Am Fam Physician. 2016;93(3):online
Related editorial: Frequently Asked Questions About Family Medicine: 2016 Edition.
Author disclosure: No relevant financial affiliations.
This article provides answers to many of the common questions that medical students ask about the specialty of family medicine. It describes the crucial role that family physicians have in the evolving health care environment, the scope of practice, the diverse career opportunities available, the education and training of family physicians, the economic realities of a career in family medicine, why the future is so bright for family medicine, and why family physicians are passionate about their work.
Family physicians are personal doctors for patients of all ages and health conditions. Now more than ever, they have an essential role in the transformation of the U.S. health care system. Medical students often have questions about the specialty of family medicine. This article provides answers to many of those questions.
There are more family physicians than there are physicians in any other specialty. (Although there are more internists than family physicians, they practice in various subspecialties, all with fewer numbers of physicians.) Family medicine has more residency programs than internal medicine, although it is second in the number of residents. Family physicians make up 13% of the physician workforce, but provide more than 25% of ambulatory care in the United States and more office visits than any other specialty.1 In addition, family physicians deliver many secondary and tertiary health care services, ranging from care of special populations (e.g., those with human immunodeficiency virus infection) to intensive care.
Why Is Family Medicine Such an Important Specialty?
Of all of the medical specialties, family medicine best meets the definition of primary care: first-contact, continuous, comprehensive, and coordinated care to populations undifferentiated by sex, disease, or organ system.2 Health care systems with a primary care foundation have better quality of care, better population health, greater equity, and lower cost.3 The United States has not traditionally emphasized a strong primary care workforce and has not fared well compared with other Western nations in many important measures of health system performance. As the U.S. health system moves to paying for quality rather than quantity of services provided, family medicine is poised to make a substantial positive impact on the health of the nation.
What Are the Family Medicine Model of Care and the Patient-Centered Medical Home?
Family physicians are dedicated to treating the whole person. They provide easily accessible care that includes a comprehensive range of services within the context of a continuing relationship. Even when patients require care beyond the scope of family medicine, family physicians maintain responsibility for their patients by coordinating the care provided by other health care professionals. This model of care has been referred to as the patient-centered medical home (PCMH). In an increasingly complex and fragmented health system, the PCMH is a deviation from traditional models of care. It is truly person-centered vs. physician-centered.
There is no single model of the PCMH, nor is it defined as existing within a single practice or building. The format is best determined by the community's needs. It is recognized that a team-based approach to care, reducing barriers to care through improved communication and expanded office hours, implementing advanced information systems such as electronic health records, focusing on quality and safety, and providing patient care in the context of family and community, helps to achieve the quadruple aim of better health, better health care, lower cost of care per capita, and improved work life for physicians.4,5
There is a growing recognition that a sustainable health care system will require the integration of primary care, behavioral and mental health, and public health. Some PCMH practices are already expanding the traditional model to incorporate mental health and population health tools.6 As PCMH models evolve, family physicians will continue to strive to provide the right care, at the right time, in the right place, in a manner that best meets their patients' needs.
What Is the Scope of Practice and What Career Opportunities Will Be Available to Me?
As a family physician, you will be uniquely trained to provide comprehensive care for acute and chronic conditions, provide wellness care and disease prevention, perform a variety of procedures, and manage care through collaboration with other specialties. The combination of the broad scope of training, patient-centered care in the context of families and communities, and an understanding of how health systems work will allow you to adapt to any location and setting. For this reason, family physicians have been referred to as “pluripotent stem cells.”
Most family physicians are in clinical practice and provide care in ambulatory settings and hospitals. These settings afford a variety of educational and research career opportunities. Teaching is important to family physicians; many regularly train students or residents in their clinical practices. Others choose careers in academic settings such as residency programs or large academic health centers. Some family physicians are research scientists, whereas others participate in practice-based research by contributing data to answer important research questions. The range of career options within family medicine is broad and includes geriatrics, adolescent medicine, hospice and palliative care, pain medicine, sleep medicine, emergency medicine and urgent care, hospitalist medicine, sports medicine, public health, international medicine, and wilderness medicine. A brief video summarizing the opportunities available to family physicians is available at https://vimeo.com/25152825.
