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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Family Physicians are being outflanked
New Model of Family Medicine
'New' Method of Financing Primary Care
Family Medicine: Simplicity Beyond Complexity, Leading with Questions
Why Family Medicine?
We need this dialogue
Family Medicine's Future - The Real Story
A few thoughts
Critical Issues for Family Medicine
Ashamed
TAKING STEPS INTO THE FUTURE
New Model on the Wrong Track
Future of Family Medicine Includes New Role for Nurses
Too much navel gazing...
Good Intent, Great Potential, Wrong Direction
What About the Future of the “Physician” in Family Medicine
CIRCLING THE WAGONS
The Future of Family Medicine
EDITOR'S QUESTIONS AND FURTHER SYNTHESIS
Administrative/Academic vs. Private Practice Perspective
Patient-centered approach needs shared responsibility
Response to The Future of Family Medicine
I am not a professional hand holder!
most important factor left out
A Smart Move.
The Need for Family Doctors is awesome
Future of Family Medicine Project
One Early Synthesis of the Discussion
Comment on "The Future of Family Medicine" report.
The Future of Family Medicine
Family Practice Reimbursement Issues Inadequately Addressed
Future of Family Medicine: Chaos Theory in Practice
Personal medical home and access to care
Pills and Procedures
provocative report
Concerns of the FFM report
Personal Medical Home
Future Trends in Primary Care: Lessons for Family Medicine
No,it's not the modern day Willard report
Who cares for all Americans . . .
Great Concept But Incompatible with Reality
A truly new approach to family medicine
From melting pot to the final "ingot"
a nightmare scenario.
Response to "Future of Family Medicine"
Re: Giving Up
ANOTHER PAT ON THE BACK
FP decline
Medical Organization Overkill
response
The movement toward retainer medicine
It's about the money!
STOP THE MADNESS
Perspectives from U.S. Representative Jim McDermott
Health Promotion, Technology and Joy
Whither Family Medicine?
Complexity and Benificence
Future of Family Medicine
Living The Dream
A new "old-fashioned" approach to Family Medicine
There won't be a practice if...
We must evolve
Giving Up
Allow Our Marketing Consultants to Help Us
Blue Cross Blue Shield Plans and AAFP: Creating a Better Future
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Charles L. Quilty, Amargosa Valley, Nevada, USA physician with Nevada Health Centers, none
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The comments and articles about redefining family medicine sound good but are also becoming hollow in their impact on family medicine as physician assistant and nurse practitioner programs are about to outflank family physicians for our target population, especially in urban areas. The is a recent move to give NP's a doctoral title on the cheap. Soon, you'll be able to call your local NP "doc". Unless family physicians become more aggressive in their approach, all this "redefining" will be more like a new paint job for the Titanic. The numbers of family physicians will shrink as med students well recognize the lack of place for family physicians economically in American medicine. In other words, family practice is headed toward becoming economically unviable for many, with a cheaper alternative being pushed as our replacement. I intend to practice another 14 years until I turn 70. I feel badly for my younger colleages who appear to be getting lip service and little else from the leaders in family medicine. Sincerely: Charles L.Quilty, M.D. Competing interests: None declared |
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Charles Anderson, San Marcos, Texas, USA Physician, What?
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The New Model of Family Medicine is a worthy goal to improve the speciality. However, most of it was what I thought we were doing when I was in my residency 30 years ago. Several new labels have been formulated to describe the New Model, like "personal medical home", "evidence-based medicine", "lifelong learning program", "high quality care", "practice based research", "quality of care", and "team approach to patient care". I thought we were doing these things, or similar things, 30 years ago. If the New Model is all new, then what have we been doing for the last 3 decades? It appears that the primary purpose of the New Model is to shape present Family Medicine residency programs for the future. If so, I think that no matter what these recommendations are called, they are still worthwhile. However, the most important thing that can be done to improve the specialty is to change the way physicians are paid (Not "reimbursed". I never gave an insurance company or the government any monitary sum for which I need to be "reimbursed"). If family physicians were valued and paid commensurate with their value, then their impressive income would be more than enough to lure medical students to the specialty. I hope that this is what happens. Competing interests: None declared |
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Thomas A. Tomlin, Ponte Vedra Beach, Florida, USA Family Physician
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Imagine thousands of social services units all across our nation providing high quality medical care and equal access to patients. How could this be? This existed prior to 1987 in our primary care offices (social services unit) because in each individual office mercy was given to those who could not afford to pay the full charges for service, and those who could and did pay were subsidizing the care of those who were ‘medically poor’. The primary care offices (social service units) were able to pay their increasing business costs by increasing their fees and expecting them to be paid by community members who themselves had ‘received much’. These primary care offices became business units and ceased to be social services units when their finances changed in 1987 by Medicare ruling that balance billing could not continue (Medicare became the social service unit!). Our government social service unit did it right in this country for our children. For children from poor families as determined by our government (social services unit), our primary care offices receive identification cards that only a discounted payment will be received for services and the remainder will need to be charged off (pre-determined mercy for Medicaid patients). For children from medically indigent families as determined by our government (social services unit), parents are allowed to purchase ‘Kids Care’ for a subsidized monthly amount and the primary care office receives an identification card that only a discounted payment will be received (See prior sentence.) With Medicaid and ‘Kids Care’ the primary care physician knows that the patient has access to specialty care and prescription drug services if needed without providing additional hardship on the family. For children who are neither poor nor medically indigent the primary care office expects full payment for services unless a prior arrangement has been made and agreed to by the primary care office (business unit). While primary care physicians have a business choice to be in a managed care plan or not, it is not a practical choice to not be a Medicare insurance provider because half of all primary care services are for our patients over 65 years-old. Is there a way Medicare could spend our tax dollars for seniors that would not put primary care offices (business units) out of business or would encourage new physicians to go into primary care? The solution is ‘Senior Care’. Primary care offices know when a Medicare patient presents with a Medicaid ID card that they can expect total payment from the government for this poor person and that the remainder of the charge will be disallowed (pre-determined mercy for Medicaid patient). What we do not have is a ‘Senior Care’ program for the medically indigent Medicare recipient that would assure specialty and prescription access without additional financial hardship. Instead we have a piece meal program that is confusing to even the professionals and the hardship continues for the medically indigent in our country. An example of part of the piece meal program that has gone wrong and has exacerbated the financial problems of seniors is that “well” seniors shift to the lower cost no prescription Medicare supplemental plans until they personally need the prescriptions; this raises the cost of the policies for those who do need the prescription plans. Now we have a prescription card fix that is misunderstood and underutilized. If a ‘Senior Care’ program that allowed medically indigent Medicare beneficiaries to buy into Medicaid were combined with allowing only private Medicare supplemental insurance policies with a prescription drug benefit then we would have a simpler and fairer system. How do the primary care offices benefit from ‘Senior Care’? With ‘Senior Care’ our government (social services unit) will have identified those Americans who mercy needs to be given. For a business to be successful there has to be a way to pass on costs to customers who can afford to pay; if a business charges too much it will have fewer customers and less revenues. Since we are business units Medicare should remove the balance billing restraint on physicians who decide to not accept assignment. Our specialty societies have to lobby for reversal of the no balance- billing rule and as a minimum accept removal on Evaluation and Management Services. This ‘new’ method of financing primary care will unleash competition and actually increase access to primary care by retaining experienced physicians and recruiting new physicians. Competing interests: None declared |
