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.

Primary Care Grants from HRSA: not enough, not wisely done

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In late September, the Health Resources Services Administration (HRSA), a branch of the federal Department of Health and Human Services (HHS) released the funding announcements for its grants support a variety of educational programs for academic year 2010-11. This was long anticipated news by those who had applied for them, since the time period that they cover began in July. The grants cover a wide variety of areas largely involving enhancement of the health professions workforce in primary care, oral health, physician’s assistants programs, minority health, geriatrics, pipeline development, and this year (with ARRA funds) $50 million for equipment. State-by-state funding (very important politically!) can be found here, broken down by state and category here, information on individual grants, by county, can be found here.

Virtually all of the programs supported by HRSA are in important areas that I have written about previously, but I will focus here on those I know best, the “Primary Care Cluster”, part of Title VII. These grants support program innovation in Residency Training, Medical Student (Predoctoral) Education, Faculty Development, and “Academic Administrative Units” (essentially departments of primary care). They have their roots in the development of Family Medicine as a discipline in the 1970s. The feds then, as now, saw primary care (family medicine) as an important need, but one which needed nurturance. Residency programs were being started and needed funding to develop and experiment with different curricula that would be most appropriate to create family doctors. There were no departments of Family Medicine in medical schools, or even academic faculty in the discipline, so the Academic Units grants were created to help support the creation of the former, and the Faculty Development grants the latter. Predoctoral grants helped develop the curriculum for educating medical students in family medicine.

These grants were successful, both in creating programs that trained more family doctors and doctors who went into practice in underserved communities, often through the National Health Service Corps (NHSC), another HRSA program. In addition, another (possibly unanticipated) outcome was that the formal training of family medicine faculty and fellows in educational skills, felt necessary because there were not existing physician educators in this field, created a core cadre of physician medical educators that was far more extensively and formally trained in areas such as teaching skills, curriculum development, implementation, and evaluation, and other education methodologies than faculty in other departments, revealing a large, previously unrecognized need in medical school and residency faculties. In the 1980s, the grants were expanded to a larger pool of primary care programs, primarily General Internal Medicine and General Pediatrics, and later Physician’s Assistants.[1] They became critical supports for innovation in the education of students, residents, and faculty.

While these programs were very successful, reported in numerous articles reporting on general internal medicine[2], general pediatrics, and family medicine (notably in a special issue of Academic Medicine, November 2008) and has been demonstrated to increase the number of physicians practicing in community health centers (Rittenhouse DR, 2008), and have actually enjoyed bipartisan support (after all, both Republican and Democratic legislators have underserved rural and urban areas in their districts), funding has always been threatened. For many years, Presidents of both parties would “zero out” funding for these programs in their budgets, only to have them restored by Congress after significant pressure from their constituents. Even then funding has often been cut; in 2006 there was just enough to fund the existing (usually 3-year) grants and no new ones were funded, and the years since have been marginal.

So there was great anticipation this year, with large (for a small program such as this, compared, say to the NIH funding of biomedical research in the tens of billions) increases from previous desert levels. Much of this was ARRA (stimulus) funding. And the results have been very disappointing. Like much of ARRA, emphasis was placed on projects that would programs that could show quick, tangible results so a good portion went to equipment grants. Some went to specific Congressional earmarks. ARRA funds supporting traditional Title VII Primary Care grants were for 5 years, and were all that was available to General Internal Medicine and General Pediatrics; the relatively small number of programs that were funded thus received relatively large grants. ARRA funds also supported a miniscule number (5) of new Academic Units Grants for Family Medicine. The pot for “regular” funds for grants was smaller than it has been in many other years, and large numbers of faculty development, residency, and medical student education grants that were highly-scored by the peer reviewers did not qualify for funding. The application of ARRA funds made this a particularly crazy year; in the Spring those with existing funding were told that they “might” have to submit new grants, in two weeks, so they wrote them before being told “never mind”. The grant reviews happened late and so funding was late. The staff at HRSA, a highly committed group, must have felt whipsawed by changes in rules from above and urgent questions from potential and current grantees.

So, life is tough. Not all grants get funded. Maybe only a small minority do – talk to those who apply for funds to NIH. And so the money came late – it came (to those who received it.) For grants other than those supporting faculty development fellowships, which would have needed to recruit fellows months before the end the academic year – this is not such a big problem. But with all the talk – justified – about the need to produce more primary care physicians for the US, this is a very small pool of funds to be divided up. Some family medicine leaders have given up on HRSA funding; one writes “Title VII is a dinosaur…it has not effectively funded new ideas for more than a decade…it is no better than a random lottery…” The rigid priority and preferences, good for some reasons, do tend to stifle innovation.

The other issue is the disposition of funds between the 3 primary care specialties, and especially the large 5-year grants to general internal medicine (the leader quoted above continues, “…although it doesn’t seem very random if all the AAU grants went to internal medicine.”) As has been noted on this blog before, the percent of graduates of 3-year IM residencies who enter primary care (general) internal medicine is vanishingly small; most go on to subspecialty fellowships, and most of the rest become hospitalists. The New England Journal of Medicine’s health policy writer, John Iglehart, describes this in the August 5, 2010 issue in an overview of the impact of the ACA law on residency training, “Health reform, primary care and graduate medical education”,[3] in which he indicates 10-20% of internal medicine residency graduates will enter primary care (I think 20% is dreaming; even 10% may be!) From one perspective, perhaps GIM needs a “jumpstart”, but there is little reason to believe HRSA grant funding will change the decisions (largely financial) for most IM graduates. On the other hand, Family Medicine residencies are producing primary care doctors in every study (Iglehart says 91%), so it could reasonably be argued that the funding should go with proven success.

Interestingly, one of the priority criteria for funding was that “90% of students entering ‘primary care’ specialties (FM, IM, Pediatrics) are in primary care practices 3 years later.” Given the large number entering IM, and the low % at almost all schools entering GIM, this is an extremely high bar, even though it generously uses 3 years rather than the 8 years post-graduation used in the study by Mullan and colleagues cited previously (A New Way of Ranking Medical Schools: Social Mission). The social mission of medical education: ranking the schools[4] used 8-year data to account for such things as a delay for a year or 2 between completing residency and entering a subspecialty fellowship as might occur for a 2-year NHSC commitment or a brief stint as a hospitalist to make money. My school, the University of Kansas, was ranked #5 nationally, mostly for its success in getting graduates into primary care and rural practice, but this was almost entirely due to family medicine; when the HRSA criteria are applied, only 70% of graduates of FM, GIM, and Peds were in primary care in 3 years, reflecting the fact that for KU graduates, as those from most institutions, the retention of internists in primary care is abysmal.

In any case, it is critically important to have significant federal funding for education and training in primary care if we are to meet our nation’s health needs, have physicians for rural areas, and staff our community health centers. The funding needs to be much greater, it needs to be reliable year-to-year, it should have consistent criteria, and it decisions should be made well before the start of the grant period. It is the least that Congress can do.

[1] Funds are also available to support nurse practitioner programs, but through a different stream, targeted to nursing.
[2] (Lipkin M, 2008)
[3] Iglehart JK, Health reform, primary care and graduate medical education, NEJM 5Aug2010;363(6):584-90.
[4] Mullan F et. al., The Social Mission of Medical Education: Ranking the Schools, Annals of Internal Medicine, 15Jun2010;152(12):804-10
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