Duke University Medical Center will no longer train family physicians, long the foot soldiers of primary care.
Citing falling interest in its training program and in primary care in general, Duke leaders plan to eliminate the medical center's three-year residency in family medicine. Instead, Duke will focus on refining a team approach to primary care that delegates many clinical duties to physician assistants, nutritionists and other nondoctors.
"We need to figure out how to deliver care more effectively with a likely shortage of physicians," said Dr. Lloyd Michener, chairman of Duke's department of community and family medicine. He said he wants Duke to lead a shift in primary care that puts less emphasis on physicians.
Some fail to see how Duke, whose family medicine residency is one of the nation's oldest and most distinguished, is helping by pulling the plug on family doctors. Like all primary care providers, they are in short supply in many parts of the state, and population growth is only expected to stretch them further.
"Losing any residency program in the state would not be good," said Dr. J. Carson Rounds, a family doctor in Wake Forest who is president of the N.C. Academy of Family Physicians. "We need every family doctor that's produced in the state."
Residency programs are an important source of doctors for the state because physicians often set up practice where they trained. Family doctors, in particular, are key because they are more likely than other types of physicians to settle in rural areas where doctors are most needed, said Erin Fraher, who studies health care work force issues at the Cecil G. Sheps Center for Health Services Research at UNC-Chapel Hill.
Over the years, Duke's residency program has turned out scores of family doctors who remained in North Carolina to practice medicine.
Michener said Duke, which established its residency program in 1972, would fulfill its obligation to train its current family medicine residents, including the class that signed contracts to train at Duke this March.
Rounds said he hopes the family physicians group can intervene and persuade Duke to keep its residency program. He notes that Duke tried in the 1980s to eliminate its entire department of family medicine but reversed the decision after physicians and state leaders objected.
Others aren't optimistic that Duke can be swayed this time.
Dr. Conrad Flick, a Raleigh family doctor and past president of the N.C. Academy of Family Physicians, said it has been clear for years that something was awry in Duke's program. The academy monitors the state's 14 family medicine residency programs to track their success at attracting residents through the national process that matches medical school graduates with residency training opportunities.
Other family medicine residencies, including those at UNC-Chapel Hill and East Carolina University, have consistently been able to fill most or all of their slots. Meanwhile, Duke has struggled, cutting the size of its program. At its height, it was the largest in the state, producing 13 family physicians a year.
"If other programs comparable to you are filling and you're not filling, you have to ask, 'Is the problem inside, or is the problem outside?' " Flick said. "You need to look at what you are doing because what you're doing is not working."
Duke's troubles extended beyond filling residency slots. Discontent among residents at Duke prompted many to leave.
Between 2003 and 2005, seven Duke family medicine residents -- about a third of those training with the program -- opted out. National accreditation rules require residents to complete their last two years of training at the same residency program, so most who left Duke had to repeat at least one year of training.
Current and former family medicine residents said the Duke program offers too little opportunity for hands-on learning. They said training focused on busy work, such as compiling patient data for research studies or treating patients with uncomplicated medical complaints. Residents said they had little exposure to challenging and unusual problems that would help them develop as clinicians.
Dr. Dan Woydick, a Duke resident who will finish his training in July, said he will leave Duke not feeling as confident or as prepared as he would like to. A few days after he is done at Duke, Woydick will fly to an Army base in Germany, where he will be a base doctor charged with caring for hundreds of soldiers.
"No one wants to show up for their first job feeling like they haven't been optimally trained," he said.
Residents who expressed frustration or suggested changes were ignored and sometimes faced retaliation, current and former residents said. It was common for "troublemakers" to be accused of mental instability or anger issues and required to see a psychiatrist. One former resident, now completing residency at Mount Sinai Hospital in New York City, sued the Duke program, alleging unfair treatment. The lawsuit was dismissed last month.
Michener, the Duke family medicine chairman, said some residents failed to meet Duke performance standards or behaved unprofessionally. But he also said many residents didn't like Duke's team approach to primary care and chafed at what was new and unexpected.
Duke will continue to offer fellowships -- advanced specialty training many physicians complete after residency -- to family physicians who want to develop expertise in team-based health care and community medicine. The family medicine department also will expand its training programs for two-year degree physician assistants and physical therapists. In that way, Duke can supply primary care providers, Michener said.
Staff writer Jean P. Fisher can be reached at 829-4753 or firstname.lastname@example.org.