Will Training in Family Medicine Prepare Me to Practice Global Health?
Optimal health is a fundamental human right that extends beyond national borders and is best achieved with access to primary care.7 Despite headline-grabbing news of outbreaks of diseases such as Ebola, the burden of disease in developed and developing countries has evolved from infectious diseases to chronic illness. Well-trained family physicians with skills in childhood, adolescent, adult, and obstetric medicine and a broad set of procedural skills are well suited to practice in all settings across the globe. This same skill set can be applied within the United States to the care of immigrants and refugees.
What Do I Need to Know About Family Medicine Training?
The aim of family medicine residency training is to prepare graduates to provide comprehensive, continuous care for patients of all ages. A critical part of this education is learning how to access the best evidence at the point of care, to manage and apply information, and to use resources efficiently.
Most family medicine residency programs are three years in duration, as are internal medicine and pediatric residencies. Graduates of family medicine programs are well equipped for clinical practice. A few family medicine residency programs are participating in a long-term national pilot program to examine the optimal length of training.8 These programs are four years in duration and offer special tracks or advanced degrees.
What Types of Combined Residencies or Advanced Fellowship Training Are Available to Family Medicine Residents Who Wish to Pursue a Specialized Interest?
The goal of family medicine education is to produce an optimally trained workforce to deliver primary care to patients, families, and communities. Family physicians have unique interests and some pursue a degree of focus within or in addition to their generalist training. As a resident, you may wish to combine your requirements with electives in an area of concentration.9 You may wish to gain in-depth experience in a particular area by participating in a combined residency program, or you may choose to pursue fellowship training after you graduate (Table 1).
|Human immunodeficiency virus/AIDS care|
Combined residency training programs are hybrids that combine elements of two different specialty programs. They do not constitute a separate specialty, but are designed to lead to board certification in both specialties. There are currently four types of dual-degree residency programs for family medicine: family medicine/psychiatry; family medicine/emergency medicine; family medicine/internal medicine; and family medicine/preventive medicine. These combined training programs are generally four to five years in duration.
Internal medicine/pediatrics programs differ from family medicine. These programs combine internal medicine and pediatrics into a single four-year residency. According to a recent review, most internal medicine/pediatrics programs do not require training to deliver maternity, gynecologic, surgical, dermatologic, or musculoskeletal care.10 Approximately one-third of internal medicine/pediatrics graduates subspecialize, rather than practice primary care.
A 2013 American Academy of Family Physicians (AAFP) survey of graduating family medicine residents shows that approximately 14% plan to pursue advanced training, including fellowships or advanced degrees.
The AAFP is often asked why there are fellowships in some areas and not others. The answer is complex. There are two categories of fellowships based on whether they are accredited by the Accreditation Council on Graduate Medical Education (ACGME) and eligible for specialty certification through the American Board of Medical Specialties (ABMS).
The ABMS has 24 primary specialty boards granting certification (e.g., internal medicine, pediatrics, family medicine, surgery). In circumstances where another primary specialty certifying board exists, the ACGME will not accredit a fellowship in that field, and the ABMS will not grant specialty certification. This is why there are no family medicine fellowships in pediatrics.
ACGME-accredited fellowships may exist when multiple primary specialty boards offer certification that could be used as the foundation of subspecialty training. One example is adolescent medicine, in which training in pediatrics or family medicine provides the foundation needed for subspecialization in adolescent medicine. Fellows in programs accredited by the ACGME are subject to similar supervisory, evaluation, and work hour requirements as residents.
Most U.S. fellowships are not accredited by the ACGME. They can vary in curriculum, duration, and resources. An important distinction regarding nonaccredited fellowships is that fellows in these programs may function as junior faculty. Maternity care is one example of a nonaccredited fellowship. These fellowships may vary in length (one month to two years) and scope (operative maternity care or other procedural training).
