Leading Family & Community Medicine at Northwestern with Deborah Smith Clements, MD

Erin Spain, MS: This is Breakthroughs, a podcast from Northwestern University Feinberg School of Medicine. I'm Erin Spain, host of the show. Today, I am delighted to have Dr. Deborah Clements on the show. She is the chair of the Department of Family& Community Medicine at Feinberg and was recently honored with the Illinois Academy of Family Physicians Distinguished Service Award at Northwestern. Dr. Clements has established three thriving family medicine residency programs and has published many papers focused on improving residency training and family medicine. Welcome to the show!
 
Deborah Smith Clements, MD: Thanks so much, and I am pleased to be here.
 
Erin Spain, MS: I want to talk about your career path. You always wanted to be a physician, but that's not how your career started. Tell me about your journey from undergrad to where you are today.
 
Deborah Smith Clements, MD: When I was an undergraduate at the University of Michigan, I really always thought I wanted to be a physician, and I was paired with an advisor who, at that time in the 70s, told me, "Well, you're a girl and you're not from a medical family, and I'm not sure that you're really smart enough to be a physician." And as we do with advisors, I took his words to heart and went off and embarked on another career. And so, I had a long, very good career in healthcare administration. So in the 80s, fast forward a decade later, there was a nursing shortage, and I was working in healthcare administration and still really felt a passion for direct patient care and thought, "I'll go to nursing school and satisfy that desire to be involved in patient care." And I did one semester of nursing school, and the dean of nurses called me in, and she said, "Well, dear, we think you're a very good example to the rest of the students, but we really don't see you in nursing. We really think you should apply to medical school."
 
Erin Spain, MS: This is the opposite of what you heard as an undergrad.
 
Deborah Smith Clements, MD: Exactly the opposite. And I chose to believe that. So, at that time, I had three children and I applied to one school, one time. And surprisingly, I was accepted. And so that started me on the journey of becoming a family physician.
 
Erin Spain, MS: So not the traditional path, but it has worked out pretty well. You came to Northwestern in 2013 after having have a career as a physician, and you came here and you really transformed the department. Tell me what happened when you came to Northwestern in 2013.
 
Deborah Smith Clements, MD: My first job out of residency was with the American Academy of Family Physicians. And at that time, we had a list of medical schools that did not have a Department of Family Medicine, and that was called our "target school list," and Northwestern was one of the schools on that list. We did not have a Department of Family Medicine at Northwestern until 1997, which was long after many, many, many universities did -- not that we weren't in good company. There were some fine schools on that list. So it was remarkable to me that I was invited to apply to become a chair at one of those schools that I had originally pursued for not having a Department of Family Medicine. So here I am.
 
Erin Spain, MS: You're a Chicago native, is that right?
 
Deborah Smith Clements, MD: Yes, I am.
 
Erin Spain, MS: So this was a bit of a homecoming for you.
 
Deborah Smith Clements, MD: It was. It was wonderful. My family of origin is here. My sisters are here. Chicago is truly my favorite city in the world.
 
Erin Spain, MS: Why is Chicago such an ideal place, and Chicago suburbs, such an ideal place to practice family medicine?
 
Deborah Smith Clements, MD: We have such diversity in this city, and it's such an exciting place to be, such high energy. And there are so many resources. It's the best of all possible worlds. We have the excitement and the energy and the scientific rigor of what happens on the Streeterville campus downtown, and we have the community hospital settings where we really can immerse ourselves in what's happening in the communities and be a personal physician for our patients. As an organization, we're so fortunate to have so many resources, and I'm proud to see us put those resources in a place where they can do the most good.
 
Erin Spain, MS: So let's talk about what happened at Northwestern after you came. What were you tasked with in 2013 and what has transpired since then?
 
