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Tuesday Sep 09, 2014

The Value of Family Medicine: Stating the Obvious to the Oblivious

I recently participated in a state-level meeting with Medicaid administrators that also included a number of subspecialists. The discussion revolved around the appropriate dosing of proton pump inhibitors for acid reflux, with some Medicaid representatives opining that these medications were being over-prescribed by "general physicians." Some, in fact, called for implementing a stricter prior authorization process if drugs in this class are to be prescribed by primary care physicians.

Both the administrators and the subspecialists offered misguided statements, such as

  • "Family physicians can't follow treatment guidelines because of the complexity and ever-changing nature of those guidelines."
  • "Treating acid reflux should be left strictly to subspecialists."
  • "Primary care physicians don't actually think about what they do but reflexively prescribe medications that they don't fully understand."

As the lone family physician in the room, I defended our specialty. However, thoughts like these remain prevalent among some payers and subspecialists who fail to understand the value we bring to the health care system.

I know I am not the only one facing these gross misperceptions, so I want to refresh everyone's memory about why family medicine is the foundation of health care and, thus, one of the most important areas of medicine in any health care system.

We Care for the Whole Patient
Probably the biggest reason family physicians are best suited to caring for patients is our broad training and how we apply it to patient care. For example, a patient's depression impacts his or her diabetes, which, in turn, can affect his or her chronic obstructive pulmonary disease and heart failure. Medication side effects often worsen another disease process. And a patient's social context frequently provides significant insight into his or her symptoms. Understanding how to look at all of these pieces and see beyond a specific organ system to the complete person provides many of the clues to proper diagnosis and treatment. Comprehending how these issues fit into the patient's framework of values, beliefs, community and culture presents the key to healing.

We Blend the Evidence With Our Knowledge of the Patient
Providing quality care for patients is a central principle of family medicine. We use the best medical evidence to guide our diagnostic and treatment recommendations, but we also recognize when the context of a patient's illness calls for tempering that evidence-based approach. The medical decisions we make in conjunction with patients may not always look best to an administrator, but that doesn't mean they're the wrong decisions. They simply reflect the biopsychosocial model of family medicine training that uniquely positions us to respond to a wide variety of complaints and situations to better meet patients' needs.

We Provide Value to Our Patients and the Health Care System
Family physicians deliver higher quality care for a lower price(www.commonwealthfund.org) than does any other specialty. This topic has been studied extensively by researchers, such as Barbara Starfield(www.ncbi.nlm.nih.gov) and others, who recognize the impact family medicine has on individuals, as well as systems. With the ever-increasing costs of health care, the solution to the problem is to better utilize the value that family physicians provide instead of viewing us as merely a source of referrals to subspecialty care. But reaching that solution -- providing the value that we as a specialty are truly able to deliver -- means safeguarding the time we spend with each patient from being restricted by payers.

By no means is this intended to disparage the contribution subspecialists make, because we all recognize their worth and how necessary they are in treating many of our patients. But our health care system is never going to be able to overcome its main pitfalls if more people cannot recognize the essential role of family physicians. It is our responsibility to continue to educate those around us about our role so that together, we can continue to improve the health of our individual patients and the performance of our entire health care system.

Kyle Jones, M.D., is a faculty member at the University of Utah Family Medicine Residency Program in Salt Lake City. He is the director of primary care at the Neurobehavior HOME Program, a patient-centered medical home for those with developmental disabilities. You can follow him on Twitter @kbjones11.

Posted at 02:54PM Sep 09, 2014 by Kyle Jones, M.D.

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