The AAFP maintains a fellowship directory that illustrates the breadth of postgraduate experiences for family medicine graduates (https://nf.aafp.org/Directories/Fellowship/Search).
Some residency programs incorporate advanced degree programs into residency training, such as a Master of Business Administration or a Master of Public Health.
What Types of Procedures Do Family Physicians Perform?
As a family physician, you may perform a variety of procedures (Table 2).11 The frequency ranges from approximately 7.5% for cardiac stress testing and 9.9% for deliveries to 64% for musculoskeletal procedures and 79% for dermatologic procedures.12 Family physicians who provide a more comprehensive scope of practice have greater success at achieving the quadruple aim of health care.
|Digital, local, and peripheral nerve blocks|
|Gastrointestinal and colorectal procedures|
|Enteral feeding tube placement|
|Excision of thrombosed hemorrhoid|
|Incision and drainage of perirectal abscess|
|Nasogastric tube placement|
|Advanced Cardiovascular Life Support|
|Advanced Life Support in Obstetrics|
|Advanced Trauma Life Support|
|Neonatal Resuscitation Program|
|Pediatric Advanced Life Support|
|Spontaneous vaginal delivery, including fetal monitoring, labor induction/augmentation, and laceration repair|
|Vacuum-assisted vaginal delivery|
|Initial management of simple fractures|
|Injection/aspiration of joints, bursa, trigger points, and ganglion cysts|
|Reduction of shoulder dislocations|
|Upper- and lower-extremity casting|
|Incision and drainage|
|Basic maternity ultrasonography|
|Ultrasound guidance for central vascular access, paracentesis, and thoracentesis|
|Urgent care and hospital procedures|
|Anterior nasal packing for epistaxis|
|Fluorescein eye examination|
|Foreign body removal|
|Peripheral venous access|
|Women's health care|
|Intrauterine device insertion/removal|
|Uterine aspiration/dilation and curettage|
How Do I Know if Family Medicine Is Right for Me?
The best way to know if family medicine is the right fit for you is to work with family physicians in action, by doing a rotation with a family physician in practice. Family medicine is right for different people for different reasons. As you speak with family physicians, you will hear different themes about what they love about their jobs. Some develop deep, meaningful, and continuous relationships with their patients and communities. Some love the ability to practice a broad scope of medicine from birth until death, regardless of condition or disease. Others enjoy the comprehensive training that allows for diverse practice options and that can be adapted to the community they serve.13 Others are drawn to family medicine because of the ability to tackle almost anything, whether at home or abroad. For some, it is the ability to care for the entire family, including managing deliveries and prenatal care.
Family medicine is broad in scope, so if you enjoy all of your clerkship rotations and are having trouble choosing just one field, then family medicine may be your home. Try to recall what inspired you to want to become a doctor. Then imagine where and what your ideal practice would be, and explore residency options that would allow you to create it.
What Factors Should I Consider When Choosing a Family Medicine Program?
Although there may or may not be a perfect program, there are probably multiple programs that would be a good fit for you. Program location is often cited by students as one of the most important factors to consider. Proximity to family, needs of a significant other, the lifestyle associated with a community, and patient populations served by the residency can be elements that differentiate programs. More than one-half of family medicine residents will eventually practice in a community within 100 miles of their residency training.14
The institutional context of the residency within a university/academic health center, community hospital, or community health center and the presence of residents or fellows in other disciplines may be important factors for you to consider. In contrast with other specialty residencies, which are typically based in large academic health centers, many family medicine residencies may be located at smaller community hospitals or community health centers. Most likely, as a student you are being trained in a university or large academic medical center environment where there are many residents and fellows training in a variety of specialties. For residency training, you may prefer an academic environment where there are residents and fellows from other specialties training side by side, with a variety of unusual cases and an abundance of resources. A smaller community hospital or community health center with less competition for patients and procedures, and more focus on common conditions may be a better fit. These descriptions represent broad stereotypes, and there is significant variability within these categories. You will need to choose the best learning environment for you.
