Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 2

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!

---

[1] Mullan, Fitzhugh. Big Doctoring in America: Profiles in Primary Care. Millbank. 2002.

Primary Care, Pediatrics, and Physician Distribution

As the discussion on health reform proceeds, we are seeing several “specialized” takes on what form health reform should take, what the interests that are advanced should be, and to what degree the current privileges (income) of those who are doing particularly well in the current arrangement (insurance companies, pharmaceutical and medical device companies, many hospitals and subspecialist physicians) should be preserved; this latter is sometimes couched in terms of benefit to the health of the public, but sometimes the argument is even made de facto. In this an a future entry or two, we will discuss some of these issues regarding the physican workforce, physician training, and financial incentives.

In the May 13, 2009 issue of JAMA, Freed and Stockman write on “Oversimplifying primary care shortages”.[1] Citing the literature demonstrating the shortage of primary care physicians, they assert that the real issue is that there is a shortage of primary care physicians for adults, and that the production of primary care pediatricians has not suffered. “The most recent published data regarding pediatric residents completing training in 2008 demonstrate that 40% were planning to pursue a career in primary care, with 10% still undecided.” They warn against increasing the production of general pediatricians, fearing an oversupply, noting that “While the absolute number of children has remained relatively stable, the number of pediatricians has increased substantially. This has resulted in an increase in the number of primary care pediatricians, from 32 to 78 per 100,000 children in the period 1975 to 2005.” They then go on to talk about the “…increase in the number of recognized subspecialties [in pediatrics] and the continuing need to populate those fields with fellowship-trained pediatricians.”; essentially an argument for the need for more pediatrics residents to choose subspecialty training. I will not address that except to say that this statement, unsupported is a tautology – because we have more specialties we need to train people to go into them – rather than a justification (which may well exist) for the need for more pediatric subspecialists.

The fact that the entrance of medical students into pediatrics, and the stability of the choice of general pediatrics among those residents, the first in marked contrast to the decrease in students entering family medicine and the second in contrast to the career choices of residents in internal medicine, is definitely important. It is worthy of more than note; it needs to be studied to identify the reasons. Perhaps these reasons will be unique to pediatrics and not transferable to other primary care (adult) specialties, but perhaps there are important lessons to be learned. However, a gross measure, in this case total number of pediatricians, or even primary care pediatricians, to the number of children misses some important considerations, many of which have been addressed previous in this blog. The most obvious is that Freed and Stockton completely ignore geographic distribution of pediatricians, a point noted by JAMA editor Catherine DeAngelis in her editorial. “…although the number of generalist pediatricians does not appear to be a problem, their geographic maldistribution remain.”[2] Pediatricians, like most physicians, choose to locate in certain areas, specifically in major metropolitan areas. Rural areas especially, and to a lesser degree inner-city areas, do not have enough pediatricians.

Indeed, it is only family physicians that distribute in proportion to the location of the population. Freed and Stockman are correct in asserting that we do not need to simply train more primary care pediatricians, but the reason is that they have saturated the areas in which they are willing to live. This is addressed in Dr. Robert Bowman’s guest column on this blog from January 15, 2009, “Ten myths regarding primary care”. Myth #9 is “The nation needs more pediatric graduates to meet primary care needs.” Dr. Bowman states “More pediatric graduates will not meet primary care needs. According to pediatric leadership, pediatric primary care is saturated in the locations where pediatricians choose to locate, at the same time that the United States has fewer children. Even though 15% of white female medical students remain committed to pediatric residency choices, they and other pediatric graduates will compete with all other primary care graduates already delivering pediatric primary care. This is likely to result in more practicing in part time, specialty, hospital, urgent, and emergent pediatric care settings.”

The fact that pediatricians are disproportionately female may help to explain the relative immunity of this primary care field from downturns in student selection, but, for the reasons Dr. Bowman identifies, may not solve our geographic distribution needs. It may also explain why simply looking at the numbers of doctors entering a specialty (general pediatrics in this case) may overestimate the actual number of FTEs and years practiced (Dr. Bowman’s “Standard Primary Care years). As this blog addressed on March 7, 2009, “The feminization of medicine” is in many ways a very good thing – including the persistent interest in pediatrics – but it has other implications which need to be considered in estimating workforce supply. These include the probability that female physicians, including pediatricians, will work fewer years (including time off for child rearing and earlier retirement) and the greater likelihood of female physicians to work less than full time. In addition, while there are great difficulties in getting physicians overall to practice in rural areas, the issue is even greater for women, because they are even more likely than male physicians to be married to other professionals, frequently physicians in more lucrative subspecialties, who cannot find employment in rural areas.

The challenges of getting physicians to rural areas are enormous, and have been addressed here before. Increasing the number of rural students is critical; paying doctors who work in “less desirable” (and here I want to make clear that this is not by any means a value judgment on life in rural areas, but simply a reflection of physician choice; maybe we should say “less popular”) rural areas more money than those who work in urban areas is essential. But it also requires producing the kind of doctors who can work in those settings, and essentially that means family physicians – and probably general surgeons. If students continue to enter family medicine at rates that won’t even replace the already-too-low percentage of primary care doctors, then all strategies need to be developed to encourage them. It is not sufficient to increase reimbursement for generalists a little, or even some; the entire reimbursement structure needs to be revised to encourage continuity, comprehensive management, coordination of care, and quality metrics rather than production of visits or procedures.

[1] Freed GL, Stockman JA, “Oversimplifying primary care shortages”, JAMA 13May09;301(18):1920-22.
[2] DeAngelis CD, “Commitment to care for the community”, JAMA 13May09;301(18):1929-30.