It's 2020 -- January 2001 -- FP Report

January 2001 • Volume 7 Number 1

It's 2020

It's 2020.
That's what participants at the recent Keystone III think tank on family practice envisioned.

Two speakers were asked to take opposing views explaining the state of the specialty -- Larry Green, M.D., had the daunting task of assuming the specialty had failed and saying why; Marjorie Bowman, M.D., took the premise that the specialty had succeeded and suggested why. On these two pages are summaries of Green's and Bowman's main points. Keystone III was held last Oct. 4-8 in Colorado Springs, Colo., in the tradition of Keystone I and II in 1994 and 1998 at Keystone, Colo.

Don't brand the thought-starter ideas on these pages as predictions. They're imaginary scenarios with sketches of the evolution from now to 2020 -- given either the demise or triumph of the specialty by then.

If family practice has failed, why?

Larry Green, M.D., director of The Robert Graham Center in Washington, gives a report following an imaginary Keystone V in 2020, a small gathering of believers in family practice who discussed the widespread recognition that family medicine had failed. Green first offers a context for medicine in 2020 in which it's likely the specialty would not survive.

Social/Medical Milieu
By 2020, the division of wealth among the citizenry had widened, and there were proportionately many more very wealthy and many more very poor individuals.

Medicine was still politics on a grand scale. Hospitals that survived had amassed enough capital to have the latest version of whatever technologies could be applied to generate revenue out of the medico-information complex, the economy's largest sector.

There had been no particularly accurate workforce predictions other than growth. The eruption of additional and alternative health care providers had continued for the first decade of the century, with one person in four making a livelihood in health care.

Outside of cities, general surgeons had reversed decades of decline and become the centerpiece of personal, face-to-face health care. Emergency medicine physicians comprised some 20 percent of all physicians. Midwives managed most maternity care. Nurse practitioners did some 80 percent of technical procedures and virtually all genetic counseling, and pharmacists were the first point of contact for the care of chronic conditions amenable to drug treatment.

In cities, "health care boutiques" were all the rage, each jockeying for a more enticing image, spending twice as much on advertising as on quality improvement. Their doctors were the heirs of medical subspecialization.

The psychiatrists had largely disappeared, their prescribing done by a host of others.

The OB-GYNs, after winning the skirmish with family medicine concerning maternity care, had abandoned obstetrics as not worthy of their training and expertise.

The public continued to seek more health care and openly fantasized about immortality, but despite "progress" remained as dissatisfied as ever. A decade after universal inclusion was achieved in 2010, it did not seem like everyone was guaranteed anything.

If there was a significant pocket of public dissent, it was among the wealthiest of the poor, struggling to break into the "good life" always just beyond reach. No one asked for a return to the good old days "when we had a family doctor." Yet Keystone V attendees reported anecdotes about individuals who expressed their frustrations about being treated as unknown objects by the health care enterprise and not feeling understood by anyone. The patient's message was, "How can there be so much known about me, while no one in the health care system knows me?"

The Specialty's Failure -- Why?
Participants in Keystone V -- there were only a couple dozen of these "residual believers" in family medicine -- first agreed that the steady decline in the proportion of health dollars and total dollars that went to FPs was a fact reflecting other factors and not an adequate explanation in and of itself. They also agreed that failure doesn't really exist as a thing, only from a position of judgment. To make the judgment, one must have a viewpoint. Thus, the residual believers organized their thoughts from different viewpoints.

Viewpoint 1: Family medicine didn't really fail; it abdicated. It made sense to turn over the care of the dying, the newborn, the adolescent, the athlete, the discouraged, the pregnant, the bed-bound, the postoperative person -- to someone else.

Viewpoint 2: Family medicine went down as part of the old paradigm. A few Keystone V participants had reminded family physicians during the past few years that the AAFP held a dominant position in the AMA as the AMA "went down."

Viewpoint 3: Family medicine failed because it chose the wrong tasks. Possibilities used to illustrate this viewpoint fell mostly into the following three categories.

Nature of the work. Someone said family physicians woke up one morning about 2010 and couldn't remember what their particular clinical task was. Little wonder that the best and brightest no longer aspired to become doctors doing the tasks FPs did each day.

Maturation of the discipline. A cardinal example was a protracted emphasis on producing more and more family physicians rather than the best family physicians.

Intellectual advancement. As the years passed with family practice separated from curiosity and a vigorous quest for discovery, there was widespread recognition that breakthroughs always occurred somewhere else, followed by agonizing about how the family physicians just weren't doing the best things anymore.

