Archive for December, 2013

A Family Physician Is…

What follows is an article that I wrote for NJAFP’s Perspectives: A View of Family Medicine in New Jersey recentlly.

While on vacation earlier this summer, as I sat on an idyllic beach setting with a good book, a cold beverage, and great jazz in my ears, the sky began to cloud over. With my peace disturbed at the thought of a less-than-perfect vacation day, I grumbled some words of dissatisfaction with Mother Nature – I thought this complaint was made in private, but not so. From about five feet away I heard a “local” say, “Don’t forget where you are. If you don’t like the weather just give it 10 minutes and it’ll change.” Since then I have been thinking about change quite a bit; the pace of change, how difficult change can be, the fact that change just “is,” it’s our reaction to the change that matters, and mostly how often the old axiom “the more things change, the more they stay the same” proves true. Consider these quotes from reports published in 1966 and 1967:

“The patient wants, and should have, someone of high competence and good judgment to take charge of the total situation, someone who can serve as coordinator of all of the medical resources that can help to solve his problem. He wants a company president who will make proper use of the skills and knowledge of more specialized members of the firm. He wants a quarterback who will diagnose the constantly changing situation, coordinate the whole team, and call on each member for the particular contributions that he is best able to make to the team effort.” 1

“Every individual should have a personal physician who is the central point for integration and continuity of all medical services to his patient. Such physician will emphasize the practice of preventive medicine… He will be aware of the many and varied social, emotional and environmental factors that influence the health of his patient and his family… His concern will be for the patient as a whole, and his relationship with the patient must be a continuity one.” 2

“The family physician is one who: 1) serves as the physician of first contact with the patient and provides a means of entry into the healthcare system; 2) evaluates the patient’s total health needs, provides personal medical care within one or more fields of medicine, and refers the patient when indicated to appropriate sources of care while preserving the continuity of his care; 3) assumes responsibility for the patient’s comprehensive and continuous health care and acts as leader or coordinator of the team that provides health services; and 4) accepts responsibility for the patient’s total health care within the context of his environment, including the community and the family or comparable social unit. The family physician is a personal physician, oriented to the whole patient…” 3

A while back, I asked a group of people to complete the sentence “a family physician is…”  Some of the people in that group were themselves family physicians, and some were non-physicians with strong ties to family medicine.  The answers were strikingly similar to those 50+ year old quotes.  

“Your one-stop shop for relationship-based, comprehensive, broad-scope care.”4

 “Someone who cares for the entire patient as a human being, who is on the front line of today’s complex medical care system who cares for newborns to the elderly and is usually someone who knows the patient best, like a good, trusted friend.”5

 “A family physician is someone who looks at the big picture, not just the medical conditions, but also their mental health and social/family situation and advises and supports the patient accordingly.”6

 On first glance, one might argue that it is only natural that the specialty would be defined, or define itself similarly from one generation to the next.  Accountants are still accountants, attorneys remain attorneys, and while the surrounding environment may change and grow more complex, the basis of a profession is likely to be consistent.  Still, the focus of so many conversations and articles (even this one) is how much change family physicians must endure and navigate.  I do not disagree with the premise, but I was also struck by the simplicity of the truth.  At the end of the day, through all the change, the basic nature of family medicine, the value of family physicians, and the role they play in their patients’ lives and in the healthcare economy are strikingly similar to the earliest visions of family medicine.  Family physicians are ultimately, as one respondent stated with eloquent simplicity, “your family’s healthcare partner for life.”  As family medicine travels the winding road that is healthcare in the 21st century, I maintain a hopeful perspective that this basic foundation of the quintessential primary care discipline will not change, and that my ability as a patient to have that life-long relationship with “the health professional [I] trust most to advise and guide [me] to be or stay healthy” will not be relegated to historical recollections of a reality long past. 

Unfortunately, not all similarities with the past are as positive.   