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Jeremy M. Fish, Martinez, CA, USA Martinez Family Medicine Residency Director
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The future of family medicine is bright. Healthcare and security are the only two national issues that everyone wants more of. Certainly our specialty is undergoing a serious identity crisis and our diversity makes simple solutions challenging. The FOFM report is a great starting point (1). Questioning the FOFM is a necessary step in finding our common voice amongst the cacophony of ideas, controversies, and visions of our future. There is no question that the FOFM report is complex and filled with many superb ideas and goals, though it lacks the necessary simplicity to stand as a shared vision of our future. If forced, I would call the FOFM report a sharing of visions of potential futures, not a shared vision of our shared future. We need a simpler vision of where we want to go, a simple vision that goes beyond the complexity of the FOFM. I believe William Phillips has begun that process for us in his superb essay in the October issue of the STFM journal Family Medicine: Phillips WR. Questioning the future of family medicine. Fam Med. 2004 Oct; 36 (9): 664-65. In it he shares his deeply held beliefs about our specialty and the simple dilemmas that underpin our present state which might direct us toward a shared vision of our future. As with all great works of leadership, Dr. Phillips’s essay leads with more questions than positions, more digging than shoveling pet projects, more vision than plans, and more hope than nuts-and-bolts remedies. His is the start of our finding a shared vision of our future beyond the complexity of our current way of looking at ourselves. I was particularly struck by these three probing questions in his essay (2): 1. Do family physicians have what it takes to be true generalists? Do we know what that is? 2. What exactly does the residency-trained, board-certified family physician bring to primary care that is not done well enough and cheaper by a physician assistant or nurse practitioner? 3. Are family physicians only good enough to care for the underserved? Do only the disadvantaged deserve the advantages of having family physicians? These questions prick sensitive spots in my own physician-ego. How about yours? I believe in making a serious effort to solve the dilemmas that lie beneath these challenging questions, we can begin to reshape our future with a vision more powerful and successful than that of our predecessors that brought our specialty into being. References: 1. Future of Family Medicine Project Leadership Committee. The Future of Family Medicine: A Collaborative Project of the Family Medicine Community. Ann Fam Med. 2004;2:S3-32S. 2. Phillips WR. Questioning the future of family medicine. Fam Med. 2004;36 (9) 664-65. Available in PDF at: http://www.stfm.org/fmhub/fm2004/toc.cfm?xmlFileName=fammedvol36issue9.xm Jeremy Fish, MD Program Director CCRMC Martinez Family Medicine Residency Program Competing interests: None declared |
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Edmond S Weisbart, Maryland Heights, MO; USA Physician
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I applaud the authors for outlining essential steps in the modernization of family medicine. This will help family medicine transform into a more humane, patient-oriented, evidence-based practice of medicine. I am dismayed, however, by the lack of material here that is unique to family medicine. Most of what is proposed could be equally well applied to every other primary care specialty, as well as to most subspecialty practices. Does not the urologist, dealing with a terminal prostate cancer patient, have the same issues of family dynamics, accessibility, integration of evidence, etc.? Our niche is disappearing before our own eyes. When we began in the 1970’s, we were the vanguard of a comprehensive, patient-centered holistic approach to medicine. Today, while not yet widely achieved, these goals are widely recognized as necessary components for all styles of medical practice. Is it possible that our specialty has already served its role to society and the model no longer has the cutting-edge relevance it once held? I cannot help but recall a quote from John Wyndham in The Chrysalids, “All dying species struggle against the inevitable.” The recent 50% decline in family medicine residency matches seems a bellwether of trouble for us all. If the role of family medicine is to be the vanguard of cultural and organizational change, we should explicitly state that. We would also need to be able to defend that claim, as many others would likely wish to hold the same stake. If the role of family medicine is to offer services across age ranges and for a wider variety of illnesses, we should state that. Again, in days when family physicians are limiting their ranges of service, unlikely to provide comprehensive women’s care, delegating hospital and surgical care to others, our differentiation from those double boarded in internal medicine and pediatrics is challenged. We need an answer to this challenge, if one exists. If the role of family medicine is to provide comprehensive access to care in under-served areas, where only one physician is likely to be present and it should therefore be a physician with a broad set of skills, we should state that. Again, in days when family physicians are limiting their own services and other specialties are providing services more comprehensive than their specialty’s history indicates, we need to develop and articulate the distinction. If we believe that our differentiation is limited to cultural and social values, I submit that the level of variation among us as a group is high enough that this would be difficult to demonstrate to a "non- believer". If there are other valuable ways in which we differentiate ourselves from the rest of medicine, we should articulate and promote them. A great many people do not know how family medicine differentiates itself from the rest of medicine. As much as I applaud the innovative directions in this proposal, I do not see them as addressing the fundamental identity problem. This is a good start, provides an excellent direction for all of healthcare, but it does not address the fundamental issue of our identity as family physicians. Competing interests: None declared |
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Ellen L Sakornbut, Waterloo, IA residency program director
