Reinventing the specialty
Fam Pract Manag. 2006 Jun;13(6):16-20.
As two young family physicians who are excited about our profession, we were sad to see yet another editorial outlining all that is wrong with family medicine [“Reinventing Family Medicine,” April 2006]. Lately, every time you open an AAFP publication the themes are the same: unhappiness, declining match numbers, and specialists receiving all the reimbursement. Even worse are the published opinions on how to “fix” family medicine. These opinions seem to be written by burned-out family physicians who bow down to specialists, have no idea how to cultivate successful businesses and don't know what matters to medical students when they make career choices.
We are lucky to be working in young, aggressive family medicine groups (one with three family physicians in rural South Carolina and one with 30 physicians in six locations in suburban North Carolina) where we provide top-notch medical care including same-day appointments and multiple in-house ancillary procedures such as CT scanning, MRI, DEXA scanning, ultrasound, two-dimensional echocardiography, colonoscopy, endoscopy, vasectomy, nuclear stress testing and a sleep lab. We know of several other family medicine groups who do the same.
Our patients love the fact that virtually any procedure or diagnostic test they may need can be done by their doctor in their medical home. Excellent patient care is always our primary focus. We were surprised by Dr. Sanford Brown's comment that patients select specialists to do their procedures. We have had the exact opposite experience. Our patients sometimes refuse to undergo diagnostic or screening procedures unless they are done by their doctor in our offices. We were offended by Dr. Brown's suggestion that family physicians are inferior to specialists. When did we stop believing in ourselves? Family physicians are the real doctors who cultivate patient-physician relationships and are depended on in good times and bad. Our patients call us to verify that the treatment a specialist has recommended is right for them. We must work together with specialists, remembering that they depend on us. Our excellence should command their respect, which, in turn, benefits our patients.
Dr. Brown's editorial is a perfect example of the attitude that is causing the perceived decline of family medicine. Instead of focusing our efforts on the electronic health record, as the Future of Family Medicine project suggests, or on Dr. Brown's list of skill sets, let's fight for equal hospital privileges, better reimbursement and a reduction of certificate-of-need requirements for office-based imaging equipment. Let's not expose third-year medical students to downtrodden, specialist-idolizing family doctors who feel threatened by midlevel providers and retail health clinics. Let's show them the real future of family medicine – aggressive family medicine practices where the physicians make a salary equal to any specialist while practicing world-class, comprehensive care and having fun doing it.
Dr. Sanford Brown gives a wonderful description of a reinvigorated practice of family medicine. Many pessimists believe our specialty is shrinking because of less hospital work, less maternity care and fewer procedures. Family medicine is not shrinking but morphing into a much broader community-based specialty. Thirty years ago, patients generally came to see us only when they were sick. Illness care dominated our office schedules. Today, we do comprehensive preventive medicine and chronic illness management and attend to the psychosocial needs of our patients, along with providing traditional acute illness care. Our work has become so broad and complex that brief office visits are no longer adequate for every patient. As we reinvent our specialty using online communication and electronic records shared with our patients, we should celebrate that family medicine is a specialty of great breadth that has expanded its scope of practice.
I read Dr. Sanford Brown's editorial with interest. I believe Dr. Brown's facts are right, but I suspect he is not a full-time practicing physician. I am a rural physician currently on leave of absence due to professional burnout and depression. For the past 20 years, I have tried every conceivable practice arrangement and have watched my revenues fall while my working hours, lawsuits and patient expectations increase. Meanwhile, the radiologists are taking one in every six weeks off, and the ophthalmologist is complaining that the dues at his exclusive country club have been increased to more than $30,000 a year. I don't know how to fix our broken health care system, but until primary care physicians are paid on a par with other specialists, we are going to continue to see early retirement by doctors 50 years old and older and less interest in primary care by medical students.
I found Dr. Brown's thoughts in “Reinventing Family Medicine” to be very provocative and, quite often, spot-on. Today's family physicians are frequently not family doctors in the traditional sense of the word. A lot of our residency training is wasted time. We do need to be leaders in information mastery and championing its importance for quality patient care. We should quit fighting for procedure privileges and focus our energy in a more productive way: We should reclaim house calls. That's a war we can win just by showing up!
