The debate over family physicians' scope of practice -- whether it is shrinking or growing -- can be a heated yet wonderful debate for a specialty to have. The fact that there is a debate at all suggests that the scope of family practice is rich with possibilities and that family physicians care deeply about their discipline.

Our February 2000 cover article, "Are the Edges of Family Practice Being Worn Away?" addressed this issue and generated many responses from family physicians across the country. Read on to find out how some of your peers feel about their changing scope of practice and what, if anything, should be done.

Refining the boundaries

Family practice is simply refining its scope of practice in response to a multitude of factors. Medical science has progressed so quickly in the past 30 years that it's almost impossible for a physician to remain competent in the skills and knowledge required to care for patients in both the inpatient and outpatient settings. Indeed, many family doctors prefer to dedicate their efforts to one or the other. For example, the use of hospitalists a mere decade ago would have been considered blasphemous by the purists of family practice; yet today, many family doctors, even those recently out of training, readily use them.

The ever-present threat of malpractice is another factor that drives family doctors to self-limit their scope of practice. Patients expect perfection from their physicians and sometimes sue them when they have doubts about the care they have received. Physicians want to minimize any chances of having to undergo malpractice disputes and thus prefer to practice in those areas where they feel most confident of their skills.

'Haven't all specialties undergone this pattern of evolution?'

Finally, the administrative distractions of running an office have increased immensely. Dealing with phone calls from patients, nursing homes, pharmacies and families is enervating, and making referrals and trying to get prior approval for drugs is a mind-numbing waste of time that leaves many physicians exhausted.

Family practice boundaries are not being worn away; they are being refined in response to scientific and cultural pressures. Haven't all specialties undergone this pattern of evolution?

-- Edward J. Volpintesta, MD,
Bethel, Conn.

Proud to be doctors

As someone who helped build family practice and increase public confidence in it, I am saddened by this issue. And as a recently retired family physician in ill health, I am saddened by what I find when my wife and I seek care.

'We started with $2 office calls and about 50 percent charity work. We loved it, and we were proud to be doctors.'

In family practice, a week is not 40 hours; it's 168 hours. That's when we were available to families who came to us for care, not for referrals. How can you call yourself a family physician if you only have privileges to do one-tenth of the things most families come to you for? It's no wonder nurse practitioners are taking over the field. Are family practice residencies preparing real doctors? I delivered 1,200 babies before I even started private practice. Now family physicians don't plan to do deliveries at all.

The limited-practice doctor is contributing to the unacceptable cost of health care. Today's doctors worry about reimbursement; we started with $2 office calls and about 50 percent charity work. We loved it, and we were proud to be doctors.

-- Hollis K. Lefever, MD,
Townsend, Mont.

Only half the story

Are the edges of family practice being worn away? Yes, but that's only half the story. A better question would be, "How can family physicians position themselves to thrive as old roles erode and new opportunities emerge?"

'It is crucial that family physicians avoid falling into a siege mentality.'

In my view, it is crucial that family physicians avoid falling into a siege mentality. We must honor the past but not become its prisoners. Times of rapid change, like the ones we have experienced in recent years, are both threats and opportunities. Survival and progress depend on giving appropriate attention to each side of the coin.

We must also allow for and indeed embrace diversity of talents, interests and opportunities. There is a core role and knowledge base for family physicians, but beyond that there is room for different areas of secondary focus. Let those physicians who enjoy obstetrics include it in their practices. Ditto for those drawn to the challenge of intensive care medicine or endoscopy or counseling or whatever it may be.

Finally, let's make nurse practitioners and physician assistants our allies. Put them to work doing the everyday medical tasks they do best, while we focus on more complex patient challenges and clinical management issues.

-- Robert D. Gillette, MD,
Poland, Ohio
[Dr. Gillette is a member of the FPM Board of Editors.]

Mortgaging our future

I worry about the future of our specialty. We may be mortgaging our own future when we give up inpatient and obstetrical privileges. If we insist on a scope of practice similar to that of midlevel providers, we may soon find we have the status and salary to match.

