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Tuesday Oct 09, 2018

Reclaiming Family Medicine's Broad Scope Benefits Everyone

"This time I'm walkin' to New Orleans; I'm walkin' to New Orleans."
-- Fats Domino

[definition of comprehensive]

Thousands of family physicians are convening this week in New Orleans for the 2018 Family Medicine Experience (FMX). FMX provides an opportunity for family physicians to connect with friends and colleagues, learn, and engage with the AAFP. This year's FMX offers up to 53 CME credits -- 28 in Live CME and another 25 with FMX On Demand -- and an expansive, interactive show floor that features the AAFP Office of the Future exhibit.

This year's meeting features three exciting main-stage presentations. Zubin Damania, M.D., (aka ZDoggMD) will speak on Wednesday, and HHS Assistant Secretary of Health Brett Giroir, M.D., will speak on Thursday before an interactive panel discussion on opioids. Frank Domino, M.D., follows on Friday with his popular updates on evidence-based medicine.

If you are in New Orleans, come by AAFP Central (the giant Academy booth in the Expo Hall) to say hello and let me know what's on your mind. I would love to hear how you see the future of family medicine and what the AAFP can do to make your professional life better.

Two if by "C"

The late Barbara Starfield, M.D., M.P.H., wrote extensively on the four Cs of primary care -- first contact, comprehensiveness, coordination and continuity. I have been focusing on two of those Cs more intently lately -- comprehensiveness and continuity. I don't mean to diminish the others, but these two are likely the secret sauce to high-functioning, patient-centered primary care -- and comprehensiveness is especially important.

Comprehensiveness

Confession: My focus on comprehensiveness originated in a mischievous way. I was pondering the question, "Why does dermatology exist as a specialty?" No disrespect to our dermatology colleagues. This question hit me one morning as I added a few minutes to my life on the treadmill and, unfortunately, it has stuck with me for several weeks. My curiosity quickly expanded to include other subspecialties, and I became fixated on the idea that a family physician, practicing in a comprehensive manner, could provide a more complete mix of services to patients in a more patient-centered manner than what is typical in our current health care system.

In the mid-1800s, there were two types of physicians: generalists and surgeons (sometimes they were the same person). Obstetrics, ophthalmology and orthopedic surgery were the first so-called specialties on the scene, followed by others that focused on the major organ systems. Despite some specialization in the early 20th century, the number of physician specialties was relatively small (15 to 20) until much later in the century.

Where are we today? Well, the AMA House of Delegates recognizes "more than 130 national medical societies, military service groups and professional interest medical associations." Of those, 122 are actual medical specialties.(www.ama-assn.org) That is an explosion of specialization.

In a world of limited resources, limited time and an aging population; it strikes me that we should be expanding the suite of services offered by family physicians, not shrinking it. Hear me out.

We know that a vast proportion of physician office visits are to a primary care physician. In fact, according to The State of Primary Care in the United States,(www.graham-center.org) published by the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, nearly 50 percent of all physician office visits are to a primary care physician (family medicine, internal medicine or pediatrics), with the remainder spread across the other medical specialties and subspecialties.

Let me phrase this another way: Half of all patient visits are to three primary care specialties, and the other half are to 119 other medical specialties and subspecialties. Instead of forcing patients to navigate a world of 119 specialties and subspecialties, it seems more appropriate to focus our attention on bringing some of those medical services currently being provided by nonprimary care physicians into the primary care practice.

As a profession, family medicine spends an enormous amount of time pushing back on expansion of scope by nurse practitioners, physician assistants, pharmacists, etc. I have spent my entire professional career engaged on these issues, and we should continue this important work. There are distinct differences between being a physician and, well, not being a physician. Nurse practitioners are not physicians, and I don't play this "whataboutism" comparison game they seem to enjoy. There is a role for everyone, but those roles are not interchangeable, and they never should be.

I would suggest to you that we -- family medicine -- should start our own scope campaign focusing on reclaiming full-scope family medicine as the most patient-centered, efficient model of care for patients. For the past 40 years, medical specialties have slowly and deliberately chipped away at the scope of services provided at the primary care level and forced many of those services upstream to more expensive physician specialties and sites of care. It is time to push back.

Full-scope family medicine is good for patients, good for communities and good for family physicians. That's right -- according to a recent study published in Annals of Family Medicine,(www.annfammed.org) "comprehensiveness is associated with less burnout, which is critical in the context of improving access to good quality, affordable care while maintaining physician wellness."

There are lots of converging issues impacting my thinking on these issues right now -- primary care payment models, high-deductible health plans, new technologies, rural health, health equity and many others. I will admit that my thoughts are not fully formed and this is still technically "pondering," but my pondering keeps pointing toward the need for more comprehensive family medicine and primary care.

More to come on this topic, but I would welcome your thoughts, opinions and ideas.

Posted at 12:15AM Oct 09, 2018 by Shawn Martin

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ABOUT THE AUTHOR



Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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