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The Future of Family Medicine has stirred up a tremendous amount of reactivity among our discipline. I would submit these comments: 1. I'm not sure what is new about the "new model." I've always been proud of my heritage as a "descendant" of the original physician, and I continue to feel very centered in the beliefs and values that brought me to this discipline. I'll bet the vast majority of the contributors to the report and the respondents who have commented feel this, as well. Otherwise, they would not have bothered to speak up. My guess is we all have more in common than we do our differences. Although my initial response to the "new model" is that it is something like the Emperor's new clothes, perhaps it is inevitable that we will stumble and be taken aback over word choice and our (apparently) continued need to explain ourselves to others. Now is the time for us to remember our commonality and take a little comfort while we face the current, seemingly huge, challenges of today. 2. A recent article in FP Report stated that students want role models who are the "right stuff." There has always been a balance between our knowledge and our hearts, our practicality and our intuitiveness. Do we STILL enjoy exercising our intellect, the craftsmanship of our hands, and the opportunity to share the good and the bad in our patients' lives? We should not let anyone get in the way of that, and that is our responsibility. Let's face it, none of us are getting up in the middle of the night to hitch up a buggy and drive around a washed out bridge to see some poor patient whose only benefit will be compassionate hand-holding. We have so many tools to work with, and so much to offer. Our work and our life is what we make of it. It's been my privilege over several decades to know numerous family physicians, both mentors and students, who are the "right stuff." We should not stop fighting for what is right, but we should quit whining. If a major problem facing many family physicians is burnout, surely we can find a way to be emotionally healthier, just as Dr. Fleming has challenged us all to be physically more healthy. What do we tell our patients when they are stressed? 3. The best aspect of this report, in my mind, is that there is a real acknowledgment that we need to seek innovation and consider alternatives, such as four-year residencies. Some of what is said appears too watered down to be meaningful. The practice of Family Medicine is highly variable and reflects individuals and their interactions with communities. A pluralistic approach may not comfort the insurance industry, but it's probably in keeping with the diverse nature of our society. There is no possible way this report could have been written to reflect the entirety of our diversity. I would hope that this report serves as stimulus for dialogue and involvement, not for disenfranchisement. Many of us in Family Medicine education will be trying to respond to the challenges described in this report. We need our connectedness with our colleagues in private practice to do so intelligently. If you believe something, one way or another, get involved. The Family Medicine residency in your community, your state academy, or the clinical department in your hospital is a place to start. Competing interests: None declared |
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Michael W. Turner, Alpharetta, GA USA Family Practice
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Family Medicine’s Future - The Real Story It looks as if the world is changing for Family Practitioners. The leadership has apparently determined that it is time to roll out a New Model for primary care delivery. Considering the convoluted, inequitable, yet business-oriented medical delivery system, this proposal seems to be a desperate gasp to save the specialty. Reflecting on survey results published by the Family Medicine Practice Management magazine (November/December 2003 issue), we can appreciate the problems faced by Family Practitioners today. Only 62% of family physicians feel that they chose the right specialty. Up to 40% admit that they would have thought twice about becoming a Family Practitioner if they had known in medical school what they now know. Family physicians tend to value patient’s emotional needs far more than patients’ desire for this service. Americans continue to place greater value on technology than personal relationship building with their family doctors. In fact, most Americans do not even understand the concept of a “family physician”. Being unique has gotten harder with all the ancillary providers. Referencing The Future of Family Medicine proposal appearing in the Annals of Family Medicine (vol. 2/Supplement 1, 2004), the leadership is calling for a New Model of care delivery which is uniquely patient centered. The conceptualized personal medical home promotes patient entitlement in an environment where care can be received 24/7 in whatever context the patient desires. “ Practice staff will share in decision making regarding patient care with explicit accountability for their performance to patients, to each other, and to each patient’s personal physician. The traditional waiting room will be a thing of the past replaced by a patient resource center with a patient library, computer work stations with ready access to online health education materials, and patient information gathering stations. Practices will be equipped with sufficient technology, staff, and supplies to be able to provide on-site a comprehensive set of diagnostic services, testing for important genetic predispositions, and performance of common therapeutic procedures.” Sounds more boutiquish than Fedcarish. This new model shall be one which emphasizes evidence- based medicine backed up by verifiable quality control measurements delivered by a discipline that is far more art than hard science – an art characterized by the intangible skills of perspective and appreciation for the human dimension. Board Certified practitioners staffing these futuristic offices will be required “to engage their office staff and colleagues in reading materials, audiovisual materials, and computer-based educational training related to the care and management of patients with registry creation to verify consistency with current guidelines” as part of their maintenance of certification. Meanwhile, residency training programs will remain deficient in technological and holistic training as psychosocial and obstetrical training continue to dominate the educator’s attention. The leadership – consistently delusional – proposes an “electronic medical record based world that permits the collection, analysis, and reporting of the clinical decisions and their outcomes that primary care clinicians make every day. According to them, this would support practice-based research, quality improvement, the generation of new knowledge, and practice-based clinical research using electronic audits concerning the costs, processes, and outcomes of care including HEDIS.” Please! We are talking about an industry characterized by low margins and limited capital, yet hoping to promulgate standardization of a dizzying array of software platforms without the political or financial clout to do so. Of course, the leadership promises to work towards introducing a new financing system for primary care delivery services in hopes of making the foregoing grandiosity possible. All Family Physicians can appreciate the efforts of the AAFP in 1968 when traditional general practice was significantly upgraded to meet the primary care needs of the population at large. Credibility was rendered through the establishment of a three-year residency program plus requirements for recertification every six years after entry into practice. At this juncture, however, I think that the AAFP is trying to recreate itself in hopes of not fading into antiquity. The leadership admits as much, “Unless there are changes in the broader health care system and within the specialty, the position of family medicine in the United States may be untenable in a 10 – to 20 year time frame. “ Unfortunately, the leadership fails to realize that physicians no longer control the healthcare system – business people do. Family docs doing the grunt work see this! Apparently, medical students see clearly as well. Given the cost of medical education and the public’s fascination with technology, no sane medical student would dare pursue primary care. The graying of America, deficit spending, and legislative (social) agendas will increasingly impact governmental spending. This perfect storm will make primary care increasingly untenable. Dearest Leadership – YOU ARE RIGHT! It is time to retool, but YOU MISSED THE BOTTOM LINE - literally! Competing interests: None declared |
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Jack H. Medalie, Cleveland, OH, USA Family Physician
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1] I am an optimist and believe that Family Medicine will do well in any system or non-system. 2]All Fam. Med. organizations must actively fight for a Health System which as a " right" will cover the basic health needs of every US citizen. When this happens the importance of Fam med will become apparant as the core of the system. To do this we should join with every organization working for the same outcome. As the chances of a federal change seems remote, we should concentratrate on States. For example, Oregon and Vermont seem primed for Universal coverage of their citizens. 3] To gain more clout, both Politically and Professionally, should we not form a Consortium of all Primary Care disciplines---Fam. Med., General Internal Medicine and General Pediatrics? 4] Sub-specialization. For many reasons which I won't go into, I believe the time has come for Fam. Med. to formally allow for sub- specialization activities. This might be done by joint Residency programs as is being done with Psychiatry, or additional years in the other discipline, or sub- divisions in the department, or joint departments. Some subjects that come to mind-- Genetics, Family Health. Geriatrics, Public Health/ Community Health, Sports medicine, Substance abuse, Adolescent Medicine, Womens Health, Research methods/Epidemiology, Bioengineering, Informatics, Nanotechnology, Home Care. etc, etc. Can this be done without losing sight of our Core Values? I believe we can do it. Sincerely, Jack Medalie. Competing interests: None declared |