Viewpoint 4: Family medicine failed because it never became part of the U.S. culture and was not radical enough to merit the opportunities inherent in being counter-culture. Family medicine was doomed from the beginning because of the culture of the United States, specifically its emphasis on consumption, fascination with the biological and physical sciences, and individualism. There was a certain disingenuity in family medicine's public display of its ambivalence about specialization while the populace was preoccupied with consuming the fruits of specialization. Everyone remembered the embarrassment of the specialty's being associated not with the best of modern medicine but with beer commercials and being denigrated as "medicine lite."

On the other hand, being located outside the mainstream of culturally sanctioned medicine was a primary reason family practice revenues were never greater than its expenses, always leaving the discipline short on capital in a capitalistic society and market-based medicine.

The residual believers uniformly regretted not speaking out more forcefully and effectively in academic centers, practice organizations, media and government for the core concepts of family practice and primary care.

If family practice is thriving, why?

Marjorie Bowman, M.D., professor and chair of the family medicine department at the University of Pennsylvania in Philadelphia, ponders the current state of family medicine and explores reasons the specialty may have succeeded by 2020.

Retrenchment Today
History can always identify our past errors, but we tend to overlook what we have done right. On the other hand, our biggest mistakes on occasion result in redirection that creates our successes.

Considering what is happening today in family practice, I believe we have hit a period of retrenchment. We have fewer students interested in our field, some residencies are folding, and there has been an anti-gatekeeping backlash that is directed at us. Patients are clamoring for specialists and specialty care. The patient care bill of rights can be seen as anti-FP. The AMA has taken back its support for the Archives of Family Medicine.

I would like to think we are in a recurring cycle of ups and downs, that we are now on the downslope, even preferably to think that we have hit the bottom and are going into an upswing, but I have trouble convincing myself.

What will turn this around?

Reasons For Success By 2020

Some thoughts on what we will have done right by 2020:

We will have emphasized and continued to improve the quality of care, both that provided by family physicians and that of the entire system. We should be known as the quality doctors. We should have quality-based systems, we should advertise that we work on quality, we should publish on quality, we should find new methods that increase quality.

This includes quality of the doctor-patient relationship and quality of outcomes for the entire person -- not just the process of care or an individual disease. We know that quality requires appropriate systems. You can put a good physician in a bad system, and that physician will have trouble performing well. You can put a poor physician in a good system and improve the quality of his or her care. We will have developed systems that encourage good quality.

We will have pushed for and given every person in the United States the right to health care. Every patient should have health care in the richest country in the world. Every system has primary care at its base. In fact, within almost all countries, the primary care person of first contact is usually most akin to family practice in this country -- broad-based, easily accessible.

Assuring the right to health care is the right thing to do for the country and for family practice.

We will have gained political power. We will have advanced within the ivory towers of academic institutions, in state and federal legislatures, in medical political organizations. This requires time, effort and money.

Our goal should be to endow two or three professorships in family medicine at every medical school in this country by 2020. Endowment means faculty can have time to pursue research and education and not just patient care. Our goal should be to have as many or more funded NIH investigators at every school as departments of medicine have. We need a federal agency that sees family practice as a specialty to be nurtured and developed. We need to become the "go-to" doctors.

We will have developed technology that patients like and that supports our ability to provide high-quality care to people, for which people are happy to pay.

This means thinking about technology differently and using more of the technology that already exists. It may also mean that nationally we need to be innovative in forcing reimbursement changes and in helping family physicians know how to be paid for something other than visits. Nationally, we need to get technology innovations that will help us in our offices. Electronic medical records are a part of this -- without an electronic medical record as part of our system, it would be difficult to make that next step in increasing quality.

We will have advocated for research inside and outside of our own disciplinary walls that addresses multiple concurrent problems of patients. Federal spending is too individual-disease-specific. The end result is research that does not match our patient needs, since our patients have multiple concurrent problems (both mental and physical), are on multiple concurrent medicines, and thus often do not match the types of patients entered into federal research programs.

We will have made patients the masters of their own health care. Personally, I want to be in charge of my health care, but I admit I need help (from my family physician and others). Analogously, I want to be in charge of my bank account, my own legal situations (or fill in the blank), but I need help. Most patients agree with this, although sometimes we force them to show it in passive-aggressive ways.

We have often espoused this philosophy, but I do not feel we have implemented it fully. Patients who are active in their health care tend to have better outcomes. It is the epitome of all I have said here.

Continue the Keystone III dialogue regarding scenarios for why the specialty will have failed or succeeded by 2020. Share your thoughts on the future of the specialty by e-mailing fpreport@aafp.org or by faxing (913) 906-6089, attn: FP Report.

Patients should be able to obtain health care. We should provide them high-quality care and also make sure they get it when they are not in our offices. We should use technology and research to their advantage. We should provide the tools to the patients and actively address this, not just talk about it when it is convenient.

We should be the high-quality, go-to doctors who put patients in charge. That's family practice -- that's our success.

FP Report | Headlines | AAFP Home | Search