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!

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

Helping primary care help the health of all of us

I recently described how primary care can improve the health of our population – proven by dozens of studies – as well as save significant money.  Recently, the distinguished family physician George Rust, MD, co-director of the National Center for Primary Care at Morehouse School of Medicine in Atlanta, made many of the same points in his testimony in front of the Senate HELP Committee’s Subcommittee on Primary Health and Aging (Dr. Rust is pictured here with Subcommittee Chair Sen. Bernie Sanders, I-VT). Rust specifically asked for significantly increased funding for Title VII and Title VIII, the sections of the Public Health Service law that provide grant funding for, respectively, primary care medicine and nursing programs, saying that they would represent "solid investments in the primary care workforce."

Rust also called for separating the funding for residency training provided by Medicare for primary care from hospital training of subspecialists, arguing that the current system has resulted in  "absurd proportions of subspecialists and hospitalists." I have often argued this (for example in GME funding must be targeted to Primary Care, December 10, 2011), noting that hospitals have an interest in training specialists and subspecialists who do things (usually procedures, given our current reimbursement system) that make money for hospitals, and much less for training the primary care doctors that are needed in the community. The problem is that, because academic medical centers provide a great deal of tertiary (and quarternary) care, the mix of primary care and subspecialist and super-subspecialists may be appropriate there, but not for the overall community. However, since these are the places where new physicians are minted and trained, providing the right mix for the community, for the rest of the state and country, means having a very different mix of specialists in training from those working there. This is hard; it is a very common reaction to want to replicate yourself, to want the “best” students to enter training in your specialty, so for an academic medical center which looks like the upside-down pyramid to train doctors in proportion to the right-side-up pyramid is a major challenge! Rust then suggests moving primary care training “back to its community roots”, and says "Instead, let's create direct, sustainable funding for community-based outpatient residency programs that train doctors to keep people out of the hospital”.

As strong as Dr. Rust’s arguments are, primary care will still have problems. One of the comments on the posting at the “AAFP News Brief” that covered this testimony  said “I must be missing something. Can anyone explain how creating more residency slots will increase med student interest in family medicine?” I believe that this is an excellent point – if we cannot fill the slots that exist today for family medicine, particularly with excellent medical students, how will increasing the number of slots improve things? One of the answers, certainly involves reimbursement, dramatically decreasing the difference between what primary care doctors earn and what more highly-paid subspecialists earn; work by the Altarum Institute cited by Jerry Kruse, MD MSPH in his article “Income Ratio and Medical Student Specialty Choice: The Primary Importance of the Ratio of Mean Primary Care Physician Income to Mean Consulting Specialist Income”, suggest that the ratio should be about 80%.

However, there are other factors at work. Sometimes they are referred to as “lifestyle” (perhaps defined as hours of work needed to generate a certain income, or what I have called the income/work hours ratio) but they are more profound than that. In the May/June issue of the Annals of Family Medicine, Christine Sinsky and her colleagues refer to it as “the joy of practice”. “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices” [1] identifies the “deep dissatisfaction” experienced by primary care physicians who care for adults (general internists and family physicians) demonstrated by the many reports of high “burnout” rates. The authors relate this to the extraordinary amount of time that physicians spend doing paperwork and administrative functions, and the pressure by employers to generate high numbers of visits; doctors experience this as alienating and not the reason that they became physicians.

“We propose joy in practice as a deliberately provocative concept to describe what we believe is missing in the physician experience of primary care. The concept of physician satisfaction suggests innovations that are limited to tweaking compensation or panel size. If, however, as the literature suggests, physicians seek out the arduous field of medicine, and primary care in particular, as a calling because of their desire to create healing relationships with patients, then interventions must go far deeper. Joy in practice implies a fundamental redesign of the medical encounter to restore the healing relationship of patients with their physicians and health care systems. Joy in practice includes a high level of physician work life satisfaction, a low level of burnout, and a feeling that medical practice is fulfilling.”

The authors go on to list a number of common problems, and solutions that have been found by one or more of the 23 practices that they visited and analyzed in detail. They included:

·       Reducing work through pre-visit planning and pre-appointment laboratory tests;

·        Adding capacity by sharing the care among the team;

·         Eliminating time-consuming documentation through in-visit scribing and assistant order entry;

·         Saving time by re-engineering prescription renewal work out of the practice;

·         Reducing unnecessary physician work through in-box management;

·         Improving team communication through co-location, huddles and team meetings;

·         Improving team functioning through systems planning and workflow mapping.

These are all good ideas, and the solutions are sometimes creative, sometimes painfully obvious, and sometimes obstructed by our bizarre health system. One of my favorites, the second, is an example of the latter:

“We observed that team development must often overcome an anti–team culture. Institutional policies (only the doctor can perform order entry), regulatory constraints (only the physician can sign paperwork for hearing aid batteries, meals delivery, or durable medical equipment), technology limitations (electronic health record work flows are designed around physician data entry), and payment policies that only reimburse physician activity constrain teams in their efforts to share the care. An extended care team of a social worker, nutritionist, and pharmacist may be affordable only in practices with external funding or global budgeting.”

Thus is illustrated the tie-in between innovations that can make practice again joyful and the payment reform and re-working of our entire non-system which we desperately need! There is a long way to go; as the authors point out, no single practice has solved every problem. But the linkage is clear – a medical care system designed to reward expensive interventions for a relatively small number of people has created an inappropriate mixture of physicians as well as an incentive for hospitals to focus mainly on such procedures, as it has increased the burden on, and in many cases taken the joy out of, being a primary care physician. It is important to remember that it is not just about the doctors (I try to remind my students and residents, precious as each of them are to themselves and their families and often to me, that ultimately it is not about them). The authors put it this way:

“The current practice model in primary care is unsustainable. We question why young people would devote 11 years preparing for a career during which they will spend a substantial portion of their work days, as well as much of their personal time at nights, on form-filling, box-ticking, and other clerical tasks that do not utilize their training. Likewise, we question whether patients benefit when their physicians spend most of their work effort on such tasks. Primary care physician burnout threatens the quality of patient care, access, and cost-containment within the US health care system.”

Both the macro-structural changes in the structure of the system as identified by Dr. Rust and the more micro-level changes in the practices of primary care clinicians identified by Dr. Sinsky and colleagues need to occur to make us have a sustainable, healthful, system of health care. And they need to happen soon.

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[1] Sinsky, C, et al.,, “In Search of Joy in Practice: A Report of 23 High-Functioning Primary Care Practices”, Ann Fam Med May/June 2013 vol. 11 no. 3 272-278, doi: 10.1370/afm.1531