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Reuben R. McDaniel, Austin. TX, USA Professor, The University of Texas as Austin
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The report o the future of family medicine lays out,in considerable detail, the future (or a possible future) for Family Medicine However, I believe that it overlooks several critical issues that are (or certainly should be) the provence of family medicice and which really define the unique domain of family medicine. First, family medicine physicians, along with their collaborating staffs, must be able to treat multiple interacting things at once, each at a different stage of development and each with its own nonlinear path for the future. Family medicne physicians must help patients deal with the interdependencies among a number of conditions, only some of which are medical in nature. It is the ability of the family medicine physician to focus on the patterns of development of the whole system, rather than a highly localized "condition" that makes it reasonable for one to seek a family practice physician to help mangae one's health care. Second, family medicine physicians must help the patient and clinicians develop a shared sense of "what is gong on here". This is not a question of accurate technical information which is often available on the Internet. Rather, the practitioner of family medicine smust have the requisite skills to help patients, their families, their employers, other MD clinicians involved in any aspect of care, non MD clinicians and others as appropriate, develop a shared sense of, "who am I, now that I have X & Y", "why am I here, when the possible choices of interventions are so many and so uncertain", "what is going on, and what is my role in that unfolding?" Thirdly, practitioners of famly medicine must clearly know the difference between "correct theraphy" and "plausible theraphy" Evidence based medicine, regardless of its other merits, cannot distinguish between the correct and the plausible in a health care setting. This requires a skilled family medicine physician who can help patients, their families and and other clinicians develop and monitor a path of theraphy designed to enhance the quality of life of the patient in the world in which the patint must live (or die) rather than in the world of the clinical trial. These three areas define for family medicine domains of medicine and health care that are not the responsibility, at this time, of any other specialty. Each is a gold mine of research opportunites, given how little we know in a scientific sense about any of them. Patients and policy makers can be educated about the value of attention to these matters because each now feels the lack of wholeness in medical care. And certainly young people, who are considering medicine as a career but who want to work with people rather than diseases, or broken bones, or cancers, will find a welcome home in a discipline that attends to the kinds of issues articuulated here. The report on The Future of Family Medicine articulates many welll defined and worthwhile goals. But the report does not lay any unexpected and interesting directions for the field. The report almost says, fix the finances and we will continue to do what we have always done, only we will do what we do now a little better in return for more equitable treatment. Certainly Family Medicine deserves better treatment at the reimbursment table. Certaily Family Medicine can and should do some obvious things better. But in the final analysis, the future of Family Medicine rests on what value it can add to the lives of people irrespective of the political economics of the moment. Competing interests: None declared |
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John Lewis, Charleston, USA Solo FP
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I will not go into all the problems I have with this "Future". So many have already discussed them in great detail. All in all, I believe this is the most disturbing collection of garbage I've read in quite a while. I'm disappointed in this project. I'm ashamed of our board for caving in to the consumer advocacy groups and essentially transforming all of us into lifelong residents. Why would med students choose to be FP's when our own organizations and advocates are making our profession more unpleasant? Competing interests: None declared |
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Lee Gan Goh, Singapore, Singapore Associate Professor, Department of Community, Occupational and Family Medicine, NUS
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The Future of Family Medicine (FFM) project has put together the nuts and bolts of the paradigm of family medicine and its 10 recommendations cover the activities that must be around to keep the discipline fighting fit: the new model of care of personal medical home providing a basket of services; medical records; Family Medicine education; life-long learning; research; quality of care; role of academic departments; best practices; communication to promote the new model of care; and leadership and advocacy. Together they form the syllabus for training for the future. What the FFM project has not addressed are the critical step to take to remain alive and well into the future. It is clear that family medicine is losing grip in the United States judging by the declining number of doctors enrolling in its residency programmes. And America is not alone in this predicament. In faraway Singapore a similar phenomenon is being seen too. So, what can we do about the situation? Negotiate the turf. The first step is to negotiate the turf. A discipline that has reimbursement issues will face a decline in takers. To that extent, countries like the United Kingdom, Australia, and the European countries are faring better than the United States. Singapore faces the same problem too, although the details are different. In the United States managed care and the advanced practice nurse (APN) erode into the margin of sustainability of the primary care doctors. In Singapore, it is the reimbursement system where employers and insurance companies are unwilling to pay more than acute care rates for primary care doctors’ work that have pared margins to make it tough for primary care doctors to keep going. Patients with chronic medical conditions tend to drift to the specialists because employers and insurance companies will reimburse services provided by the latter. The primary care fraternity may need to consider a future where negotiating with the payors, patients and other providers for a piece of the turf and reimbursement is a major ongoing activity. Shared care amongst the providers – primary care doctor, APN, and hospital specialist; getting managed care and employers to consider not only cost control alone but quality assurance; and best practice in the basket of services becomes of survival importance just as patient-centred care is important. Minimum standards. The second step is establishing minimum standards of service as a national programme and helping to make these happen. This helps to keep the fraternity together. At least, there will be quality standards that could be used to pull patients and providers together. Such endeavours as life long learning, best practice, and evidence based medicine which are covered within the 10 recommenddations of FFM will find a place here. The American Academy of Family Physicians (AAFP) and the academic departments of family medicine together need to set the minimum standards for the fraternity. The leaders must also achieve a buy-in from the practitioners. The institutions need also to be enablers, advocates, trainers and providers of products and services to make it easy for practitioners to achieve the minimum standards. The AAFP’s publications, Annals of Family Medicine, and other key family medicine publications, the various continuing professional development programmes are steps in the right direction. Practical short courses are invaluable in imparting common core values and skills. Finding new niches of synergistic work. The third step is finding new niches of synergistic work. Acute