Making Marcus Welby
by Judith Zwolak
Illustrations by Mark Andresen
Photographs by Michael DeMocker

In the past, Tulane trained its medical students to hear zebras. Rick Streiffer wants them to hear the horses, too.

Streiffer, professor and chair of Tulane's new Department of Family and Community Medicine, says teaching medical students in the university hospital, usually occupied by the sickest patients or those with the rarest illnesses, prepares them to expect the unusual.

"In other words, if you hear hoof beats, you are trained in the specialized world of academic medical centers to think they are caused by zebras, which are rare," he says. "Most of the time, however, out in the community, hoof beats are caused by horses."

Thirty students got to see a stampede of horses over the last school year as they volunteered to spend one month in the office of a family medicine physician in the Gulf South region. This pilot program added a family medicine clerkship to the established third-year "rotations" in general internal medicine, surgery, pediatrics, psychiatry and neurology, and obstetrics and gynecology. Over the next two years, the school will phase in the clerkship to become a two-month requirement for all third-year students.

The goals of the program are not only to graduate more students who choose to go into family medicine, but also to give those students who go into medical specialties an appreciation of the primary-care generalist.

"Even if our students become neurosurgeons or another type of very subspecialized physicians, this will expose them to where their patients come from, to the community perspective," Streiffer says.

THE NEWEST, YET OLDEST, SPECIALTY

Rich Levine can tell you from experience that family medicine is, to use the definition of the American Academy of Family Physicians (AAFP), the medical "specialty of breadth."

During his stay in the clinic of Ponchatoula, La., family practitioner Mark Tilyou, Levine saw patients with diabetes, hypertension and heart problems. He witnessed acute asthma attacks and saw kids with colds and sundry viruses. He got to suture cuts, perform skin biopsies and remove warts. He watched as Tilyou performed diagnostic procedures to detect colon and cervical conditions. He woke up at dawn for hospital rounds and collapsed into bed after a full day in the clinic. In short, Levine experienced life as a family physician.

"It was exciting," Levine says. "It was what I came to medical school to do."

Family medicine is actually a fairly new term used to describe an old discipline. Before there were cardiologists and gastroenterologists, general practitioners delivered babies, treated colds, set broken arms and served as the family's expert on health and medical matters. Typified by television's kindly Marcus Welby, the general practitioner gradually has given way to medical specialists over the past few decades.

"After World War II, there became fewer and fewer doctors who looked after whole people," Streiffer says. "You had the expert on the heart and the expert on the skin, but who knew anything about the whole person?"

The whole person--head to toe, from infancy through the last years of life--figures into the AAFP's definition of family practice. The organization defines family practice as the medical specialty that provides continuing health care for the individual and family, integrating the biological, clinical and behavioral sciences. Its scope encompasses all ages, both genders, each organ system and every disease. The American Medical Association recognized family medicine as an official specialty in 1969.

Streiffer likens the family practitioner to a general contractor in construction. "Can you imagine building a house without having a general contractor? The electrical system wouldn't coordinate with the plumbing.

"Sometimes you need specialty contractors to come in, but you still need a general contractor to take care of the project, manage most aspects of the job directly, and make sure it's organized."

With the growth of managed health care in the 1980s and '90s, health maintenance organizations helped bring back the primary-care generalist as a physician who knows and understands the patient and who can coordinate care effectively, perhaps avoiding unnecessary tests and trips to specialists. Currently, 54,183 board-certified family physicians practice across the country, nearly 600 of them in Louisiana.

Medical schools scrambled to set up family medicine departments starting in the 1970s and early '80s, Streiffer says, with public schools leading the way in response to pressures from state legislators. Private, research-oriented schools such as Tulane--which were accustomed to graduating specialists--followed shortly with their own programs.

In July 1998, Tulane University Medical Center formed its Department of Family and Community Medicine, building on groundwork laid by the decades' old Program in Community Medicine led by J.T. Hamrick, now professor and vice chair of the department. Streiffer, who received his bachelor's in mathematics from Tulane in 1973 and a medical degree from Louisiana State University in 1977, made expanding the community-medicine elective into a full-fledged family medicine clerkship one of his first projects.

MEDICINE IN CONTEXT

Clinical clerkships are a turning point in medical school. After the first two years--spent primarily in the classroom, in the gross anatomy lab or behind the pages of a thick textbook--medical students begin the third and fourth "clinical years." During this time, they encounter actual patients together with other medical students under the tutelage of an "attending" physician and perhaps a resident who is performing advanced training in a specialty. At Tulane, students perform the majority of their clerkships in the university's own hospital and outpatient clinics and other hospitals and clinics in New Orleans.

At the start of the third year, students are eager to see, talk to and assess real patients. Although they've practiced clinical procedures with Tulane staff members who act as patients in the school's standardized patient program, interacting with an actual patient brings the medical students one step closer to becoming doctors.

"At the beginning of the third year, you're very excited to see patients by yourself," says clerkship pilot participant Rich Levine, who enters his fourth year of medical school this fall.

Levine says one of the reasons he volunteered for the clerkship was to have closer relationships with patients and his physician-teacher, who program organizers call a preceptor.

"I really wanted to do a one-on-one with a doctor," he says. "I was looking for more of a mentorship than being one of a bunch of students and residents with an attending."

His mentor came in the form of family practitioner Mark Tilyou, an 18-year veteran of a bustling practice of six doctors in the small town of Ponchatoula, about an hour-and-a-half's drive from New Orleans.

During the first few days of his month in Ponchatoula, Levine observed Tilyou as he talked to patients and assessed their problems. Eventually he began to see patients by himself, reporting to Tilyou his diagnosis and thoughts on treatment. Doctor and student then saw the patient together, with the final diagnosis and treatment plan falling to the more experienced clinician.

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