“We believe the cost of medical care can be reduced, the availability of medical care increased, and the quality of medical care improved, if the American people will accept the policy of each person turning to a general practitioner as his family doctor, personal medical guide, and health advisor.7 

Yes, it is far too simple to suggest that we have been saying the same thing for more than 60 years.  It is foolish to overlook the dramatic changes in our capabilities and understanding of science and medicine that have helped to drive cost over that time, and to merely suggest that we have been promoting a solid primary care foundation as the answer to skyrocketing costs with little success.  Still, the words were almost exactly the same in 1949 as they are today.  The call to embrace primary care is not a new one.  We’ve made progress, but perhaps not enough, and I am reminded of a potential version of the future included in the 2000 Keystone III report where Dr. Larry Green, then of the Graham Center, looked forward to the 2020 Keystone V Conference to discuss “why family medicine failed.”  While he suggested that this fictional group came to no consensus, there were four main points of view for the “failure” of family medicine. 

 The first was that the specialty didn’t fail, but rather abdicated.  

“In the specifics of specific places, it made sense to turn over the care of the dying, the newborn, the adolescent, the athlete, the discouraged, the pregnant, the bed-bound, the post-operative person – to someone else…but the ultimate result of these adaptations was the erosion of the functional domain until it lost its coherence, that essential totality that made it what it was.”8

 The second point of view was that “Family Medicine Went Down as a Part of the Old Paradigm.”  Here Dr. Green suggested that in addition to well discussed issues within organized medicine and the academic health centers, the demise of family medicine was hastened by the “nearly absent local family doctors” whose “near worship of their independence, lack of curiosity and solid contributions to better medicine, and focus on payment systems, resulted in their getting lost in their administrative methods and being ‘out-competed’ by others in the best execution of specific tasks…the idea of a healer-person was, at least for now, replaced by a healer-virtual, residing somewhere in the healthcare system as a whole.”8

 Additionally, Dr. Green suggested a third and fourth viewpoint; that family medicine failed because it “chose the wrong tasks” and “never became part of the culture.”  Both of these viewpoints offer equally chilling foreshadowing as we sit closer to the year 2020 that the paper envisioned than the year 2000 in which Dr. Green authored the paper.  The pessimist can look at this set of predictions and draw clear parallels to the reality of today. Many will suggest that the most dangerous crisis in family medicine today is the loss – or abdication – of comprehensiveness, which coupled with the inability or unwillingness of many family physicians to embrace change is not only killing, but in fact may have killed, the specialty.  Others will point to the same set of facts and suggest instead that it is rigidity coupled with a focus on integration, reporting, and validating at the expense of the traditional physician-patient relationship which is the core of the problem.  I understand both points of view, and while I have concerns, I still choose optimism for the future. 

I believe that the rumors of the demise of family medicine have been greatly exaggerated.  To be certain, there is great change all around us.  Today’s family physician is far different than the GP of 1949, the family doctor of 1966-67, and even the family physician of 2000.  

A family physician is more than a doctor of medicine.  A family physician can throw a curveball or change a diaper, watch his or her child play little league soccer or baseball and most importantly, provide care to the whole family and the whole person with a unique quality of care with caring, which is different than most other physicians.9 

Practice environments, patterns, and even the people practicing family medicine are changing.   Still the more they change, the more they remain the same.  Family physicians are still the centerpiece of a healthy healthcare system, they are still the best opportunity we have as a culture to “bend the cost curve” and by far the most well equipped to keep us and our children healthy now and in the future.  They are “the ultimate life coach – [working] tirelessly to care for the physical, mental and emotional health of their patients.”  And while I maintain my role as determined realist, I also remain boldly optimistic about the future – 2020 and beyond.

References

  1. The Graduate Education of Physicians: The Report of the Citizen’s Commission of Graduate Medical Education (Millis Commission). Chicago, American Medical Association, 1966
  2. Folsom MB, American Public Health Association and National Health Council. Health is a community affair. Report of the National Commission on Community Health Services. Boston, MA: Harvard University Press; 1967.
  3. American Medical Association. Ad Hoc Committee on Education for Family Practice. Council on Medical Education. Meeting the Challenge of Family Practice. Chicago: American Medical Association, 1966. (Also known as the “Willard Report”)
  4. Anonymous
  5. Ibid
  6. Ibid
  7. “G.P. Campaign Picks Up Speed,” Medical Economics, 1949
  8. Keystone III: The Role of Family Practice in a Changing Healthcare Environment. Washington D.C.: The Robert Graham Center, American Academy of Family Physicians, 2000
  9. Anonymous

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