care volume is dwindling in most developed communities. Chronic care, elderly care, home care and preventive care are new areas of work. Shared care in oncology and defence against the chronic disablers – the metabolic syndrome, arthritic conditions, respiratory problems, atherothrombosis, strokes and dementia, offer new areas of shared care for primary care doctors to work in synergy with the APN, the hospital speciailist, and paramedical professionals like dietitians and physiotherapists. Working together fosters mutual support and satisfaction as opposed to mutual destruction and paring of reimbursements, and huge amounts of negative energy and cost will be saved. We need to provide the positive energy and embark on the training into these new niches of work. Family Medicine trainers will be busy again. Reconciling training and service delivery. The fourth and final step to be considered is helping practitioners reconcile training and service delivery. Primary care doctors are trained in the principles of personal, primary, preventive, comprehensive, continuing and community care. Yet, in the real world, not every patient will appreciate nor want the whole basket of services. So the idea of a personal medical home for every one may be doomed to fail with some patients and may at the same time demoralize the practitioner. Some patients do choose to have only selected aspects of service delivery. There may not want patient centered care but rather prefer a doctor who is more paternalistic. The ability to reconcile the scope and the scenario will be important to the professional well- being of the primary care doctor. It must be part of the training agenda into the future. Competing interests: None declared |
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Armando F. Delgado, M.D., Merritt Island, FL USA Family Physician, Private practice
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The development of the proposed New Model of Family Medicine evidently involved a tremendous expenditure of time, effort, and money for its formulation. Unfortunately, as I review the published report, all I perceive is a great deal of newspeak, marketing and political correctness thinking and rhetoric, yet very little substance. The entire premise for the New Model is based on two fallacious concepts. One is that technology--the electronic medical record--will eliminate human error and create an environment conducive to research and improved communications. The other is that funding for the proposed agenda will be available. The cast of characters involved in the Future of Family Medicine Task Force is impressive, but somehow they got sidetracked on ideological concepts and failed to recognize the realities and practicalities of modern medicine, and Family Medicine in particular. The American Academy of Family Physicians already embraced the concept of the electronic medical record (EMR) and is intent on enforcing its use in the future by all family physicians. The problem with the EMR is that presently the hardware development and the software available is not standardized and is very expensive. For a standing practice to acquire an EMR system and implement it requires a large capital outlay without any guarantee that the present system will meet future standards that might evolve. In fact, we are being asked to subsidize the research and development of the EMR system. Secondly, the further assumption made is that the EMR will eliminate medical errors resulting from misread handwritten information. How this magic will happen is not entirely clear, since human beings will have to enter the data into the computer, and as long as humans are involved, human error will occur. Perhaps the types of error will be different, but they will nevertheless happen. Also assumed is that once office records are computerized, family physicians will be able to do "collaborative research that produces new knowledge about the origins of disease and illness, how health is gained and lost, and how the provisions of care can be improved." It all sounds grand, but good research requires money and time, two things that busy family doctors do not have. No doubt the EMR also figures in the plan for the "Lifelong Learning" that family doctors will have to adopt. The first facet of this process is already being implemented in the new American Board of Family Practice requirements. The details are not defined yet, but it seems that the new plan will require physicians to surrender more time to meet vacuous prerequisites, with no guarantee that the doctors will benefit from it. Of course, all the recommendations from the task force are couched on a presumption that if we package Family Medicine as a "new" concept, money will pour into our offices and training programs. How this rationale was developed is not clear either. Presently, all third party payers are squeezing health care spending, and there is no evidence that private or public leaders are willing to make changes. The New Model further expects family doctors to become the leaders of multidisciplinary teams, but does not clarify how these teams will be funded. The Model also fails to clarify how that leadership role will benefit the physician and where he will find the time to coordinate all these professionals. Under the current paradigm of health funding, the doctor will likely have to assume the leading responsibility at his own expense. Active physicians presently are under attack from many fronts. Attacks that are making the practice of medicine increasingly difficult and that are driving prospective students away from the profession. It would seem that our professional organizations would concentrate their resources in correcting these disparities instead of wasting funds chasing daydreams. Competing interests: None declared |
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Mark R. Sanazaro, Nederland, CO USA Medical Director, Mountain Family Health Centers, Jennifer Lake, RN, Site Coordinator
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The Future of Family Medicine project labors under one of the traditional barriers to a transformed specialty, namely, the total focus on physicians, with only passing reference to the office team. We wrote a renewal plan for our family health center in Nederland, Colorado two months before the publication of the Future of Family Medicine Project. It is strikingly congruent with the FFMP report, except that it reflects a close collaboration between physicians and nurses. Even as family physicians are disrespected by the specialty-laden U.S. health care system, so do office nurses receive less pay and respect from the nursing establishment. The radical reformulation of the role of these committed partners in the delivery of compassionate, evidence-based care to the whole family is absolutely essential to the renewal of family medicine. Physicians must recognize their dependence upon the office team, and must liberate and cultivate the vast array of talent, which remains constrained by traditional office roles. Competing interests: None declared |
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Kristin K. Elliott, Marquette, MI Family Physician, Marquette General Health System
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As a family doc "in the trenches", I was disappointed after reading the final FFM report. While it is a very worthwhile academic exercise, it doesn't provide much that is helpful in actual practice. Our specialty is in trouble because we have allowed it to be. Our leadership has not been a voice or a force in the way it should be. Students are not excited about family practice because we are not excited about it. "The Medical Home" is an excellent concept, but it is the idea we have been trying to get across to our patients, the medical community, and the lay community seemingly forever without anyone recognizing its importance. Instead of continuing to reiterate this excellent concept, we need to some how put real energy and action behind it as a specialty. People want and need family docs; most of them (and most of us!) just don't realize it. We don't need to explain ourselves or justify our existence. We need to act now and show what it is we do and why, and I believe we will have all the respect, reimbursement, and "future" we could ever possibly want. To paraphrase something I once read: there is nothing wrong with castles in the air. That is where they belong. Now we just need to put foundations under them. Competing interests: None declared |
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Omar L. Hamada, Brentwood, TN Family Medicine & Ob/GYN