-- Jon F. Bode, MD,
San Antonio, Texas

Ego and money

I believe the scope of family practice is being shaped by the same egocentric and extrinsic forces that are changing all of health care delivery. These forces encourage physician competency and efficiency on one hand, while burdening the physician with paperwork and regulations that distract from individualized patient care.

If family physicians are "burned out" and unable to practice a full scope, I suspect it's because they're tired of battling a health care empire based on population statistics instead of individual patients and on profit instead of patient care.

-- Paul J. Grimm, MD,
Charleston, S.C.

Quality of life

I take exception to the characterization that doctors who give up obstetrics and other procedures have a laissez-faire attitude to our professional roles. Dropping procedures that demand an hour or more from an already busy day is indeed about lifestyle, but that should never be treated as dismissively as it was in the article. I mean no disrespect to my academic colleagues, but it is easier to continue all these activities in academic medicine than it is in private practice.

It's not that family physicians like myself want lifestyle changes to allow for a 40-hour work week. Patient expectations and the need to be consumer-friendly have grown ever higher, demanding increased accessibility, timely appointments and flexible office hours. We need these lifestyle changes to achieve even a 60-hour work week. As a former medical director for a primary care satellite system, I found that new providers we sought to hire were willing to make less money in exchange for a more human lifestyle. Work weeks of four 12-hour days, less call, a more manageable patient load: These were the requests I received from my providers.

As I counsel my patients on stress, anxiety and making quality-of-life decisions when faced with job stress, I have to think also about myself and my colleagues and the example that we set. We, as family physicians, got caught in the same trap that many Americans did in the 80s and 90s: work more, spend more, owe more, work more. We are now seeing in our profession the same backlash that has given rise to the voluntary simplicity movement. Its credo is own less, work less.

The desires expressed by our colleagues to drop certain procedures and concentrate on others should be seen as a chance to reevaluate our own commitments as a profession, to hold onto those things we do best and to provide a framework of flexibility in our field to help all of us achieve satisfaction in our lives inside and out of the arena of medicine.

-- James E. Meade, MD,
Watertown, Wis.

An open letter to family practice residents Inspired by our recent article on family physicians' scope of practice, Scott E. Rand, MD, a faculty member at the University of Texas Medical Branch Family Practice Residency Program, penned the following letter intended for all graduating family practice residents. Dear fellow family physician, Congratulations and welcome. You are joining a select group of physicians with the training and experience to be called real doctors. Your training is inclusive, not exclusive, limited only by what you wish it to be. You now have the opportunity to truly make a difference. Like the men and women you join today, you entered medicine for many reasons. You enjoy the intellectual challenge. You thrive on being able to diagnose virtually any problem and treat virtually anyone who presents to you. You realize that treating patients is more than knowing what disease they have and what pill treats that disease. You understand that in order to be a real doctor, you have to understand your patients' lives, their communities and their families. You have seen throughout your training that patients respond best when they are cared for by someone who cares about them and understands them as people and fellow community members. Today is not a day to be timid or to acquiesce to the opinions of the limited practitioners who would try to dictate who or what you should care for. They may have more knowledge about a particular age group, gender, organ system or disease process, but they cannot begin to comprehend the abilities you have or the care you can provide. Be gentle with them, for their lack of education and experience will often cloud their judgment. Never allow yourself to be relegated to the role of "gatekeeper," "primary care provider" or some other insulting euphemism meant to define you as less than you are. Avoid the temptation to limit voluntarily the things you do simply because the subspecialist does it better or more frequently. Your patients want and need you to do all that you can for them, not for you to be a speed bump on their road to care. If your consultants do not respect you enough to return your patients after answering the question you asked, find other consultants. Their role is to answer a question or perform a procedure you choose not to perform, not to expound on their superiority in some field or another. Your job is to take care of your patients, not to make the limited practitioners feel better about themselves. Choose to deliver babies. The essence of family practice is in the delivery of care throughout the spectrum of life. If you choose not to deliver babies, do so because your community doesn't need you to, not because the hospital, the insurance company or the limited practitioners tell you it is in the best interest of your patients. How arrogant of them to assume that you cannot assist your patients in a process that is done without any medical intervention all over the world every day! However you choose to define your practice, remember that you have the ability and the obligation to make a difference. Make a difference not only in the lives of your patients, but in the community in which you live and practice. Speak out when you are confronted with obstacles to the health of your community. Become involved, for the duty you have to care for your community extends outside the walls of your clinic or hospital. The schools, the environment and the culture of your community all demand your expertise and input. The responsibility is huge, but the reward is just as great, and you are all equal to the task. Welcome to the club. We've waited a long time for you to get here. Your practice and your life await you. No career on earth is more difficult, but no job is more rewarding. You are not an "ologist"; you are a real doctor. And there is no greater compliment in the world than being introduced as "my doctor." Scott E. Rand, MD, FAAFP Assistant Professor, University of Texas Medical Branch Galveston, Texas

