Forget transforming America's health care system. The nation needs a revolution, and family medicine must lead the charge.
That was the challenge set forth June 11 by John Saultz, M.D., professor and chairman of family medicine at Oregon Health & Science University, Portland, during the 2007 Nicholas Pisacano Memorial Lecture at the AAFP Workshop for Directors of Family Medicine Residencies here. The specialty can meet that challenge only by razing the current definitions of "good health care" and "competent physicians," and then replacing them with standards that meet the nation's needs, said Saultz.
Call to Arms
Family Medicine Educators Must Revolutionize Health Care Assumptions
By Leslie Champlin
• Overland Park, Kan.
6/14/2007
"Our task is not to transform, but to revolutionize," says John Saultz, M.D., as he urges residency program directors to lead the charge to revamp the U.S. health care system. Saultz delivered the Nicholas Pisacano Memorial Lecture at the 2007 Workshop for Directors of Family Medicine Residencies.
"Our task is not to transform, but to revolutionize," he said. And the revolution begins by completely rebuilding family medicine education.
Contemporary family medicine education, which is hospital-based and hospital-sponsored, follows the postulates of overall medical education: that the scientific method underlies all of medicine, that depth of knowledge defines excellence, that specialization improves the system, that knowledge of disease defines competence, and that physicians treat diseases as they present in people.
As a result, "our value, our self-esteem depends on the credibility from hospitals and other specialists," said Saultz. "Their approval matters greatly to us," and this has given them the power to define family medicine education for the specialty.
That must change, said Saultz. Throughout its history, family medicine has upturned the postulates of health care. From the 1950s, when general practitioners became the first to call for community-based residency education, through the 1990s, when family medicine introduced evidence-based and population-based medicine, the specialty has revolutionized health care.
Family medicine can do it again, said Saultz. The specialty can refocus the health care system from personal care to population care; from a small-business mentality to an interdisciplinary organizational systems approach; from quality processes to quality outcomes; from single, discipline-based practices to interdisciplinary teams; from understanding the patient to helping the patient understand; from thinking about what health care is provided to how health care is provided.
It all starts with educators. Family medicine residency programs must lead the educational community in developing curricula said Saultz. Here are some examples he gave.
Contemporary family medicine education, which is hospital-based and hospital-sponsored, follows the postulates of overall medical education: that the scientific method underlies all of medicine, that depth of knowledge defines excellence, that specialization improves the system, that knowledge of disease defines competence, and that physicians treat diseases as they present in people.
As a result, "our value, our self-esteem depends on the credibility from hospitals and other specialists," said Saultz. "Their approval matters greatly to us," and this has given them the power to define family medicine education for the specialty.
That must change, said Saultz. Throughout its history, family medicine has upturned the postulates of health care. From the 1950s, when general practitioners became the first to call for community-based residency education, through the 1990s, when family medicine introduced evidence-based and population-based medicine, the specialty has revolutionized health care.
Family medicine can do it again, said Saultz. The specialty can refocus the health care system from personal care to population care; from a small-business mentality to an interdisciplinary organizational systems approach; from quality processes to quality outcomes; from single, discipline-based practices to interdisciplinary teams; from understanding the patient to helping the patient understand; from thinking about what health care is provided to how health care is provided.
It all starts with educators. Family medicine residency programs must lead the educational community in developing curricula said Saultz. Here are some examples he gave.
- Define excellence as a breadth -- not depth -- of knowledge that results in whole-person and population-based care and that capitalizes on a primary care team to coordinate all of a patient's health care. "The team -- not just the doctor -- has to be able to play the whole game," said Saultz.
- Employ innovation-based -- not just community-based -- education in which family medicine educators create an intellectual agenda for the specialty. "It is not OK for faculty to be trained as teachers. They have to be trained as idea-generators," said Saultz. Family physicians "can't be better by extracting ideas from other fields. They get better by coming up with their own ideas."
- Train residents as leaders who will break family medicine's habit of looking to hospitals and other medical disciplines for credibility. "Credibility from hospitals and other disciplines is important, but not essential," said Saultz. "We need to define basic competencies that flow from family medicine, not from the hospital or other disciplines. We need to build residencies on competence, not rotation modules. We need to count, evaluate and measure everything we do because it's those measures that we have to have to convince the (Residency Review Committee) that what we're doing meets competency requirements."
More important, family medicine educators must propose alternatives for patient care systems, align with patients and the community in implementing those alternatives, and let hospitals and subpsecialists follow that lead, said Saultz.
With that approach, the benefits of educational reform will seep into the community, Saultz told program directors. He urged them to welcome all who want to join the effort, but "make no compromise with those who don't want to include us. The forces of revolution are not coming from within medicine. They are coming from people who are fed up."
Solving the health care crisis involves plain talk and its inherent risks. But family physicians are best suited to question a system in which 25 cents of each health care dollar goes to patient care.
"Too many people are extracting money and not adding value, and that's unconscionable in a system where we have 45 million people without access to care," said Saultz. "Speak out about greed. Incite public debate about the moral content of our health care problems."
He adds that the revolution won't come easily. Particularly because health care comprises 16 percent of the economy. Eliminating parts of the system that add to companies' bottom lines without enhancing patient care will affect the nation's economy. The health care job market would shrink significantly if reforms slashed health care spending by 25 percent, said Saultz. That specter may dampen enthusiasm for overhauling the system.
"But revolutions require risk-taking," he said. Family medicine, he added, must "stop being in denial. This is not someone else's problem to be solved."
With that approach, the benefits of educational reform will seep into the community, Saultz told program directors. He urged them to welcome all who want to join the effort, but "make no compromise with those who don't want to include us. The forces of revolution are not coming from within medicine. They are coming from people who are fed up."
Solving the health care crisis involves plain talk and its inherent risks. But family physicians are best suited to question a system in which 25 cents of each health care dollar goes to patient care.
"Too many people are extracting money and not adding value, and that's unconscionable in a system where we have 45 million people without access to care," said Saultz. "Speak out about greed. Incite public debate about the moral content of our health care problems."
He adds that the revolution won't come easily. Particularly because health care comprises 16 percent of the economy. Eliminating parts of the system that add to companies' bottom lines without enhancing patient care will affect the nation's economy. The health care job market would shrink significantly if reforms slashed health care spending by 25 percent, said Saultz. That specter may dampen enthusiasm for overhauling the system.
"But revolutions require risk-taking," he said. Family medicine, he added, must "stop being in denial. This is not someone else's problem to be solved."