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Family Medicine has needed a dramatic overhaul for the past decade. I appluad your gargantuan efforts to address our plight. However, after spending 10 years on the frontlines with medical students and residents in the Predoctoral Division and on Faculty at U of TN, and now having joined the ranks of those in Private Practice, it seems to me that the changes suggested in the FFM Project are a nice facelift, but will do absolutely nothing to address the true problems - lack of respect for the specialty, turf wars, declining quality of residency candidates, competition from non -physician providers. I agree with a previous writer, "No, we have not been heard". We have recommended changes for the past decade. These recommendations have, for the most part, fallen on deaf ears. How do we solve the problems? By changing perception and improving training. Increase the residency to 48 months. Limit clinic involvement during subspecialty rotations and take in house call like everyone else. Change the name to Family Medicine. Raise the bar for those admitted into our residency programs, and make sure they speak English. Make research relavant. Get involved. Be professional. Work hard. We have the reputation of being bumbling country docs. We know that's not true, but we have to convince the medical community that that is not true. And, yes, it starts in academia - in the ivory tower. Excellence breeds excellence. Anything less will see our demise. Overhauling our offices, getting EMR, etc... will do little to address the true problems. Competing interests: None declared |
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William J. Schultz, Sugarcreek, Ohio Family Physician
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If we don’t produce a roadmap for our future, someone else will plan it for us. I still remember the day, after having been in practice some five years, when an insurance rep came to my office telling me how managed care would be making my life easier, how it would be “physician friendly”, and that it’s main aim was to direct patients to my office and make sure I received the maximum reimbursement. At the time I didn’t realize that my patients would never again be “my own”, but belong to an insurance plan. In response to these changes I watched a few physicians embrace capitation and managed care, some became employees of the hospital and some just retired early, but most of us have just plodded along hoping for some real answers to a career that is becoming more and more burdensome and less and less rewarding. Through all this I’ve had a progression of “health industry” generated titles; from PCP, to gate-keeper and now back to physician. I hope “The Future of Family Medicine” generates some concrete answers and does not become another exercise in semantics that can not be implemented in the real world. After reading your report I felt compelled to write down a few observations I’ve made after almost twenty years in private practice. 1) Lets be honest and proud about who we are I am a family practitioner, the direct descendant of the general practitioner who descended from the allopaths and osteopaths, who descended from the itinerant physicians, who descended from the apothecaries who consulted with the barber surgeons. Whether I am called a “specialist” is irrelevant to who I am or what I do. It may be important in the academic world or in hospital politics or to how insurance companies or funding agencies see us, but it sure doesn’t make a great deal of difference to the people I care for. Every time I’ve been called a general practitioner I’ve always felt obliged to go through a narrative on how we are a specialty that requires three years of training beyond medical school with board certification and continued education, providing and coordinating care from cradle to grave, etc, etc. The usual response is “oh I see”, but in their mind I can sense they’re thinking, “just as I thought, he is a general practitioner”. But that’s not such a bad thing. If we are honest, our true hang up is the fear people will think “family practitioners” are doctors who were not capable of being specialists, and that’s the fallacy we must address. We should take advantage of our unique role as generalists and draw our “best practices” from our own experiences and also follow the “best practices” of the specialists. I accept the fact that “specialists” who concentrate on a particular organ system or discipline may be a step ahead in their care. Each referral I make can be a learning experience for me to better care for my own patients. 2) What are the needs of practicing physicians? What are our immediate concerns? #1 Economic survival - Many of us are in private practice and face all the hassles and hazards of any other small business with a shrinking margin of profit. I am a physician, yet I cannot find affordable health insurance for my family, no less for my staff. I’ve had to employ an additional person just to deal with referrals, workers comp claims and all the other un-funded responsibilities we’ve taken on. More and more of my income is going to pay increasing malpractice premiums despite the fact that I’ve never had an adverse claim. The very first issue the New Model needs to address is how to decrease the rampant overhead, or there will be an irreversible attrition of well-trained family physicians. Whatever recommendations are made for restructuring the office setting must be sensitive to the finances of the practicing physician, the plaudit that improved office efficiencies will increase revenue is of little comfort when we are being asked to provide and co-ordinate more services. #2 Career long learning and improvement – For me one of the benefits of being in private practice was a feeling of controlling my own destiny. I thought that once I ran the gauntlet through medical school and residency I would be recognized as having the knowledge and discipline to conduct my practice in the best way suited to care for my patients and to be personality fulfilling. I had the freedom to explore facets of medical knowledge that held a special interest or where I felt deficient. Now that many aspects of care have been taken over by third parties I’ve found that I am scrutinized on multiple levels. I am required by the State to maintain a certain number of CME’s every three years; the hospital has continuing medical education requirements, chart reviews, and quality assurance as well as board re-certification. Each of the insurance companies reviews my office and charts, referrals and prescribing patterns, and gives me a quarterly report card. I spend so much time making sure all the “bullets” are addressed in my office notes for coding purposes that I lose sight that their true function is for communication between my colleges and myself. Now I must not only take the boards every seven years but I must advance through a series of yearly modules for which I have the privilege of paying. I truly understand the need to be competent, but there comes a point when all this scrutiny becomes demeaning. If the vision of the future is to add another tier of “education and assessment”, it must replace or simplify some of the scrutiny we already receive. If modules are given they must reflect the nuts and bolts of primary care that can readily be assimilated into practice. If we are to go through modules, then eliminate the redundancy and drudgery of the board exam every seven years. If the board exams continue then at least make them more relevant to my daily practice and provide more guidance on key points to study – the field of medicine for the generalist has become too vast to just say; know it all, and here are some sample questions to review. Professional growth has to be an enjoyable and enriching experience and not one more onerous task. 3) We must make Family Medicine appealing to future physicians. I entered family medicine envisioning a career I would want my children to aspire to and perhaps carry on when I retired. Because of the hassles I face I no longer feel that way. It’s no mystery why family practice residences don’t fill their positions. The prospect of a life with little personal time, increasing responsibilities and scrutiny, decreasing finances and constant fear of lawsuit has to make any graduating medical student think twice. If the New Model does not create a future that is economically and personally fulfilling we will find our numbers dwindling at the very time an aging population creates an unprecedented need for primary care physicians. 