Rekindling the Fire of Family Medicine
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Dissatisfaction is growing among family physicians and throughout primary care. Can the trend be reversed?
Fam Pract Manag. 2006 Jan;13(1):15-17.
From reading the lay or medical literature lately, you would think that physicians are ready to tear down their shingles and become stockbrokers, house painters, lounge singers – anything other than doctors. Physicians often are portrayed in the popular press and in prominent medical journals as miserable in our jobs. While some studies show that primary care physicians are relatively content,1 other surveys report that a significant percent are sorry they went into primary care.2,3
Unhappiness in doctors is not good. Dissatisfaction can lead to increased job turnover,4,5 and dissatisfied primary care physicians are more likely to express difficulty caring for patients and are less able to provide quality care.6 Dissatisfied doctors also are more likely to have dissatisfied patients.7 So, we must ask ourselves: Why are we so unhappy, and what can we do about it?
Why are family physicians so unhappy?
We know that physicians who choose to enter family medicine do so because they feel the advantages outweigh those of other specialties. Researchers have found that students entering primary care are more likely to value interpersonal relationships, independence and public service over prestige or wealth.8 These values complement other factors that influence students to choose family medicine, such as a sense of altruism, favorable role models during training and the presence of family medicine clerkships in the medical school. In sum, students who place a higher value on relationships and independence are more likely to enter primary care, while those who place a higher value on wealth or prestige may be more likely to pick a subspecialty career. In reality, all physicians might want all of these things, but when pressed to choose one or the other, primary care physicians tend to sacrifice wealth and prestige for other values.
Family physicians are unhappy because the health care environment inhibits us from achieving the goals that first attracted us to the specialty. Changes have eroded the values that were the foundation of family medicine. Even the central value of family medicine (i.e., forming a lasting relationship with a core set of patients) is slowly dissolving. Relationships that had been established and nurtured over decades are severed when employers change health plans and our patients are forced to find new doctors. Primary care has become a commodity that many believe any physician can provide equally well.
A study in Britain found that the quality of the interpersonal interaction was one of the major determinants of general practitioners’ satisfaction in their practice.9 In other words, the patient relationships are what make being a family doctor fun. But instead of developing lasting, quality relationships, we now treat large numbers of patients who are simply strangers.
In addition, primary care doctors have lost a significant amount of independence. Family doctors, like other physicians, have coalesced into larger and larger groups. Whether we are able to shape our practices and services to meet the needs of patients is now secondary to the needs of the larger group or system.
With quality relationships and independence eroding, many of us may feel that we are not receiving what we bargained for when we chose our career. Not only are we not getting the relationships and autonomy we desire, but we also lack the monetary reward and prestige other specialties enjoy. It is no wonder so many of us are dissatisfied.
Where did things go wrong?
According to the attribution theory, when things go well, individuals are eager to take personal credit; however, when things go wrong, external forces must be to blame. When this principle is applied to a physician who is unhappy with his or her career, that physician is likely to blame insurers, specialists, patients, the government and nearly everyone else for ruining the practice of medicine. Ascribing blame to external forces makes it easy to throw up one’s hands and conclude that little can be done to help the situation. Family medicine is especially vulnerable to this negative thinking. While it is certainly true that these external forces contribute to our sense of dissatisfaction, we as family physicians have made critical errors that have amplified our current discontent.
To begin with, we have placed a dollar value on continuity. When offered higher fees for new groups of patients, we jumped at the benefits of increased reimbursement without accounting for the emotional costs of discontinuing established relationships. At first, some physicians did not recognize that by embracing the concepts inherent in managed care, we would be trading valuable relationships for dollars. Many physicians have discovered that the few dollars they received in return were not worth the sacrifice.
Second, we have been lured into large multispecialty groups with promises of security, more money than we could earn on our own and management efficiencies that would allow us to practice medicine the way we want. But these benefits all come at the cost of autonomy. This way of delivering health care is not founded on the values of family medicine (i.e., strong patient relationships and independent decision making). Instead, these systems were erected based on the values of our sub-specialty colleagues to maximize revenue and increase prestige at the expense of individual patient relationships and physician independence. If we had realized from the outset that these systems needed us more than we needed them, we might have been able to reshape them to reflect our values.
So how do we recapture the relationships and independence we have relinquished? Some physicians have developed practices that are wholly independent, sometimes to the extent of having no employees and developing very rich relationships with patients. However, most physicians are not prepared to shift their career to this extent.
Even so, we need to return to emphasizing continuity for individual patients. Not only would this be good for our morale, but also it results in better care for patients.10,11 In addition to producing improved outcomes, continuity appears to be a key feature in the development of trust between patients and their physicians.12,13
Additionally, we must regain our independence. Only groups that embrace our values are capable of providing an environment that will allow us to be happy. In some cases, this may mean returning to single-specialty groups and abandoning large multispecialty organizations. Another approach is to move into leadership roles within multispecialty organizations and encourage these groups to adopt our values. Those organizations that do not value what we believe do not deserve to have us in their groups.
The task ahead
With family physician satisfaction waning, it is more and more apparent that family medicine is not meeting our expectations. To return to the foundations of primary care, we will need to make patient relationships our top priority and hold this value paramount in our business models. If we don’t, we are risking nothing less than the future of our specialty and the health of our patients.
WHAT DO YOU THINK?
The views and opinions expressed in the editorials published in Family Practice Management do not necessarily represent those of FPM or our publisher, the American Academy of Family Physicians. We recognize that your point of view may differ from the author’s, and we encourage you to share it. Please send your comments to FPM at email@example.com or 11400 Tomahawk Creek Parkway, Leawood, Kansas 66211–2672.
About the Author
Dr. Hueston is professor and chair of the Department of Family Medicine at the Medical University of South Carolina in Charleston. Conflicts of interest: none reported.
1. American Academy of Family Physicians. Members assess AAFP, its activities, the specialty. Available at: http://www.aafp.org/x40158.xml. Accessed Nov. 30, 2005.
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8. Kassebaum DG, Szenas PL, Schuchert MK. Determinants of the generalist career intentions of 1995 graduating medical students. Acad Med. 1996;71(2):198–209.
9. Daghio MM, Ciardullo AV, Cadioli T, et al. GPs’ satisfaction with the doctor-patient encounter: findings from a community-based survey. Fam Pract. 2003;20(3):283–288.
10. Love MM, Mainous AG III, Talbert JC, Hager GL. Continuity of care and the physician-patient relationship: the importance of continuity for adult patients with asthma. J Fam Pract. 2000;49(11):998–1004.
11. Gill JM, Mainous AG III, Nsereko M. The effect of continuity of care on emergency department use. Arch Fam Med. 2000;9(4):333–338.
12. Baker R, Mainous AG III, Gray DP, Love MM. Exploration of the relationship between continuity, trust in regular doctors and patient satisfaction with consultations with family doctors. Scand J Prim Health Care. 2003;21(1):27–32.
13. Mainous AG III, Baker R, Love MM, Gray DP, Gill JM. Continuity of care and trust in one’s physician: evidence from primary care in the United States and the United Kingdom. Fam Med. 2001;33(1):22–27.
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