Our specialty is ailing. The dissatisfaction and unhappiness of our physicians is mirrored in years of declining Match numbers and the consequent decline in the number of training programs. The old model of adding two or three years to the postgraduate education of general practitioners to give them more clinical training no longer works in today’s medical marketplace. In the 1970s, when the American Academy of General Practice became the AAFP specialists were less common and midlevel providers rare. Today midlevels and specialists abound. The former claim to do what we do, and the latter claim to do it better. Our clinical expertise, both cognitive and procedural, is being assailed.
Many family physicians have long felt that our specialty needs redesign. The Future of Family Medicine project1 is one institutional manifestation of that need. But reinvention requires that we first be clear what makes us different from other medical specialties. Is it that we value interpersonal interactions leading to lasting quality relationships more than other specialties, as William J. Hueston, MD, suggests in his editorial “Rekindling the Fire of Family Medicine”?2 Perhaps, but that’s hard to achieve when some of us have to see a patient every 15 minutes all day long. Besides, what gives us bragging rights over other primary care physicians? Don’t internists, pediatricians and ob/gyns value their long-standing patient relationships as well?
The old GPs worked solo, did almost everything and truly did care for families. Today’s FPs work in large multispecialty groups, are mostly employed and tend to subspecialize. Today’s FPs can be hospitalists, emergency medicine physicians or holistic health practitioners; they can concentrate on dermatology, women’s health or pretty much anything else they choose. What exactly is a family physician today? What is our core identity?
We need a new paradigm for a new time. The old models are obsolete. If we are going to be a specialty unto ourselves, then we need new areas of expertise. These have to be taught and nurtured in our residency programs. Here are a few suggestions for skill sets that will help redefine us in the new millennium:
1. Practice management. Our new initiates need to know how to run an independent practice, because only working for ourselves gives us absolute control of our time and enables us to deliver the highest quality care. Practice management should be taught as a core competency in our residency programs. Physicians tend to shun it, but it really is not that difficult to master. It is certainly a lot easier than getting into medical school. Our forebears ran their own offices and, with computers, it’s even easier to do today.
2. Wellness medicine. This is territory that needs mapping. We should be leaders in keeping our patients well and out of the hospital. That requires special expertise in nutrition, exercise and stress management. We need to train our patients to come in annually for a health maintenance exam that tells them how healthy they are and what they need to do to remain well. We shouldn’t be competing with our colleagues in treating diseases; we should be at the forefront in preventing them.
3. Information technology. No, not the electronic medical record but learning how to use available technologies to access up-to-date medical information, patient education materials and sources of referrals. This could involve something as simple as phoning up the junior author on a paper that speaks to a patient’s problem or as complex as researching a database for cutting-edge therapies. We need to learn to use statistical tools to evaluate the evidence. Since we have always been a source of referrals, we need to develop contemporary expertise in that realm and not just rely on anecdotal experience. Perhaps we need to implement evidence-based systems for referring our patients to other specialists to assure our patients the best possible care.
4. Home visits. House calls are a rarity in medical practice today, but what better way to get to know our patients than to see them at home in the presence of their families? We need to reclaim the house call as our province and have sophisticated systems for caring for our patients in their homes. Now that so many Americans have no health insurance, this could be an economical way of providing health care and avoiding the high costs of hospitalization.
5. Family dynamics.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. Nor can we claim special expertise in dealing with families, since meaningful education in family dynamics is conspicuously absent from our training programs. If we claim to specialize in taking care of families, then we have to master the social and psychological skills needed to better understand and help our patients. Knowing how to listen and respond in a therapeutic way to our patients’ concerns and health problems will separate us from the herd.
6. Community medicine.. We need to be leaders in our communities not just in preventing disease and disability but in preventing violence, accidents and obesity – not to mention health care disparities and the diseases they cause. We also need to be able to recognize the community as a patient and create programs to take care of our communities’ needs. These skills can be learned from our colleagues in preventive medicine and from organizations working in prevention. Family physicians need to think more globally and become leaders in these efforts.
The fight for privileges to do procedures saps our energies and is one that we will eventually lose, not only because specialists are better trained to do them, but because in this day of consumer-driven health care, our patients will select the doctors with the most experience and best track records to do their colonoscopies, colposcopies, cardiac stress tests, C-sections, hernia repairs and critical care. Perhaps no other specialty trains its residents to do so many things they will never use in practice, while spending so little time training them to do what most of them will wind up doing – clinic medicine.
To maintain the dynamism of our specialty, we must define ourselves by what we can do better than everyone else, not by what everyone else is doing. The skills inventory I have outlined above is compatible with an office-based practice. It is a listing for our time. It should excite medical students considering family medicine and residents already in family medicine by showing them ways to actualize the core values of the “New Model” of family medicine (“continuing, comprehensive, compassionate and personal care”3) while maintaining patient loyalty, getting adequate remuneration, developing independence and building the profound interpersonal relationships that will afford them immense satisfaction in practicing their healing art.
WHAT DO YOU THINK?
The views and opinions expressed in the editorials published in Family Practice Management do not necessarily represent those of FPM or our publisher, the American Academy of Family Physicians. We recognize that your point of view may differ from the author’s, and we encourage you to share it. Please send your comments to FPM at firstname.lastname@example.org or 11400 Tomahawk Creek Parkway, Leawood, Kansas 66211–2672.