4) We cannot let our profession be exploited It started when the first ad on television said, “ask your doctor about---“, and we all laughed and mumbled to ourselves, “no, please don’t ask your doctor”, but since then, that tactic has snowballed. In a clever and subtle way the pharmaceutical industry has enlisted us into their sales force. These television ads have become so commonplace that we don’t even think about them any more, but even more insidious is the flood of discount coupons, drug cards and discount programs we are asked to “pitch” to our patients. We are often placed in an untenable position. Every day a patient with limited means or without drug coverage asks for samples and in some cases the patient’s compliance depends on what periodic help we can give them. Yet the gimmicks, ads and promos that take up our time and imply endorsement of a drug should not have a place in a doctor’s office. There is no reason that these marketing promotions could not be done at the level of the pharmacies; but for the fact that the drug companies appreciate the power of our prescription pads. If we want real clout and make an impact on the drug industry we should follow prescribing patterns directed by a formulary generated by our Academy, based on drugs that fulfill two requirements; that they are therapeutically safe and effective, and just as important, that they are cost effective. There is no point in prescribing a medication if the cost negates compliance. We shouldn’t be so wedded to the drug industry that we can’t recommend to our patients that they seek a safe and cheaper source – even if that means they go to Canada. It seems absurd that anyone can go on line and obtain anything from Viagra to Xanax, yet my diabetic who is finally controlled on a certain oral agent has to consider insulin because it may be cheaper in the short run. We must become aware of the power of our prescription pad and use our clout without being exploited. 5) Above all create no bureaucracies Ten years ago I wrote an article where I stated, “ I wish I could get bureaucracy classified as an illness because then I could just treat the insurance companies and not have to see my patients”. Above all please DO NOT add another level of bureaucracy to an already burdened system. The New Model must constantly seek ways to streamline and simplify our lives and not become another intrusion. 6) Family Physicians also have families and a finite amount of time for their own lives. For some reason the assumptions been made that we live only to be family doctors. The New Model will fail if it expects us to be superhuman. If we are expected to run a business, maintain professional excellence, study and be tested on practice modules, orchestrate a multidisciplinary team approach, maintain an electronic medical record, provide a “personal medical home” and a patient centered relationship, answer patient’s emails and voice mails, deal with third party payers, see patients in the office, hospital and nursing homes, be on call, attend CME’s, attend hospital committees and meetings, practice defensive medicine, perform community services etc, etc. there will be no room for the things that keep us sane, our families and our personal time. I have reached a stage in my life where I cherish the time I have with my family and have discovered interests and talents outside the realm of medicine. I have always enjoyed patient care because it was a positive expression of myself that included some insights that came with time and experience. The relationship a doctor has with his patients can not be contrived or learned in a module or condensed into an electronic medical record. When the future of Family Medicine becomes a reality I hope it recognizes the needs and limits of the person who also happens to be a family physician. William J. Schultz MD Ohio Family Physician Year 2000 Sugarcreek, Ohio April 19th, 2004 Competing interests: None declared |
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D. Y. Egerton, Iowa City, IA Family Physician
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Let's not forget there are two problems here: both medicine in general and family medicine in particular are under attack. We find ourselves in the awkward position of attempting to justify our very existence not only to the system as a whole but also to our colleagues and even to ourselves. This is dangerous ground and given the current climate we need to hunker down and wait it out, to make ourselves resilient enough to weather the present situation and to survive to fight another day. For example: 1. Cut the GME slots to meet demand (or even make it a competitive specialty!) 2. Increase residency training to four (or even more years) to obtain greater procedural expertise (see N. Schleidler, "Proceduralism would boost interest in the specialty", Letters to the Editor, FPM, May 2004). 3. Aggressively advance MEANINGFUL primary care research 4. Aggressively address reimbursement. Are all or any of these necessary to the essence of family medicine? Some will argue that they're not, but remember, PERCEPTION IS REALITY, and if our colleagues and insurance companies see us as little more than costly alternatives to PAs and NPs, then it's UP TO US to change that perception. Competing interests: None declared |
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Ricky D Edwards, Corpus Christi USA Director CCFPRP
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I commend the members of the Project Leadership Committee for undertaking this task of The Future of Family Medicine, though after examining the results, I believe this could be more accurately called “The Leadership Role of Family Medicine In The Future of Medicine in the United States.” The results clearly reveal that Family Medicine with its current concepts and attributes have a place in the current and future of medical systems in the United States. Diagnostic technology is quickly advancing and will call for even a greater need for physicians who can take this wealth of diagnostic information and apply with specific knowledge of the patient to help the patient decide on the best course of medical care for them. While disagreeing with some of the descriptions of “Traditional Model of Practice” current Family Medicine, i.e., not patients centered, etc., I do believe the attributes stated desired in Family Medicine are accurate. It seems clear that in order to achieve these goals for the future of medicine and the ideas of access to medical care, consistency in care, competency, patient safety, continuing education, enhanced practice finance, as well as research, all depend heavily on a universal electronic health record. I believe it is most vital in order to realize stated goals for the future of medicine and the leadership therein of Family Medicine for the organizations of Family Medicine to put their greatest focus and resources into the development and availability of this universal electronic health record. Thank you for undertaking this project. Competing interests: None declared |
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Kurt C Stange, Cleveland, USA Family Physician
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The following questions and summary of the online discussion will appear as part of the On TRACK feature of the May/Jun issue of Annals, which will be published later this month. I am posting it now in the hope that it will help to move forward the very thoughtful and passionate discussion that readers have been having. I am grateful to the online discussants who gave me feedback on my early attempt at a synthesis, and have modified this summary based on the many helpful comments. The Future of Family Medicine (FFM) Project aims to launch efforts "to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment." The Table below depicts some of the early themes apparent in the ongoing discussion about the Project report, which was published as a supplement to the previous issue of Annals. We encourage readers to participate and invite diverse others to join in. Invite patients, people without access to becoming patients, other health care professionals, policymakers, and others to bring their voices and insights. The early online TRACK discussion personalizes the sense frustration on the front lines of a dysfunctional, imploding health care system. The assessment of many is succinctly summarized by Douglas W. Morrell, a family physician from Rushville, Indiana: "the article 'The Future of Family Medicine'... is a great idea, but the reality is that it just can't happen without great changes in the American health care system." A number of TRACK discussants (including Dr. Morrell) identify survival strategies in the current system. The discussion also suggests helpful frameworks and some innovative approaches for pursuing practice change. At the same time, it calls for a crusade to reform the larger health care system.