Deborah Smith Clements, MD: So in 2013, we had one residency program that had just started as a result of a grant through the federal government called the Teaching Health Center Grant. And so, there were residents here at that time. There were 16 residents in that program. I was tasked with beginning a community-oriented family medicine residency program associated with Northwestern Lake Forest Hospital. We were able to begin with the work of a lot of people -- lots and lots of people were involved in this, not the least of which was Mr. Tom McAfee, who is the CEO and regional president in the North-Northwest region. We started our new residency program at Northwestern Lake Forest Hospital with eight residents per class. So 24 total residents. We continued our residency program that is in Humboldt Park. And so, eight residents per class for the three years in that program. And then in 2018, we started a third residency program when we acquired Delnor Hospital.
 
Erin Spain, MS: Family and community medicine is different than other specialties. What are you looking for in these residents, who's drawn to this field to do these programs?
 
Deborah Smith Clements, MD: We look for candidates for physicians who understand that health is not just about the individual. It really depends upon the role of the family, the patient's environment, their job, their community. All of those factors contribute to a person's individual health. And so, physicians who have a passion for caring for a person in the context of their family, community and environment is really well-suited for family medicine. We know that that access to high quality primary care really benefits the system, the health system, in ways that are unsurpassed anywhere else.
 
Erin Spain, MS: So there's a lot of medical students who listen to this podcast. Why would you encourage them to consider a career in family and community medicine?
 
Deborah Smith Clements, MD: It's such an interesting question, because we have so much new technology in medicine, and so it's very attractive sometimes to be drawn by all the flashy new things, right? Family medicine is based in relationship. It's based in intellectual curiosity, and really being able to identify the source of a problem in an undifferentiated patient. But it's about more than that. It's also about walking alongside a patient through their life. So, I have an example, if that's OK. Recently, I had two patients show up on my schedule -- they're siblings 18 and 20 -- and even though I've been doing this for more than 30 years that day, it occurred to me that I had been seeing those two young adults since they were small children, and I knew everything about their family history, and I knew about some pretty significant family issues that they had had while they were growing up that never would have come out of an interview because as a young adult, they didn't have the perspective to see themselves as children the way that I did. And so, I could see how their history and how their family influence contributed to where they were today, which really gave me a window into how to care for them in the future and what they might need. We form a relationship with patients in a very different way, and we understand the interplay of what happens in their family dynamics. And so much of what we do is not just on the medical side, but also on the behavioral health side. So, we're not the flashiest specialty. We're not a specialty that draws a lot of attention in terms of new technology. But we are the foundation of healthcare, and our job is to keep people well to provide prevention so that problems don't spiral into chronic disease, they don't escalate out of control. We try and limit visits to the emergency department because we want our patients to be as healthy as they can be from the beginning.
 
Erin Spain, MS: What is it been like during COVID-19 through the residency match process? What's been different? What's working, what's not?
 
Deborah Smith Clements, MD: You know, in terms of recruiting candidates, it's been challenging. It's been really challenging. Students have not been able to travel to the extent that they did previously to look at the place where they're going to continue their medical education. They've had to take a leap of faith in terms of of choosing the site of their next three to five years of training, which can be really challenging. We've been fortunate to have a great team that put together a fairly representative visual depiction of who we are, and we have heard from the interns that came in last year that we were pretty accurate in describing who we are and what we do here. But I know that's been challenging for lots and lots of places. We've also seen that students have had some gaps in their experience because they weren't able to get the same medical education that they had historically and not even being aware of what those gaps were. So, we've had to do some really careful assessment of students when they come in as interns to make sure that that we know what those gaps are, so that we can get them on the right start in their residency training.
 
Erin Spain, MS: Well, tell me about some of the publications. You've published several lately on the topic of family medicine and residency training. Share those with me.
 
Deborah Smith Clements, MD: So one of the other things that has become apparent over the past several years has been the escalating number of applications that students make as they apply to residency programs and the extraordinary costs that they're assuming in order to undertake that next phase of their training. We have to think of a better way. And it's become unnecessarily complex and competitive in a way that doesn't suit anyone well. We have begun some modeling at the National Resident Matching program to consider different mechanisms to be able to fairly and equitably place students into residency programs while reducing that burden. We don't want to return to the days that really disadvantaged a lot of students because of inequitable selection processes. We don't want to go back there. So, looking forward, we hope to find some solutions.
 
