Editorials
The Future of Family Medicine Project: Embracing the Future
Most family physicians would agree that there has been a professional lethargy in our specialty over the past decade, compounded by a broken, inefficient national health care system. The issues behind this problem are complex and intertwined: the decline of professional prestige and practice reimbursements, waning student interest, an increase in physician frustration, toxic environments for family medicine in many academic health centers, quantification of our discipline's impact on the health of our country, and more than 40 million uninsured patients. Medical students increasingly are choosing other career specialties based on perceived prestige, applied technology, and lifestyle issues.
To combat these problems, the Future of Family Medicine (FFM) project was developed. Its mission is to devise a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. After extensive planning and considerable expense, the FFM report1 was published in March 2004 in the Annals of Family Medicine.
Family physicians are relying on the FFM project to identify strategic directions that resonate across the discipline. The project was designed to serve as a compass to point us in the right direction rather than an exact blueprint filled with details.
The FFM project initially was designed around five task forces. Task Force One considered core attributes and values of family medicine and proposed ideas for reforming family medicine to meet the needs and expectations of patients. Task Force Two determined the training needs of family physicians to deliver these core attributes and system services. Task Force Three explored ways to ensure that family physicians deliver core attributes and system services throughout their careers. Task Force Four determined strategies for communicating the role of family physicians to purchasers and consumers. Task Force Five determined family medicine's leadership role in shaping the health care delivery system.
The groups distilled 41 implementation tactics into 10 major project recommendations covering the following issues: (1) a new model of family medicine, (2) electronic health records, (3) family medicine education, (4) lifelong learning for each family physician, (5) enhancing the science of family medicine, (6) quality of care, (7) the role of family medicine in academic health centers, (8) promoting a sufficient family medicine workforce, (9) a unified communications strategy, and (10) leadership and advocacy.
Early in the project it became evident that, without significant changes in reimbursement and financing, the work of the five task forces would be in vain. Therefore, a sixth task force was created specifically to make concrete recommendations for improving practice finances to make the new model an economic reality. Its report2 has been published as a supplement to the November/December 2004 issue of the Annals of Family Medicine. The group is composed of family physicians with practice management expertise and representatives from major payers and consumers, including the Centers for Medicare and Medicaid Services, Families USA, AARP, BlueCross BlueShield Association, Aetna Inc., WellPoint Health Networks Inc., and Kaiser Permanente Inc.
Task Force Six created economic models that demonstrate that implementation of the new model significantly increases family physicians' incomes, in both the current fee-for-service environment and future pay-for-quality reimbursements. The results should serve as a stimulus for widespread adoption of the new model for practicing family physicians. Every family physician should read the entire FFM report to realize fully the opportunities that lie before us.
Another major goal of Task Force Six is the development of a national resource center to allow family physicians access to a centralized organization that can help them implement the new model and its components.
The FFM report has been a featured topic at national and state chapter meetings. It has been received with cautious optimism by many physicians and with a sense of cynicism from others, who realize that without a revision of our health care system, the potential of these recommendations will not be realized.
The FFM report offers a credible model to address many interrelated issues. Numerous studies have shown that a primary care-based health care system provides cost savings and better clinical outcomes. The FFM project focuses on a medical home for all Americans-one that is best provided by primary care physicians. To date, no other specialty has addressed the way its issues tie in with an efficient health care model for America's patients.
We are currently in the communication phase of the FFM project. AAFP members are encouraged to read the report online at http://www.annfammed.org/cgi/content/full/2/suppl_1/s3. As a discipline, we cannot afford to sit passively on the sidelines. We must actively advocate for our profession and patients and embrace the adage of the American "philosopher” Yogi Berra: "The future ain't what it used to be.”
John R. Bucholtz, D.O., is program director of the family practice residency program at Columbus (Ga.) Regional Healthcare System.
Address correspondence to John R. Bucholtz, D.O., Family Practice Residency Program, Columbus Regional Healthcare System, 1900 10th Ave., Suite 100, Columbus, GA 31902 (e-mail: john.bucholtz@crhs.net). Reprints are not available from the author.
REFERENCE
1. Martin JC, Avant RF, Bowman MA, Bucholtz JR, Dickinson JR, Evans KL, et al. The future of family medicine: a collaborative project of the family medicine community. Ann Fam Med 2004;2(suppl1):S3-32.
2. Spann SJ. Report on financing the new model of family medicine. Ann Fam Med 2004;2(suppl):S1-21.
Personalizing Prevention: The U.S. Surgeon General's Family History Initiative
RICHARD H. CARMONA, M.D., M.P.H., and DANIEL J. WATTENDORF, M.D.
