Greenfield recalled. “And the reason I did it was because of my respect of Harvey Estes.”

Another residency “phase out”

The Department of Community and Family Medicine and Michener again faced criticism in 2006 when, according to a Sept. 15, 2006, article in Family Practice News, the department announced plans to “phase out the residency program” to “provide ‘more consistent care by senior clinicians’ and to better coordinate ‘innovative programs’ in the community with the on-campus faculty practice.”

According to Michener, the reasons behind the decision included issues with the applicant pool, resident attrition, and frustration of the faculty with training residents in a model of family medicine they themselves no longer practiced. Michener was cited in the article as saying the decision could be revisited if the Accreditation Council on Graduate Medical Education “would give the university more flexibility in how it structured the residency program.”

At that time, the department was operating multiple community- and school-based clinics throughout Durham, in addition to implementing other care management and preventive programs to reach people where they lived. The focus of clinical care was shifting toward community medicine and team-based clinical care — with attending physicians and residents working alongside nurse practitioners and physician assistants.

A June 1, 2006, article in the Wilmington Star-News said that many residents were leaving the Duke Family Medicine Residency Program to complete their training elsewhere because they didn’t like the program’s team-based approach to training.

Michener recalled receiving thousands of angry letters and emails from the family medicine community, some threatening and some calling for his termination. Family medicine was again on the chopping block at Duke, and, according to the Family Practice News article, the decision was “greeted with disappointment by much of the academic community in family medicine.”

A joint statement was issued by The American Academy of Family Physicians, the Association of Departments of Family Medicine, the Association of Family Medicine Residency Directors and the Society of Teachers of Family Medicine: “Most respected family medicine departments across the nation, including those at other top-tier private universities, have been able to balance the priorities of patient care, research, and training while maintaining the integrity of their residency training programs.”

Michener said that the university put together a review committee, led by the president of the Association of American Medical Colleges, to study what the department was doing, not only at Duke, but also in the Durham community.

“The basic conclusion … was we may be crazy, and we may be right,” Michener said. “So we became a national test of whether family medicine could organize around partnering with communities to improve health outcomes.”

“We never technically closed it [the residency],” Michener explained in a recent interview, saying that the program took a one-year hiatus from recruiting to redesign itself.

Redesigning the curriculum

Residency program director Viviana Martinez-Bianchi, M.D., FAAFP, assistant professor of community and family medicine, arrived at Duke around this time and recalled believing that the program could be restructured to focus on engaging communities instead of being phased out completely.

“We just needed to have more people who believed that family medicine should be working more in the community,” she said. “We should train a cohort of residents … who are strong believers in the role of primary care in … improving the health of the public.”

The design of a new family medicine residency curriculum was then planned to meet the needs of Durham and similar communities, and to prepare physicians for leadership roles promoting health in their communities.

Department faculty — including Brian H. Halstater, M.D., associate professor of community and family medicine and then-director of the Duke Family Medicine Program; and Martinez-Bianchi, then-associate program director — redesigned the residency program’s curriculum in 2007 to focus on public health, community engagement, critical thinking, teamwork and leadership, with clinical excellence as the platform of a competent family physician.

“That started us on the road to a new residency, really aimed at a new form of family medicine,” Michener said. “There was more community focus than hospital focus. It’s focused on understanding the needs of family, people in their context of families.”

The residency created and implemented the Population Health Improvement through Teamwork curriculum, and Martinez-Bianchi said once the shift took place, the program started to grab the attention of medical students who had masters of public health or had been actively involved in their undergraduate and medical years in working with communities that were suffering health disparities.

Today, the program has 15 residents and Martinez-Bianchi said the applicant pool went from about 50 people prior to the curriculum shift to about 300 U.S. graduates per year for the five intern positions.

“The residency program stands out as a program that teaches and trains people who have an interest in improving population health and reducing health disparities, by using family medicine as a means for social justice,” Martinez-Bianchi said.

Family medicine now

The Duke Family Medicine Residency Program has consistently been ranked among the Top 10 family medicine training programs in the nation by U.S. News & World Report for more than a decade, reaching its highest ranking of No. 3 in 2015. Its current ranking is No. 10.

Martinez-Bianchi said the program has a very high visibility nationally.

“Now, you hear people talking about using the ‘Duke Framework’ for population health on a regular basis,” she said.

In 2015, the Duke Family Medicine Center saw 9,915 patients and conducted 31,885 patient visits.

Sharon Hull, M.D., MPH, professor of community and family medicine and chief of the Division of Family Medicine, said family medicine at Duke has long been ahead of its time.

“Duke was an early adopter of the nascent specialty, and, in spite of multiple attempts to dismantle it and challenges to its very existence, it survives and is strong,” Hull said. “We recruit some of the top family medicine residents in the country, our residency program is growing, and our clinical and educational programs are at the cutting edge of the health care delivery system changes in our country.”

Paul R. Newman, senior vice president of Duke’s physician practice, the Private Diagnostic Clinic (PDC), said that today, family medicine is a very important part of the medical center, citing the training program and the department’s community- and school-based clinics.

“I think we’d be in trouble without family medicine, absolutely, as a system,” Newman said. “They have an important function and I think a lot of people won’t even remember the fight that took place or the debate [in 1985], and would probably be shocked to understand that was actually out there at that time.”

Michener said that the department, since its founding in 1966, has always had a role as a change agent and that sometimes puts you in tough situations.

“We have been through those tough times and I think made the right choices,” Michener said. “We helped the institution and the discipline adapt to a future that’s very different than … when the department started.”

Where are they now?

E. Harvey Estes, Jr., M.D.

Estes retired from Duke in 1990 at age 65 to head a new program at the North Carolina Medical Society Foundation in Raleigh, a position he kept until 2000. More recently he has returned to his cardiology roots, doing research and reviewing articles for medical journals.

In December, he published “Individual components of the Romhilt-Estes left ventricular hypertrophy score differ in their prediction of cardiovascular events: The Atherosclerosis Risk in Communities (ARIC) study,” in the American Heart Journal.

George R. Parkerson Jr., M.D.

Parkerson resigned as chair of the Department of Community and Family Medicine in 1994, but continued working at Duke full-time. He conducted research with the department until 2000, then became one of the chairs of the Duke University Health System Institutional Review Board (IRB). In 2015, he returned to the Department of Community and Family Medicine to get more involved with the work the department was doing in the community and with population health.

His current project is with Howard J. Eisenson, M.D., and the Lincoln Community Health Center (LCHC). Parkerson and Eisenson have created a short, practical tool for assessing population health. The 15-item, voluntary questionnaire will evaluate information such as employment, economic circumstances and housing for a sample of 500 patients at LCHC.

Learn more about the Duke Population Health Profile.

Joseph Greenfield, Jr., M.D.

Greenfield, James B. Duke Professor of Medicine, was chair of the Department of Medicine from 1983 to 1995. He currently works half-time at the Durham VA Medical Center reading electrocardiograms.

David Sabiston, Jr., M.D.

Sabiston was chair of the Department of Surgery for 30 years, retiring from Duke in 1994. He died in January 2009 at the age of 84.

William Anlyan, M.D.

Anlyan served as the dean of the School of Medicine and chancellor of health affairs from 1964 to 1988. He died in January 2016 at the age of 90.