The 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:
Part II: More whence, and some whither family medicine
Family medicine introduced many great things to
medical education. We had non-physician faculty in our departments and
residencies, psychologists and educators, unheard of then. We valued education,
and realized that just being a good doctor was not the same as being a good
teacher, so created faculty development programs, including fellowships, often
supported by Title VII grants. Our Board required recertification from the
beginning, and no one, not even those who created it, were immune, or “grandfathered
in”. Many of these innovations (if not the “no grandfathering”) were adopted
later by other specialties, although not always crediting the discipline family
medicine. And many specialties have not adopted them yet, still to their shame.
But, in the US, family medicine is
still somewhat on the margins. It never completely took over as the centerpiece
of the health system, not as in Canada or the UK. Much of the opposition has
been regional, especially in the NE, and in cities where there were already
plenty of doctors who did not want to give up control – or money (remember that word, money, we’ll be coming
back to it). Of course, then, as now, most pundits who comment on medicine
– actually, on all things – are, at least relatively, well to do. Poor people
often adopt such attitudes as “specialists are better”, because they assume
that what the rich have is better (bigger houses, better cars, certainly better
doctors), although those of us who went to medical school know that that is not
necessarily true. Our classmates who wanted to become elite subspecialists
caring for the rich did that, and those who wanted to serve the needy did that,
and it had little or nothing to do with class rank or skill. Of course, the
obstacle to poor people getting what the rich get is, well, they don’t have,
and so their doctors wouldn’t make, enough
money!!
The small-town white picket fence
practice, of Marcus Welby and many fathers and grandfathers (less commonly
mothers or grandmothers) of current FPs, such as many of those portrayed in Fitzhugh
Mullan’s book ‘Big Doctoring’,[1]
may be mostly gone, but that model was
long the darling of the RRC; those of us working in inner-city training
settings often felt that the rules were written for someone else.
Other issues confront us, sometimes
divide us. Should the future of family medicine be about “full scope” practice,
including caring for children, delivering babies, hospital work, emergency
care, musculoskeletal care? Or should it be limited, specialized even (OB,
geriatrics, sports medicine)? Should we
be using the term primary care or family medicine? What about general internal
medicine? Pediatrics? GIM has pretty much abandoned the field, since 80% of IM
graduates become subspecialists and over half the remainder become
hospitalists. Should we just stop saying “primary care” and insist on “family
medicine”?
Most of us recoil at the
oft-heard-from-medical-students idea that GIM is family medicine without the OB
and pediatrics. We think that there is a conceptual basis for our specialty
that has to do with caring for the whole person and caring for them in the
context of their lives, families and communities. Despite the concerns of the
young Josh Freeman, this context is critical. The pediatrician cares about the
health of the child she cares for, and likely that of the adult that child will
become. The family physician also cares for both, but more concretely than the
pediatrician experiences the health issues that adults face that often have at
least part of their roots in their childhood experiences. In addition, the
family doctor cares for that child’s family, and knows, for example, that the
child’s mother is not just “mom” (I hate
that usage!) but someone with their own problems, maybe a hard job, maybe
not enough money, maybe a troubled relationship, maybe caring for her own
parents, maybe with her own health issues. I have often said that if clinical
sciences have associated basic sciences (like psychology for psychiatry, and
anatomy for surgery) then anthropology is the basic science for family medicine
because it examines people in the context of their families and communities.
Family medicine is also comprehensive,
per se, by its nature. I was once
able to recruit an anthropologist to our department because she wanted to work
in that comprehensive context, and public health/preventive medicine didn’t
really offer it. Preventive medicine is seen by some as holistic, but it
segments just as medical specialties do: I do smoking, you do seat belts, she
does bicycle helmets, he does violence. But the family physician has to address
them all. We can’t say “wear your seat belt” but ignore “stop smoking”! Or, is
that what we want FM to become? Geriatricians and sports medicine and women’s
health? Hospitalists and ambulists, nocturnists and weekendists? (By the way,
that anthropologist went on to help run the AAFP’s national research network.)
Sometimes the issue of how family
physicians practice is formulated as a conflict between lifestyle and scope. Is
that true? Maybe. Maybe it is good to not take call, or too much call, or have
to round in the hospital or have to get up to deliver a baby in the middle of
the night. But it may also be true that for a well-trained family doctor, 8-5
clinic patients can become drudgery. Sometimes teaching helps. And what about
the issue of lifestyle vs lifestyle? People want to move to and practice in
cool places to live, with a lot going on, stimulating cultural events and good
educational systems. But these places may pay less money and cost more to live
in. Besides your practice, do you want to be San Francisco poor or Nebraska
well-to-do? That old white picket fence family doc may have had no
conflict, but now young people do.
There have been lots of changes in the
health system in my lifetime. Family medicine was created in the 1960s and grew
to adolescence in the 1970s. In the 1980s we had lots of promise; Nixon pushed
for HMOs, and in the 1990s we had gatekeepers – and different opinions about
whether that was good or bad. Our best resident matches were in the late 1990s;
no student wanted to be an anesthesiologist because they were afraid of not
getting a job. But now ….
One study showed a student entering an
anesthesiology residency can expect to make $7 million more in their lifetime
than one entering family medicine. In this country. When I was in Denmark a few
years ago I visited a rural family practice. In conversation, the doctor
mentioned his daughter was married to an anesthesiologist. Tied to my own
country’s norms I joked that at least he wouldn’t have to worry about being
supported in his retirement. Oh, he replied, in Denmark family doctors make
more than anesthesiologists!
Is it all about money?
We have a health system that fails to
focus on the health of the people. We have almost abandoned the concept of
public health. Indeed, the currency of the term “population health” is more
than a semantic difference. Population
health can be narrowly defined to be any population – the population of your
practice, say -- and it can and does often leave people out. The people who are
hard to care for, or don’t make money for us, or mess up our statistics. Public health
requires us to look at the WHOLE public. Eew! How messy!
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