An immense gap exists between what American families know about health and what they need to know. Chronic diseases currently account for seven out of 10 deaths in the United States. Although all of these diseases have hereditary factors, most can be prevented with relatively simple steps: healthy eating, being physically active, and not smoking.
Many families share different susceptibilities to disease; persons with a family history of coronary artery disease, for example, are more likely to have an acute myocardial infarction a decade earlier than those without such a history.1 Although healthy behaviors can benefit everyone, persons at increased risk for disease may benefit from targeted health promotion strategies.
The Human Genome Project has helped identify genetic variations that contribute to the risk for common diseases.2 These diseases most often are caused by a combination of genetic, environmental, and lifestyle factors. Because one's genetic predisposition to certain diseases cannot be changed, lifestyle choices and preventive measures must be directed specifically to persons who carry the preponderance of risk. Family history is a broad indicator of genetic variation associated with disease and may serve as a proxy for laboratory-based testing. In fact, DNA testing is indicated only when the family history is strong, the responsible genes are identified, and an intervention is available. Evidence-based guidelines for screening and management of common diseases often use family history information as a nodal point for changing the clinical intervention.3
Regrettably, the family history is underused.4,5 Patients often are unaware of their relatives' health information. In a survey6 conducted in November 2004, 96 percent of respondents felt that knowledge of family health history was somewhat or very important, yet only 30 percent had collected health information from their relatives. Cultural factors and patients' educational levels may be barriers to obtaining a complete and accurate health history. In addition, short office visits, a focus on acute care, inaccuracies in patient recall, and the absence of reimbursement make family history collection in the medical office challenging.
To "personalize” disease-prevention efforts, our patients must be able to collect accurate health histories from family members and record relevant information in a standardized format that health professionals can use to guide education, screening, and disease management. This process will establish a foundation for preventive medicine by highlighting diseases that have occurred in the patient's family and revealing nonmodifiable and modifiable risk factors.
To achieve these goals, the Office of the Surgeon General, in conjunction with the National Institutes of Health, the Centers for Disease Control and Prevention, the Health Resources and Services Administration, and the Agency for Healthcare Research and Quality, launched the U.S. Surgeon General's Family History Initiative in November 2004. Thanksgiving Day was chosen as "National Family History Day,” taking advantage of the time that many American families gather together.
Information about ways to collect a family history, as well as information that helps health professionals encourage the collection of a family history, is available at http://www.hhs.gov/familyhistory.
The cornerstone of this initiative is a free, computer-based tool, available in both English and Spanish, called "My Family Health Portrait,” which can be downloaded securely so that no information is collected or recorded on the Web site. The tool includes questions to ask relatives and instructions for entering the information. Although this campaign ultimately will encompass many diseases, the initial focus currently is on heart disease; diabetes; stroke; and breast, ovarian, and colon cancers. In addition, there are two open entries for other diseases specific to a given family. The result is a standardized family history that patients can print and take to their physicians.
We think this initiative is an important step in allowing the family physician to focus on disease prevention rather than treatment, thus helping more Americans to live longer, healthier, happier lives.
Vice Admiral Richard H. Carmona, USPHS, is United States Surgeon General, Commander, USPHS, Commissioned Corps, U.S. Department of Health and Human Services, Washington, D.C.
Maj. Daniel J. Wattendorf, MC, USAF, is liaison to the Office of the Surgeon General for the Office of the Director, National Human Genome Institute, National Institutes of Health, Bethesda, Md.
Address correspondence to Daniel J. Wattendorf, M.D., Building 31, Room 4B09, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD 20892-2152 (e-mail: dwatten@mail.nih.gov). Reprints are not available from the authors.
REFERENCES
1. Harpaz D, Behar S, Rozenman Y, Boyko V, Gottlieb S. Family history of coronary artery disease and prognosis after first acute myocardial infarction in a national survey. Cardiology 2004;102:140-6.
2. Collins FS, Guttmacher AE, Drazen JM. Genomic medicine: articles from the New England Journal of Medicine. Baltimore: Johns Hopkins University Press, 2004.
3. National Guideline Clearinghouse. Rockville, Md.: Agency for Healthcare Research and Quality, 2004. Accessed online December 1, 2004, at: http://www.guideline.gov.
4. Sifri RD, Wender R, Paynter N. Cancer risk assessment from family history: gaps in primary care practice. J Fam Pract 2002;51:856.
5. Frezzo TM, Rubinstein WS, Dunham D, Ormond KE. The genetic family history as a risk assessment tool in internal medicine. Genet Med 2003;5:84-91.
6. Yoon PW, Scheuner MT, Gwinn M, Khoury MJ. Awareness of family health history as a risk factor for disease-United States, 2004. MMWR Morb Mortal Wkly Rep 2004;53:1044-7.
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