I was, however, disturbed to read the following excerpt from Dr. Brown's editorial:
“Do we truly take care of families? In fact, if we had to restrict our practices to families, we would not survive. Our patients are family members, but for the most part we don't care for whole families.” I do take care of families.
I do take care of families I see children, their parents, their grandparents, their aunts and uncles, and their cousins. Families are my base. I have multiple four-generation families in my practice. In contrast to Dr. Brown's assertion, I could not survive on “individual” medicine.
Although I do not claim obstetrics as part of my practice, four years ago I delivered a baby in the emergency department of our 25-bed hospital. Since then, I have taken care of him, his mother and his now 2-year-old sister. Last year, all were present in the exam room when I triaged and initiated treatment for his grandmother who was having an MI. This is the family medicine for which I signed up – not the OB and the MI parts, but the family dynamics part.
In areas where the population is transient, primary care physicians are abundant or patients are more specialty-focused, family physicians are going to struggle. Do we still have something unique to offer? Absolutely. But we're misleading ourselves and our future colleagues if we ignore the reality that family medicine in a city of 500,000 has very different challenges than in a town of 5,000 or less.
Rather than change the definition of family medicine, let's be open to the reality that family physicians are appreciated and rewarded most where they are needed most. Other disciplines in medicine seem to acknowledge this concept without reservation. If you're not a physician who is inclined to work in a high-need area, be prepared for the challenges that lie ahead.
Perhaps this is where Dr. Brown and I find common ground once again. If our training included preparation for these challenges rather than checklists of irrelevant clinical rotations and procedures, maybe the disillusionment and dissatisfaction felt by so many family physicians would be avoided. We need to train our residents to navigate the turbulent waters of practice in the “real world,” wherever their real world turns out to be. But they still need to understand that “family doctor” is what it says it is, and they should be proud to be one. If they are not, they picked the wrong job.
I agree with much of Dr. Sanford Brown's editorial. However, if we return to simply encouraging well visits and prevention models, we have given ourselves the kiss of death. If we go back to teaching prevention, doing well visits and “managing families,” as Dr. Brown proposes, family medicine should be passed to midlevel providers. These are the areas where they excel. There is no need for 11 years of post-high-school education and training to do the things Dr. Brown outlined. I am wholeheartedly in favor of better training in our residencies in the very areas he suggests. However, we must be the forerunners of treatment, not just prevention, for the ailments we see daily. We should be managing patients' diabetes, COPD, asthma, heart disease and other chronic conditions. This is well within our realm, and we should be good at it. We should also be doing more procedures. As an employed physician, my scope of practice no longer includes all the things I was trained to do, but I remain grateful for the training I received. It makes me a better doctor.
If family medicine continues to decline, we may need to reduce the time it takes to complete our training, which would in turn reduce our educational debt. This would make family medicine a more attractive career choice for many students.
I wouldn't want to be on the receiving end of a colonoscopy from Drs. Grunsky and Capps until they've done as many as the gastroenterologist who did mine, who also did a yearlong scope fellowship before he began private practice. It's comforting to know your doctor does 50 colonoscopies a week and has done more than 10,000 procedures. I don't worry about his technique or whether he knows what he's looking at. I find it much more comforting than going to an FP who took an Academy course and just finished his 50th proctored case. Ditto for endoscopies and reading CTs, MRIs, ultrasounds and nuclear stress testing.
I sympathize with Dr. Holscher but suggest that it is conceivable for us to make as much money as ophthalmologists, radiologists and other specialists if only they would accept our pay scale. Barring that, it really is possible for an FP to make a good living – even while working part time as I do – if they know how to run their own practices. I preached this for more than six years when I wrote FPM's “Practice Diary” department.
I suspect that Dr. Switzer was a GP before he became an FP. It is ironic that the old GPs were more family physicians in the true sense of the word than are many of our current FPs. Practice in a city of under 5,000 and you may still be able to do it all.
Dr. Buffey objects to spending 11 years on post-high-school education only to practice prevention and family dynamics. Might I point out that preventive medicine and psychiatry are specialties with training programs as long as family medicine's. What I object to is us working for people with far less education than that. I agree that we need to reclaim our niche of doing acute and chronic ambulatory care better than everyone else instead of copying bits and pieces of every other discipline.
It is gratifying to me that Dr. Scherger shares my vision for the specialty.
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