Erin Spain, MS: Because of the different ways that you've had to go about interviewing residents because of COVID-19, has that created a more equal playing field in some ways?
 
Deborah Smith Clements, MD: Absolutely. It is absolutely a more equal playing field in that there are always students who are unable to bear the expense of traveling around the country to find a program. That's been opened up to them. We have more than 750 family medicine residency programs in the country, and with virtual interviews, students have been able to, in a way, take advantage of applying at places that they wouldn't necessarily have applied to otherwise.
 
Erin Spain, MS: Did you get some of those doctors this time?
 
Deborah Smith Clements, MD: Actually, we did. We got a candidate from Philadelphia that likely would not have traveled to Chicago, but was really attracted to us and selected us and is very happy here.
 
Erin Spain, MS: Give me an update of what it's like right now to be a family medicine physician during the COVID-19 pandemic in recent months and even today.
 
Deborah Smith Clements, MD: We have always known that there have been inequities in society. But the COVID-19 pandemic really amplified just the pervasive economic and mental health and societal disparities that we have always seen. It's high time that people have recognized that there are such disparities in our healthcare system, and hopefully we're on our way to correcting some of those disparities that have been uncovered. I do believe I speak for all of us when I say that we're all really tired. This has been a long, almost 24 months now that we've been in the middle of COVID. We're smarter, we know a lot more about what's happening, but we also are meeting with resistance to the things that we know work, and that's been a real challenge for us. So we keep up the fight, and we continue to work at our communication skills to try and consider why patients are hesitant to receive vaccines and help them understand the benefit. We continue to care for people that that are in our hospitals that maybe didn't need to be and recognize that our role is to provide the care that's needed. And so, we go out there every day and we do that. The thing that's the most striking for us now at this point in time are the number of people that did not pursue medical care for things that are chronic conditions that have now worsened to the point where they're a lot sicker than they need to be. And that's been very, very challenging where we're seeing what we feared and that our resources are very limited. Our hospital beds are limited, our appointment times are limited, and we're being overwhelmed at this point.
 
Erin Spain, MS: So people put off things related to cardiology or other annual screenings and checkups.
 
Deborah Smith Clements, MD: People put off mammograms, they put off their regular care for their diabetes and hypertension, and those are things that can't be ignored.
 
Erin Spain, MS: So you're passionate about not only training students but also health policy and social justice. How do these areas come together with the work you do as chair of Family Medicine at Northwestern?
 
Deborah Smith Clements, MD: Primary care is a fundamental right, just like education is in this country. And until we can get to the place where everyone in our nation has access to the common good of primary care, we're not doing our jobs. As chair, I've been able to surround myself with a team who believes the same thing, who believes that one of our primary responsibilities is to train physicians who will serve their communities, who understand that we don't all start off with the same footing, but we all deserve to have an optimal level of health. So starting from that foundation, then we can look at: so what are our levers? What are we able to change within the system to make that dream a reality? And part of that is our teaching. Part of that is how we interact with students and residents. Part of that is also how we interact with our legislators and how we can impact health policy. Oftentimes, we expect our legislators, both at the state and the federal level, to have an understanding of healthcare in a way that I think is unfair. They don't have the background in healthcare that we do. It's a complex system. The more that we can partner with those leaders and help them, through our stories and our examples, help them to understand the complexities, the systems and the inequities in the system, the more that we can gain allies to help us make those changes.
 
Erin Spain, MS: Well, I do want to say congratulations on the Illinois Academy of Family Physicians Distinguished Service Award.
 
Deborah Smith Clements, MD: I'm just speechless about this award. I'm really overwhelmed with having received it. One of my former medical students, who was also a resident in my program, who is now faculty in my program, nominated me for this award. And I'm just really grateful to the family medicine community for recognizing me with this honor.
 
Erin Spain, MS: Thanks for listening. Be sure to follow us on Apple Podcasts or wherever you listen to podcasts. And if you're a member of the medical community, you can claim CME credit for listening to this podcast. Go to our website feinberg.northwestern.edu and search CME.