The ship is turning. After years of drifting through policies that discouraged medical students from choosing primary care, America's medical community has recognized the danger of drifting too close to the shores of subspecialization, according to AAFP leaders. Nowhere was that more clear than during the 2006 annual meeting of the AMA House of Delegates.
The June 12-15 meeting was a landmark, said AAFP President Larry Fields, M.D., of Ashland, Ky. Not only did deliberations demonstrate the Academy's new emphasis on positive contributions to the AMA, but they also revealed a growing concern about Americans' access to much-needed primary care medicine, he said.
AAFP Board Chair Mary Frank, M.D., of Mill Valley, Calif., agreed. "The issues that were most important to us -- the graduate medical education, funding for primary care education, payment reform -- were all good," she said. "We're very happy with the results of these issues."
Among the most telling signals were recommendations in a Council on Medical Education report to the AMA house. The recommendations, adopted by the delegates, called on the organization to focus its workforce initiatives on policies that will ensure a balance between generalists and specialists, said Fields and Frank. Specifically, the report included recommendations that the AMA
'A Landmark Victory'
AMA Sharpens Focus on Fostering Primary Care
By Leslie Champlin
6/28/2006
- "develop policy regarding the development and maintenance of the appropriate workforce balance between generalists and specialists in its Initiative to Transform Medical Education and in future studies or deliberations related to the medical workforce,"
- "support the concept of partnerships between primary care physicians and patients to coordinate access to all needed medical services and consultations (a 'medical home') for all patients," and
- "work with the (AMA) Federation (composed of state medical societies and associations and professional/medical specialty groups) to convene and staff a 'medical workforce commission' … to project the optimal medical workforce for the United States and to develop strategies" to achieve that (goal).
Generalists Versus Specialists
The AMA council report also notes that the AMA always has been concerned about the balance between specialty and general care in the United States. However, primary care specialties have voiced a growing concern about the supply of physicians offering primary and general medical care. The AAFP and the American College of Physicians have warned about a future with "too few primary care physicians to take care of an aging population with increasing incidence of chronic diseases," according to the report.
"The rapid expansion of the number of subspecialties has resulted in the fragmentation of many services," the report says. "The American Academy of Pediatrics, the ACP and the AAFP all have advocated for the value of a primary care physician in coordinating the care of individual patients (or their families) and have embraced the concept of a 'medical home.'"
The rate of recognizing subspecialties has increased exponentially since the mid-1960s. The AMA's 1964 Directory of Approved Internships and Residencies listed 21 specialties and comprised 25 pages. By 2005, the AMA's Graduate Medical Education Directory listed 121 specialties and subspecialties, and comprised 546 pages. In the past five years, the Accreditation Council for Graduate Medical Education, or ACGME, has approved program requirements for an additional 17 subspecialties.
The rising trend in medical specialization among physicians also may threaten patient access to care.
"Finding a primary care physician is increasingly difficult, especially for minority populations, the elderly and those in rural areas," the report says. "Even in large metropolitan areas where doctors abound, it may be difficult for some patient groups (especially the uninsured) to access a primary care physician. … Without a medical home, even well-insured patients may assume the responsibility of coordinating their own care and transporting medical records, X-rays and lab reports from one subspecialist to another."
Finding Answers
The remedies proposed by the AMA council report echo many of those outlined in the 2004 Future of Family Medicine report, including encouraging medical homes and rewarding patient-centered care. Other strategies in the AMA document include
The AMA council report also notes that the AMA always has been concerned about the balance between specialty and general care in the United States. However, primary care specialties have voiced a growing concern about the supply of physicians offering primary and general medical care. The AAFP and the American College of Physicians have warned about a future with "too few primary care physicians to take care of an aging population with increasing incidence of chronic diseases," according to the report.
"The rapid expansion of the number of subspecialties has resulted in the fragmentation of many services," the report says. "The American Academy of Pediatrics, the ACP and the AAFP all have advocated for the value of a primary care physician in coordinating the care of individual patients (or their families) and have embraced the concept of a 'medical home.'"
The rate of recognizing subspecialties has increased exponentially since the mid-1960s. The AMA's 1964 Directory of Approved Internships and Residencies listed 21 specialties and comprised 25 pages. By 2005, the AMA's Graduate Medical Education Directory listed 121 specialties and subspecialties, and comprised 546 pages. In the past five years, the Accreditation Council for Graduate Medical Education, or ACGME, has approved program requirements for an additional 17 subspecialties.
The rising trend in medical specialization among physicians also may threaten patient access to care.
"Finding a primary care physician is increasingly difficult, especially for minority populations, the elderly and those in rural areas," the report says. "Even in large metropolitan areas where doctors abound, it may be difficult for some patient groups (especially the uninsured) to access a primary care physician. … Without a medical home, even well-insured patients may assume the responsibility of coordinating their own care and transporting medical records, X-rays and lab reports from one subspecialist to another."
Finding Answers
The remedies proposed by the AMA council report echo many of those outlined in the 2004 Future of Family Medicine report, including encouraging medical homes and rewarding patient-centered care. Other strategies in the AMA document include
- recruiting medical students who are committed to generalist practice and who have deep roots in communities of need,
- requiring family medicine departments in all medical schools,
- expanding the ethnic and racial diversity of medical school applicants and matriculants, and
- making competence in generalist skills a prerequisite for state licensure and mandating maintenance of generalist skills for continued certification.
"This report is a landmark victory. It's the most significant change in AMA policy affecting family medicine that I know of since the Millis Report," said Fields, referring to the AMA's 1966 Millis Report that called for increasing the number of physicians capable of replacing the then-dwindling number of general practitioners. (The AMA-sponsored Willard Report took this concept one step further, encouraging the formation of a separate training track and specialty certification board for family practice.)
Frank agreed. "The ship is turning," she said. "It's slow, but it's getting there, and we're the ones who are pushing it."
Both Fields and Frank credit the AMA's renewed emphasis on primary care to collaboration and a focus on offering positive solutions to issues affecting all of medicine.
"This meeting and its success has been a culmination of a deliberate effort by the AAFP to be a more positive influence in the AMA," said Fields. "All credit goes to the (AAFP) delegation."
Frank agreed. "The ship is turning," she said. "It's slow, but it's getting there, and we're the ones who are pushing it."
Both Fields and Frank credit the AMA's renewed emphasis on primary care to collaboration and a focus on offering positive solutions to issues affecting all of medicine.
"This meeting and its success has been a culmination of a deliberate effort by the AAFP to be a more positive influence in the AMA," said Fields. "All credit goes to the (AAFP) delegation."