Accept the responsibility

In my rural practice of seven family physicians, we have had no pressure to limit our scope of practice. More often we find ourselves doing things that push the envelope on our training and abilities!

I have noticed one interesting thing, however. As a female physician, I've never done a vasectomy in practice, although I was trained to do them. I also stopped doing sigmoidoscopy because, with my largely female, mostly young patient population, I was only doing about one a year and didn't feel I was keeping up my skills. Conversely, my husband (who is one of my partners) stopped doing colposcopy because he was only doing about one a year. I think our patients are determining our scope of practice along gender lines, to a certain extent.

I have also noticed that scope of practice seems to be split along the lines of practice location. When I meet my colleagues who practice in nonrural areas, it's almost as if we are no longer in the same specialty. The problems they face in everyday practice are not the problems I face. They no longer want to attend conferences on obstetrics, intensive care or procedures because that's not the type of medicine they're practicing.

'The less we do, the less others will think we are capable of doing.'

As a specialty, we need to guard against this division and encourage as many family physicians as possible to maintain as wide a practice as possible. Otherwise, we do run the risk of unnecessarily restricting our practice opportunities as a specialty. The less we do, the less others will think we are capable of doing. No one else can provide the type of care a family physician can, and we need to accept that privilege and responsibility when we decide to become family physicians.

-- Kristin K. Elliott, MD,
International Falls, Minn.

Making due

I've experienced all too vividly the decline discussed in the article. After leaving residency in the early 80s, I went into solo practice and did it all: obstetrics, pediatrics, hospital care, surgery assists, etc. But I was never able to find another family physician to join me -- perhaps the scope was too broad -- and I finally had to give up my solo practice in order to save my health and avoid burning out.

Now, I am part of a staff-model HMO, and although I am a family physician, I see very few children and no newborns (the corporate culture from appointment clerks on down is that pediatricians see kids). I have given up almost all procedures, and I do inpatient work on a rotating basis (without ICU or surgery assisting). Just the idea of delivering a baby horrifies many family physicians worried about issues of coverage and payment for extra time.

Since the loss of my solo family practice, I look for satisfaction in places other than just the practice of medicine. With hope, reform in the medical system will some day allow family physicians to enjoy a restored esteem.

-- Misha Askren, MD,
Los Angeles

Caring for all aspects of life

As the first DO to have privileges in our rural community, I have worked hard to gain the trust and respect of my peers and patients. It would be easy to scale back and give up some or many of the facets of medicine, but they truly are what sets us apart.

The true gift of medicine -- and the art of practicing medicine -- is being led by your heart, not your wallet. If that means pronouncing a patient at 3 a.m. when the family is waiting for you to add closure to that person's life, then you must be there. When I look back on my years of practice, I hope to feel rewarded by the people I took care of and the lives I helped to enrich. And I hope to be remembered not simply as a good and knowledgeable doctor but as a compassionate and caring human being who helped to take care of all aspects of life.

-- Curtis P. Swagler, DO,
Wellsboro, Pa.

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