How Do Family Physicians Keep Current with Medical Advances Across the Breadth of the Specialty?
All physicians, regardless of specialty, have an obligation to provide the best care possible for their patients. You may worry that family medicine is too broad of a specialty and that you cannot possibly learn everything you need to know. Nothing can be further from the truth. Family medicine residencies give you the core skills to manage most patient concerns comfortably, acknowledge your limitations, use your resources, and give you lifelong learning skills that allow you to grow and evolve with your patients and interests.
As medicine advances, it is important to be aware of the most current and the best medical evidence. Family physicians have multiple resources that can be matched to your preferred learning style. These include live and recorded courses; monographs; audio podcasts, such as the American Family Physician podcast; and journals, such as American Family Physician. The use of medical apps has exploded in the past few years; these offer continuing medical education opportunities as well as bedside tools.
What Are the Economic Realities of Medical Education and a Career in Family Medicine?
Medical education is expensive, and nearly all medical students incur significant debt over the duration of their training. The Association of American Medical Colleges reported in October 2014 that the median level of debt is $180,000.15 Family physician salaries support a comfortable lifestyle that allows family physicians to repay their debt through careful planning and a variety of loan repayment options.16
More than one-third of medical students plan to enter a loan forgiveness or loan repayment program.15 These programs typically require residency graduates to practice in an underserved community in exchange for loan forgiveness while earning a salary and benefits like other practicing physicians.
Family physicians have been the most recruited specialists since 2006, with an average starting salary of $198,000.17 As the demand for family physicians grows, so do salaries. One large integrated health system in southern California recently increased the starting salaries of family physicians to $250,000. Average family physician salaries are among the top 6% of all U.S. household incomes.18
How Does Family Medicine Training Prepare Me to Be a Leader in Health Care?
The breadth of training in family medicine, as well as the emphasis on systems-based practice, makes family physicians natural leaders who are highly sought after to lead health care teams. Patients, communities, and health care systems need clinically trained leaders with an intimate understanding of the complexities involved in providing a combination of preventive, acute, and chronic care services. Family physicians work with other physicians, health care professionals, and health care supporters across the realm of specialties, giving them a big-picture view of health care delivery. There are many opportunities to get involved and develop your leadership skills within your local and state chapters of the AAFP.19
Why Is the Future of Family Medicine So Bright?
There is growing public recognition that comprehensive primary care is the solution for the health of our communities and the nation to improve health, reduce health disparities, improve health care quality, and lower the cost of care. Around the world, primary care–based health systems have lower costs, higher quality, and better access to care.20,21 The Josiah Macy Jr. Foundation, the Council on Graduate Medical Education, and other respected organizations and policymakers have identified the need to train more primary care physicians.22,23
The Patient Protection and Affordable Care Act contains several key provisions to strengthen primary care. These include enhancing payments to primary care physicians and fostering the creation of advanced primary care models of care.24 A new payment system that rewards outcomes and quality over volume of services provided is being ushered in after the passage of landmark legislation in April 2015.25
The Family Medicine for America's Health project, which was launched in 2014, creates a roadmap to improve practice models, payment, technology, workforce, education, and research.27 It aims to collaborate with patients, employers, payers, policymakers, and other primary care professionals to show the value and benefits of primary care, and the contribution that family physicians make to meet the health and health care needs of persons throughout the United States.
Family physicians make a difference in the health and well-being of others through long-term relationships, mixing the art and science of medicine. That is why they love their work and why the future is so bright for those who choose a career in family medicine.
For additional resources, see the AAFP's Family Medicine Facts website (https://www.aafp.org/about/the-aafp/family-medicine-facts.html) and Career Q&A with Family Physicians: Life and Work in Family Medicine (https://www.aafp.org/medical-school-residency/choosing-fm/physician-qas.html).