medicine is a young specialty, a mere forty-three years old (1). Unfortunately, family medicine will be
extinct before it reaches its 70th
birthday if current trends
continue and—although I write as a family physician who educates family
medicine residents and loves the idea and ideals of family medicine, I say—this
might not be a bad thing. Several
forces, both from within and external to family medicine, are conspiring to
make us irrelevant, unnecessary and obsolete.
We’ve all seen the Match Day trends (2).
Each year until 2010, fewer medical students pursued training and
careers in family medicine, and the slight increases over the last few years
are largely attributable to more family medicine residency positions
available. We cannot fill our available
positions with US graduates. Many of
those who match in family medicine are trained in a shrinking spectrum of
skills. Many new graduates quickly
jettison any broader skills they may have had in the name of work-life balance
(3). Across the country, specialists and
insurers implicitly or explicitly argue that family physicians cannot and
should not be doing surgical (or non-surgical) obstetrics, endoscopy, minor
surgery, ICU care or hospital medicine (4).
We are often complicit in this effort to minimize our domain of
practice, again in the interest of lifestyle or avoiding liability.
our skills and practice scope are diminishing, a wave of mid-level
practitioners (i.e., physician assistants and family nurse practitioners) are
moving into primary care medicine (5,6,7).
They share many of our same skills, are able to prescribe and order just
as we are in a growing number of states, and are paid less. Most of these so-called "physician extenders”
do excellent work and are viewed as equivalent to physicians by many
patients. It is inevitable that health
systems, policy-makers and third-party payers will soon realize—with dollar
signs in their eyes—that these practitioners are inexpensive physician substitutes rather than physician
"extenders.” All of the skills, more
empathy and a similar scope of practice without the egos or paychecks of
support for the Patient-Centered Medical Home (PCMH) model, while
predicated on admirable ideals, could easily be speeding our demise.|
family physicians are ill-equipped to resist our own demise because we lack a
clear sense of what, exactly, it is we do.
Not only does the public have little sense of how a "family doctor”
differs from an old-fashioned "GP” or an internist, many of us have a difficult
time explaining the distinction apart from defensively sputtering, "We’re a
specialty, too!” Family medicine, some
say, takes care of 90% of medical problems that present in the outpatient
setting. Of course, so do internists
(for adults), pediatricians (for children), and emergency physicians (for
everyone). Family medicine, some say,
provides continuity of care over the lifespan.
Perhaps thirty years ago this was true.
Now, however, vanishingly few family physicians will spend a career in
the same location, taking care of the same population.
more troubling, however, is a deeper sense of inadequacy within the family
physician’s psyche. Yes, I take care of
adults, but can I really do so as well as an internist? Yes, I take care of children, but can I really do so as well as a
pediatrician? I may deliver babies, but
can I really provide the same quality
of care as an obstetrician? If the
reader balks at these questions, consider:
if your wife were to experience a pregnancy complication, and you had the
option, would you ask for an obstetrician or a family physician? If your child was suddenly struck with
serious illness, would you bring her to a pediatrician or a family
physician? We claim we are "equal” to
our specialty colleagues—yet when serious or complex illness strikes those we
love, we may find we have been playing doctor and we want a Real Doctor to step
in to save us. Do patients sense this as
larger medical world certainly seems to have detected our impotence. Family physicians exert minimal or no
influence in determining our own payment structure, nor are our protests taken
seriously. The Accreditation Council of
Graduate Medical Education (ACGME) frequently ignores or delays our specialty’s
recommendations or intentions (8). The
AMA/Specialty Society Relative Value Scale Update Committee (RUC) continues to
perpetuate an unjust payment model despite our protests (9). Family physicians are not the doctors that
come to mind when patients think of disease-detecting, mystery-solving
"experts” at the Mayo Clinic or Cleveland Clinic, nor do many tertiary- and
quaternary-care institutions see a significant role for us in their delivery of
medical care. Our medical journals are
of comedically dubious quality, and we seem to be best at publishing, if
anything, within the review article genre (10).
