The public has an idea of what a patient-centered medical home is, but they haven't yet identified it with us.
Fam Pract Manag. 2008 Nov-Dec;15(9):10-11.
I was born in 1971. To some of you that makes me an “old guy,” and to others of you that makes me a “whipper snapper.” Either way, the year of my birth marks the beginning of the public's understanding of a “patient-centered medical home,” although it didn't have that label at the time. Why is that so important? The AAFP has put a tremendous amount of effort into promoting the medical home concept. We've spent a lot of money, built a lot of relationships and put a lot of eggs into the medical home basket. But for all that, we're still having trouble selling the concept to America. The reason is that the public has not yet linked its 37-year-old understanding of the patient-centered medical home to what we're describing. What happened 37 years ago that we've forgotten?
The original medical home
In 1971, on the day after I was born, the television actor Robert Young was the keynote speaker at the then AAGP Scientific Assembly in Miami Beach, Fla. Young was better known as Marcus Welby, MD, on the year's No. 1 TV series of the same name. Dr. Welby was a kindly general practitioner – comfortable with all illnesses, though not necessarily an expert in them; willing to listen to patients at length, but knowing that sometimes the answer would require research and chart review; understanding that a patient's temperament, fears and family environment would often be the key to making the diagnosis; and aware that patients and younger colleagues needed his advice and support and that educating them would ultimately improve the health of the community. In his fictional practice, he dealt with drug addiction, rape, tumors and autism. He followed patients in the hospital even as he turned their care over to specialists. He understood that patients had long-term problems that needed to be understood in the context of their psyche, and he knew he would need the help of his nurse, his assistant and his health department to get the job done. Now tell me that's not a patient-centered medical home.
I recently searched dozens of Web sites for information about Marcus Welby, and you know what I found? Mostly weblogs of people complaining about their doctors and contrasting them to Dr. Welby. Young was a great friend of the AAGP and gave three keynote addresses for our organization – in 1971, 1974 and 1984. The AAGP reviewed all of the scripts of the TV show, the AAGP logo was aired at the end of every episode, and Young was a visitor to our headquarters on several occasions. Despite our generally cozy relations with this influential actor, a physician at one of our assemblies once complained to him, “You're getting us all into hot water. Our patients tell us we're not as nice to them as Dr. Welby is to his patients.” To this Young replied, “Maybe you're not.”
Herein lies the problem: We in family medicine have to help the public see that the Marcus Welby they are looking for is us. We have to help them see that what they value is what we offer. Unfortunately, we have spent so much time and effort trying to convince Washington, big business and the insurance companies of the truth of this that we have nearly forgotten to bring along the real stakeholders – our patients. It is not entirely the work of the AAFP to bring the public along. Yes, it's the AAFP's job to work with Washington and big business and the insurance companies. But it's my job – and your job – to work with the public. We have to show our patients and our communities that we are already patient-centered medical homes, that family doctors will give them the value they want, that we are the ones who can help them navigate the complex health care landscape, that family physicians will be there for them when the partialists have gone to bed and that the “family” in our name means what it says.
When the public understands this, then they too will put pressure on Washington, big business and the insurance companies. Only then can the AAFP mission of advocating for family medicine be accomplished.
Words of caution
Some physicians think they can wait for the payment system to change and for payers to start paying us fairly before they do what they need to do to become a medical home. Those physicians are hurting the specialty. For now, the people who pay us hold the keys. Until they see quantifiable quality, the bank is locked. We have to provide the quality, measure the quality and prove the value. Only then will we have the ability to negotiate from a position of power.
Other physicians (many of them from my generation or younger) could care less about the medical home concept; frankly, they just want to collect a paycheck and put in as little time as possible. Those physicians need to look to the future. According to a 2007 survey by the Association of American Medical Colleges, in the next 20 years one in three U.S. doctors is going to retire, leaving 71 million baby boomers to be cared for. These patients are the richest, smartest and healthiest generation ever seen, and they are going to be around for a long time demanding every single piece of a true medical home. Unfortunately, they are going to have to be taken care of by a generation of physicians who value their time more than their money and their personal lives more than their practice. In fact 71 percent of physicians under age 50 say that personal time is a very important factor in a desirable practice, most are willing to risk career advancement for better quality of life, and 32 percent would prefer part-time hours.
I'm here to tell you, you cannot work 20 hours a week, avoid the hospital, refuse to work with midlevel providers, abandon Medicare patients, throw away your pager, charge like a lawyer for every single phone call and call yourself a medical home. If you want life balance, you must actively engage with the networks of providers around you who can pick up the slack when you're not there.
Particularly as young doctors, you shouldn't shrink from change; you should be the ones embracing technology, group visits, telemedicine, registry development, e-prescribing, quality improvement projects and patient advocacy. If you don't, your patients will see you as impotent to provide high-quality, longitudinal care for their family, and they will look elsewhere for it.
Alive and well
Marcus Welby was a great physician because he embodied how people want to be treated and how people want their families to be treated in times of illness. He taught us about the importance of equal access to health care, the appropriate provision of charity care and the importance of building relationships with our subspecialty colleagues. None of us will ever be Dr. Welby, but each of us can do something in our practices to move us closer to fulfilling the promise of Dr. Welby. Every one of us can remember that we as family doctors already are a medical home; we just have to act like it, show it to our patients, teach our colleagues how to do it and support our Academy as it markets the results of our work to the nation.
Don't let anyone tell you that Marcus Welby is dead. Instead, show them that he's alive and well in all of us.
Editor's note: This opinion piece was derived from a speech Dr. Marker gave at the AAFP's 2008 Annual Leadership Forum in Kansas City, Mo.
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