Where Family Physicians Dare
Am Fam Physician. 2001 May 1;63(9):1700-1704.
Sometimes data are compelling. In this issue of American Family Physician, researchers at the AAFP's Robert Graham Center: Policy Studies in Family Practice and Primary Care demonstrate convincingly family physicians' unique role in promoting access to health care.1 In a straightforward and clever approach, researchers at the center analyzed national physician and population data for 1995 to show how geographic access to physicians would suffer if there were no family physicians. Without family physicians, 1,332 new counties would drop below the threshold of one primary care physician per 3,500 population. Below this threshold, they would earn automatic designation as whole-county Health Professional Shortage Areas (HPSAs), thereby tripling the 784 counties now designated. If, instead, all other primary care specialists were eliminated, only 176 new counties would earn HPSA designations.
As the center's report states, the unique locations of family physicians' practices underlie these striking findings. Unlike any other specialists, family physicians distribute themselves wherever people are found, from the smallest rural to largest urban areas.2,3 In contrast, subspecialists cluster near larger medical centers and close to the regional technologies important to their work, and these centers tend to be in larger and wealthier urban settings.4 Even other generalist disciplines are distributed less democratically than family physicians, in part because a practice limited by patients' ages or gender requires a larger population base.4,5
Family physicians locate to match the U.S. population for several reasons. Some family physicians are altruists, willing to commit their families and careers to meet communities' needs.6 Others simply find acceptable employment where physicians of other specialties do not: the temperament and broad training of family physicians enable them to work comfortably in settings with few consultants and little technology.4 Still others actually prefer to practice in settings far from other physicians, thereby avoiding the inter-specialty turf struggles common in more populated medical communities. Also, many family physicians hail from smaller towns and value the life and work they find there.7 Whatever the reasons, family physicians often settle where they are needed most and then succeed there. For these reasons, the National Health Service Corps and similar state-run support-for-service-programs have deemed family physicians their preferred specialists.8,9
Even in the urban and rural areas where physician counts suggest adequacy, local sub-populations often have unmet needs. In these frequent situations where existing community resources do not meet the needs of certain groups—most often children, the elderly, pregnant women, the mentally ill, and those with medical emergencies—family physicians often respond by adjusting the content of their work. They will assume care for nursing home patients, add or drop hospital care and broaden the range of medical conditions they manage if the need is there. Their broad, unique training allows them to substitute for physicians from a range of other subspecialties. The responsive plasticity of family physicians' work has not been adequately documented, but it is substantiated by evidence such as the tendency for those in areas with fewer obstetricians to practice obstetrics.10
Family physicians' unique contributions to health care access stem from the breadth of their training, adaptability of their work and a sense of social responsibility. If medicine was a baseball team, family physicians would be its much-valued utility player.
Donald E. Pathman, M.D., M.P.H., is associate professor and research director of family medicine, and senior research fellow at Cecil G. Sheps Center for Health Services Research at the University of North Carolina, Chapel Hill, N.C.
Address correspondence to Donald E. Pathman, M.D., M.P.H., Department of Family Medicine, University of North Carolina, Chapel Hill, CB#7595, Chapel Hill, NC 27599.
1. Robert Graham Center: Policy Studies in Family Practice and Primary Care. The United States relies on family physicians unlike any other specialty. Am Fam Physician. 2001;63:1669.
2. Council on Graduate Medical Education. Improving access to health care through physician workforce reform: directions for the 21st century. Third Report. U.S. Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, October 1992.
3. Council on Graduate Medical Education. Physician distribution and health care challenges in rural and inner-city areas. Tenth Report. U.S. Department of Health and Human Services, Public Health Service, Health Resources and Services Administration, February 1998; DHHS publication no. 97–44.
4. Rosenblatt RA, Hart LG. Physicians and rural America. In: Rural health in the United States. Ricketts TC, ed. New York: Oxford University Press, 1999.
5. Randolph GD, Pathman DE. Trends in the rural-urban distribution of general pediatricians. Pediatrics. 2001;107:e18.
6. Madison DL. Medical school admission and generalist physicians: a study of the class of 1985. Acad Med. 1994;69:825–31.
7. Gorenflo DW, Ruffin MT, Sheets KJ. A multivariate model for specialty preference by medical students. J Fam Pract. 1994;39:570–6.
8. National Health Services Corps. Proposed strategies for fulfilling primary care manpower needs. A white paper. Unpublished document prepared for the NHSC National Advisory Council, dated October 6, 1989.
9. Pathman DE, Taylor DH, Konrad TR, King TS, Harris T, Henderson TM, et al. State scholarship, loan forgiveness, and related programs: the unheralded safety net. JAMA. 2000;284:2084–92.
10. Pathman DE, Tropman S. Obstetrical practice among new rural family physicians. J Fam Pract. 1995;40:457–64.
Copyright © 2001 by the American Academy of Family Physicians.
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