support for the Patient-Centered Medical Home (PCMH) model, for example, while
predicated on admirable ideals, could easily be speeding our demise. The PCMH model rests on the idea of
team-based care, where many of the functions previously carried out by
physicians are delegated to nurses, medical assistants and case managers. This is intended to free up the physician to
deal with the "hard” cases for which we are best suited. The problem is: we are not best-suited. The
endocrinologist is best-suited to deal with the complicated, uncontrolled
diabetic patient that cannot be brought under control by the nurse
practitioner’s efforts. Similarly, the
cardiologist is best-suited to deal with the refractory hypertensive; the
gastroenterologist with the complicated hepatitis C patient. The family physician, in the PCMH model, is
an unnecessary (and expensive) middle-man who has very little to add to the
best management efforts of a high-functioning team operating with
evidence-based protocols and guidelines.
Inevitably, someone in authority will realize this cost-saving,
our specialty shrinks and delegates itself out of existence, some of us take
refuge in the ridiculous romanticism of "biopsychosocial” or "patient-centered”
or "holistic” flag-waving—as if patients would rather have sympathetic
hand-holding than competent, efficient, expert medical care. That’s all fine, of course. We’re generally nice people. But while we’re spending our collective
efforts on patient focus groups, learning acupuncture, satisfaction surveys,
lifestyle balancing acts and "restoring the mystery” to medicine, our
colleagues in internal medicine, pediatrics, obstetrics, critical care, surgery
and emergency medicine are taking care of actual seriously sick people and
showing that they can do a better job of it than we can. Perhaps we should step aside and let them get
back to work.
1. Piscano, NJ. (n.d.) History of the Specialty.
From American Board of Family Medicine website.
Retrieved from https://www.theabfm.org/about/history.aspx.
2. Porter, S. (2012) Family Medicine Match Rates
Increase Slightly. AAFP News Now, American Academy of Family Physicians. Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/education-professional-development/20120316matchresults.html.
3. Kotmire S. (2012) Shrinking Scope of Practice
Raises Questions About Future of Family Medicine Training. Leader
Voices Blog, American Academy of Family Physicians. Retrieved from http://blogs.aafp.org/cfr/leadervoices/entry/shrinking_scope_of_practice_raises.
4. Should Colorectal Surgeons and Family Doctors
Perform Colonoscopy? (2012).
Gastroenterology.com, retrieved from http://www.gastroenterology.com/featured/should-colorectal-surgeons-and-family-doctors-perform-colonoscopy.
5. Rough G.
(2009). For many, a nurse
practitioner is the doctor. Arizona Republic. Retrieved from http://www.azcentral.com/news/articles/2009/02/21/20090221nursepractitioners0220.html.
6. Horrocks S, Anderson E, Salisbury C. (2002).
Systematic review of whether nurse practitioners working in primary care
can provide equivalent care to doctors. British
Medical Journal 324: 819-23. Summary
retrieved at http://apps.who.int/rhl/effective_practice_and_organizing_care/SUPPORT_Task_shifiting.pdf.
7. Flanagan L.
(1998). Nurse practitioners: growing competition for family
physicians? Family Practice Management 5(9): 34-43. Retrieved from http://www.aafp.org/fpm/1998/1000/p34.html.
8. Wood J. (2012). Changing training standards for maternity
care. Leader Voices Blog, American
Academy of Family Physicians. Retrieved
9. AAFP Opts to Remain in the RUC (2012). AAFP
News Now, American Academy of Family Physicians. Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/inside-aafp/20120313rucdecision.html.
10. Van Driel L, Maier M, De Maeseneer. (2007).
Measuring the impact of family medicine research: scientific citations or societal impact? Family
Practice (2007) 24 (5): 401-402.
Retrieved from http://fampra.oxfordjournals.org/content/24/5/401.full.
Paul D. Simmons, MD FAAFP, is Extremely Junior Faculty at St.
Mary's Family Medicine Residency in Grand Junction, Colorado where he
serves mainly as a negative example for malleable trainees. He
practiced family medicine, including obstetrics and endoscopy, for
several years in rural eastern Colorado and Wisconsin before joining St.
Mary's. His interests include antique Jungian archetypewriters,
obscure eponymous diseases, superhero movies, Sherlock Holmes and
misanthropy. He will debate the future of collaborative care during a keynote address at the CFHA Conference in Austin, October 4-6, 2012.