The original intent of family medicine as a specialty was to restore order to a health care delivery system that was nearly broken and to be inclusive rather than exclusive in the care provided. During the 1970s, 1980s and even the early 1990s, the specialty succeeded in doing just that. By the mid-1990s, however, the growing number of large, multispecialty clinics and hospital-owned medical systems began to hire family physicians as “gatekeepers” to direct care to referral specialists. The center of health care began to shift from the patient to the system, and our role as family physicians seemed to become not so much to care for patients as to feed them into the system or keep them out, depending on the needs of the system.
The absurdity of this became clear to me in 1998. I was an employee of a large health care system, albeit practicing in a two-physician satellite clinic. A patient of mine called to see if his son could have a strep test done at an urgent care center affiliated with our health care system. I called the urgent care facility to ask them to do so and to call me with the results. They refused and told the patient that he would have to wait two hours or more to be seen. That small incident started me thinking about the folly of a health care system that catered more to the system than to the patient. My partner and I soon separated from the health care system, and my patient and I ended up founding Minute Clinic, the first of the retail clinics.
Why has MinuteClinic or, for that matter, the retail clinic model become so successful? I believe it is because patients are pining for easier access, but the medical system is not changing to accommodate them. “Access to care” is an artificial construct developed by health care systems to limit care. As I have told medical students and residents over the years, if a patient wants to be seen, he or she should be seen. Who are we to decide whether a patient merits an office visit? It is not our role to limit access but rather to see, treat, reassure and, if necessary, refer.
Medicine embraces new treatments, technology and tests, often without question, but bring up a change in how patients access care and one runs the risk of being labeled a heretic and treated as disloyal to the medical guild.
We need to be up front among the generals of the practice change revolution - not just providing and directing care, but fighting off the large systems trying to remodel health care for the benefit of the system, not the patient.
Without a cohort of family physicians committed to moving our specialty forward, our ability to change the system is extremely limited. The Future of Family Medicine (FFM) project was a step in this direction; it represented the efforts of five national family medicine organizations to redefine the specialty.1 While I applaud the effort, I am dismayed at the result. The medical system, and particularly family medicine, does not need the kind of tweaking proposed by the FFM project; it needs a complete overhaul. As long as we continue to be content being the red-headed stepchild of medicine, we will continue to minimize family medicine's potential impact on medicine as a whole.
The best diagnosticians, the best communicators and, yes, the best administrators I have seen in medicine are all family physicians. We “get it,” or most of us do, but I fear that as we get more involved in helping fix the system, our role will become smaller and smaller, until eventually we become a footnote in medical history. We need to learn how to listen to our patients and colleagues, understand the overhaul that needs to happen, and use our strengths to bring it about. It seems to me that, as our first few steps toward a new system, we need to do the following:
1. Relinquish our roles as preventive health care experts. No significant studies show any true health care benefit in a practice focused on preventive health care. We should focus on what we do best – treating ill and hurting patients – and employ midlevel providers to follow chronic, stable illness and do preventive health exams.
2. Realize that the insurance networks are not our friends. With the rise of health savings accounts, there is no longer any reason that family physicians shouldn't run cash practices with all the attendant savings in staff costs, billing costs and overall complexity of operations. This would allow the development of small practices again, which is where family medicine is best delivered.
3. Replace our three-year residency programs with two-year programs that offer an additional one or two years spent in real practices as a “junior partner” learning the realities of practice and, just as important, the business of practice. We are naive to think that we can separate what we do from how we make a living. Acknowledging this will be healthy for the specialty and for medicine as a whole.
4. Recapture our hospital privileges. When family physicians started leaving hospitals, we started losing our standing with our patients and with the medical community. I still like to think of our specialty colleagues as “limited specialists,” but more and more we family physicians are limiting ourselves in our scope of practice.
We need to recapture the spirit of the pioneers of family medicine who had the vision to build a brand new specialty on the foundation of general practice. Although much effort and time went into the FFM project, I don't think the results exhibit the same courage and vision. Rather, I view the result as little more than manipulation of the system we have. What we need is a new system.
WHAT DO YOU THINK?
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