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Requiem for Family Medicine

Posted By Paul D. Simmons, Thursday, August 02, 2012
Family 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.

As 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 physicians.
Paul D. Simmons
Our support for the Patient-Centered Medical Home (PCMH) model, while predicated on admirable ideals, could easily be speeding our demise.

Sadly, 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.

Even 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 well?

The 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).

Our 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, simplifying fact.

While 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

2. Porter, S. (2012) Family Medicine Match Rates Increase Slightly. AAFP News Now, American Academy of Family Physicians. Retrieved from

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

4. Should Colorectal Surgeons and Family Doctors Perform Colonoscopy? (2012)., retrieved from

5. Rough G. (2009). For many, a nurse practitioner is the doctor. Arizona Republic. Retrieved from

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

7. Flanagan L. (1998). Nurse practitioners: growing competition for family physicians? Family Practice Management 5(9): 34-43. Retrieved from

8. Wood J. (2012). Changing training standards for maternity care. Leader Voices Blog, American Academy of Family Physicians. Retrieved from

9. AAFP Opts to Remain in the RUC (2012). AAFP News Now, American Academy of Family Physicians. Retrieved from

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


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.

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Randall Reitz says...
Posted Thursday, August 02, 2012
Paul, I look forward to debating these ideas at our CFHA plenary session in Austin.

But, let me offer a preview derived from our Olympic fortnight. Imagine for a moment, a gold medal match between Brazil and Bhutan. Brazil’s players are the envy of the world. When not representing their country, they make huge salaries playing for the best professional teams in Europe. Brazil’s soccer infrastructure is world class, allowing for many years of skill development before a player has a chance to try-out for the national team. Once within the system, players train for years together to form a cohesive unit. As a result, they have won 5 World Cups, more than any other nation. In comparison, Bhutan has no history with soccer and no world championships. According to the FIFA world standings, Bhutan is currently in last place. Their team is a ragtag group with less skilled players, far less training, a meager infrastructure, and no watershed victories. Now, with a departure from reality, let’s add to this equation, a soccer pitch that is steeply tilted with the downhill end being the goal defended by Bhutan. And, imagine that Bhutan cannot afford to send a large Olympic contingency, so each soccer player is asked to also compete in at least 1 aquatic and 1 precision shooting event.

Unfortunately, in our metaphor, family medicine is Bhutan. As you aptly summarized, nearly every aspect of medicine’s playing field is tilted to the benefit of the specialties. RUC policies are far more supportive of procedures than prevention and of specialty knowledge over comprehensive knowledge. Because of the income differential, most of the best and brightest medical students don’t choose family medicine. So, the players attracted to Team Family Medicine are frequently a ragtag assemblage of students from less prestigious American medical schools and other countries. Add to this disparity the shorter time in residency allotted for learning a much larger field of knowledge. And, the coup de grace is the expectation that family physicians are expected to train to perform in numerous settings: ambulatory care, ER, inpatient, OB, nursing home, and hospice. These untenable expectations offset by the advantages of (comparatively) inferior salarihould indeed lead family family physicians to circle the Audis.

While my overall opinion (fortified by the practice plans of recent graduates of our residency) is in-line with yours, my take home message is quite different.

• Rather than disparaging the PCMH, family physicians are wise to charge headlong into medical homes. While recent events have proven that changes in the RUC will come slowly or never, the PCMH reimbursement model is proving that a moot point. For example, in the next 3 months 75 PCMH practices in Colorado will be awarded contracts through the federal government’s Comprehensive Primary Care Initiative. Through this program, PCMH clinics will begin to receive a $20 per-member/per-month incentive. For a mid-size clinic like our residency this would equal to $1-2million per year. This is far greater than will ever be negotiated through the RUC.

• Only with this added incentive will family medicine be able to compete for the best medical students. This will finally justify increasing family medicine residency training from 3 to 4 years. Given the increasingly small resident work hours, a 4 year residency is a minimum for hoping that any family doctor could leave training feeling competent to maintain a full-spectrum practice.

• My experience indicates that the public health aspects of family medicine are among its least desirable. Residents frequently complain about seeing a schedule full of noxious conditions like chronic pain and somatization interspersed with unstimulating cases of refractory diabetes and hypertension. Rather than poo-pooing physician extenders, isn’t it time to welcome people who are eager for these cases into your clinical setting? I know this goes against physician masochism, but according to your blog post, new family physicians no longer consider self-flagellation de rigueur.

• And finally, what is missing in your requiem for family medicine is any case for the Triple Aim. While I agree that family medicine should be at the heart of any health system based on the Triple Aim, narrowly advocating for 1 guild without considering the larger healthcare system is short-sided and self-promoting.

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Sean T. Hearn says...
Posted Wednesday, August 22, 2012
The problem with Dr. Simmons message is that what family physician do is to try to understand the patient's needs, desires, illness and health and goals in an environment of a family, a community, from a particular psychological and developmental point of view. A patient is not just a disease. Diseases happen to people who become patients. I know of no other specialty that understands that better than family medicine. In addition to that , we try to explain the disease process to the person and help them develop a plan to get healthier in all aspects of there illness, not just what it does to their bodies, but their spirits, their families and their idea of who they are. If we do not do this then we are severely limiting what people experience as patients and what we experience from our roles as physicians and from our own interaction with the people we see and in our own inner lives.. We can do these things in many settings and should be. Sean Hearn MD
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Andrew Pomerantz says...
Posted Friday, August 24, 2012
At the risk of seeming an outsider telling others a thing or two about themselves, I’d like to offer a few comments. I’m a psychiatrist so telling others about themselves is really nothing new. Except I try not to do that. Perhaps that’s why I’ve been doing integrated care for all of my quarter century in psychiatry. And, incidentally, I spent more than a decade as one of those old GP’s carrying my leather bag (which my wife encourages me to turn into something useful though I can’t part with it) around the countryside in the backwoods of Vermont. This was at the time Family practice was still suffering through its birth trauma. Though I could have been grandfathered and become a certified FP, at the time I thought making such a specialty out of generalism was a bourgeois capitalist elitist scam that would destroy everything that was good about general medical care. Anyone who was around during the late 60’s and early 70’s will understand the thinking.
Since then, however, my thoughts have come full circle. I long for an FP to call my own. FPs don’t mind getting their hands dirty. I’ve come to know them as people who will do whatever it takes to help out and not just stand back and call in someone else to do the dirty work. Without FPs around, who is there to oversee care for those people in the medical home? As healthcare moves (hopefully) from its “find it-fix it” mentality to something more comprehensive and meaningful to our citizenry, the FP will become the most important person in healthcare. Who else on the team will know how the work of the surgeon, the endocrinologist, the nephrologist and the cardiologist all fits together? Who else will stop the buck as it rises through the rest of the team and everyone looks for guidance.
I was at an integrated care planning meeting a few years ago and a number of people were trying to come up with a tag line for Family Practitioners. The one that fit best was “Jack of all trades; master sof complexity.” Without you FPs, I will have to continue to oversee my own healthcare and have a fool for a patient.
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