'Be Counterculture Again,' Says Graham Center Director

The high cost of the U.S. health care system is having a toxic effect on primary care and patients, and it's time for family medicine to be counterculture again, starting with the specialty's residencies, according to Robert Phillips, M.D., M.S.P.H., director of the AAFP's Robert Graham Center in Washington.

Phillips gave the Thomas L. Stern, M.D., Lecture at AAFP's Residency Assistance Program Workshop for Faculty & Staff of Family Medicine Residencies April 3 in Kansas City, Mo. He said that family medicine began as a counterculture force 40 years ago when it pushed back against the escalating subspecialization of care and staked a claim as a specialty that treated people and communities -- "not just livers, not just toes." This time around, said Phillips in "Family Medicine Training: Time to Be Counter-Culture Again," (PDF file: 7 pages / 1.1 MB. More about PDFs.) the counterculture movement isn't about recreating the specialty but about putting in place the new model of practice proposed in the 2004 Future of Family Medicine report.

"The new model of care is counterculture," Phillips said. "It proposes a new relationship with our patients that they can't find but are hungry for."

Phillips reported on research about the critical state of the health care system. He noted that U.S. health costs escalated to $1.9 trillion in 2005, or $6,700 per person, compared with $4,600 in 2000 and $2,000 in 1980 (all figures adjusted to 2000 dollars). That means per-person costs have risen about as much in the past five years as in the previous 20 years, said Phillips. In addition, the United States comes in last among 11 developed countries for health care outcomes based on patient satisfaction, expenditures, 14 health indicators and medications per person. The tragic irony, said Phillips, is that the percentage of uninsured people keeps rising even though spending is skyrocketing.

"More money doesn't buy better outcomes," said Phillips. "Never has so much bought so little for so few."

The Future of Family Medicine project "taught us that family medicine will have to change to survive," said Phillips. The new model demands revolutionary change, he added, but sustaining the change will take evolution. He asked participants in the RAP workshop to "train to change" so the next generation of family physicians would expect to practice in the new model. He challenged the participants, "Evolve or die."

The new model of care, now known as the TransforMED model of care (PDF file: 1 page / 157 KB. More about PDFs.), will provide patients with a relationship-centered personal medical home, Phillips said. Family physicians will need proficiency in team-based care, continuous quality improvement, practice information management and mastery, population- and community-based care, delivery of a basket of services patients can rely on, research as a component of practice, and the use of decision support tools while delivering care. "These (skills) will become the new competencies for residency training," said Phillips.