Table Times are changing (e.g. as articulated by Hashim, 4/20/04) Change and the current health care reality is causing great frustration
The call is about something larger, a crusade about which family medicine is only a part
Diverse strategies are emerging
Frameworks for understanding and fostering change
Challenges for individuals and organizations
The early discussion leaves us with at least three overarching questions and many sub-questions that call for further debate, and ultimately, action. We invite readers to weigh in and to pose other questions:
Please continue to use the Annals TRACK forum to share your insights, frustrations, and joys. Give the web address to others and invite patients, policymakers, health care professionals in other fields, payers and other potential partners and antagonists to enrich the debate and action. References Competing interests: Annals Editor |
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Michael J. McGlaughlin, MD, Gettysburg, Pa Private Practice
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After first reading The Future of Family Medicine Report, I was
afraid that I was the only Family Practioner in the country who still
had things pretty good (although admittedly not perfect). After
some time for reflection and reading your comments on-line, it
appears to be mostly an administrative/academic view of things vs.
those of us "in the trenches". For the most part, the comments from
those in private practice are negative and those from
administration/academia are positive.
Our leaders need to spend more time with those in private
practice in communities across the country. Our solutions,
priorities and list of problems would look different. Dr. Fleming's
comment that "we had heard you" didn't include enough of us that
provide the majority of primary care in this country. A large
enough group of us could have quickly recommended some
different conclusions. Despite his comment to the contrary, this
report was too "ivory tower".
I'm quite concerned that our leadership will take a paternalistic
approach to this but I'm quite sure that the majority of those that
they represent would significantly alter their recommendations.
Obviously, I'll take any help with reimbursement although I highly
doubt that anything meaningful can be done. I'd like help in
easing prior authorizations and different formulary restrictions as
well as liability reform although not much was mentioned about
these issues. I'm suspect that our patients will respect us more if
we change our name to Family Medicine, tap on a computer in
front of them, trade e-mails with them and allow them to make an
appropriate appointment on-line rather than speaking directly with
my receptionist.
While the report obviously was thoughtful and has some points
we can all agree on (although difficult to implement), there are a lot
of discussion points that affect those of us who would implement it.
Our administrative leaders should do a lot more to go around the
country and elicit feedback from its membership and get back in
touch with those of us in the trenches-which I believe is the
majority of our membership.
Competing interests: None declared |
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Randy Card, Marquette, USA Associate Director, Marquette FP Residency
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I read the future of Family Medicine supplement with enthusiasm and admiration.(1) Family medicine and society should benefit from the enormous amount of energy and effort used to create the report. One issue that was not addressed is how patient behavior is often contrary to patient expressed interest regarding a patient centered approach to decision-making. Patients verbalize an interest in shared decision-making, yet they often are unwilling to accept responsibility for their decisions. The current malpractice climate, where a perfect outcome is the expectation, reflects a patient belief system where physicians and the healthcare system are financially responsible for unpredictable poor outcomes. Patient behaviors that document the difference between spoken desire and actual desire, include demanding direct access to sub-specialist care and high utilization for unproven technology. These behaviors appear to show patients want physicians to search for zebras. Society appears to want errors of commission. Errors of omission, like not recommending a PSA in a patient who is ultimately diagnosed with prostate cancer, are unacceptable.(2) The family medicine philosophy of treating the horses under the bell shaped curve and accepting, but not immediately searching for, the zebras that are two standard deviations from the mean, is at odds with patients who believe a head CT is needed to evaluate all headaches.(3) The medical home, with the hope of improved trust and communication between physician and patient, may help patients understand the morbidity associated with false positive tests. However, unless patients accept the limitations of physicians and technology, the patient centered approach decreases physician autonomy and increases physician risk for patient retaliation when the standard of care is followed but the outcome is suboptimal. Despite its limitations, the patient centered approach is a worthwhile goal. For the patient centered approach to work, decision- making and responsibility for the decision need to be shared between the healthcare system, the physician, and the patient. References: 1. http://www.annfammed.org/content/vol2/suppl_1/ 2. http://www.afip.org/Departments/legalmed/openfile97/prostateca97.pdf 3. http://www.massgeneralimaging.org/newsletter/september_2003/september.pdf Competing interests: None declared |
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John J Hopkins, Goodyear, AZ, USA Physician, Southwest Family Medicine, PC, John Hopkins, MD, Dan MacLeod, DO, Michael Keller, MD
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The article about "The Future of Family Medicine" was quite refreshing. I've long held that physicians should lead the charge in designing a health care delivery system that addresses the needs of patients from our point of view. Left without our vital lead, the government will undoubtedly impose what they feel is the best method to deliver medical care to the public. Hospitalists and Managed Care have redefined the specialty of family medicine which is why I'd like to see us actively involved in transforming our specialty of family medicine that serves our patients in ways described in this article. I don't see this happening if there isn't a tremendous amount of grassroots support from the Family Physicians currently serving the needs of patients. I would like to know more about getting behind this effort, and about how we might assist in researching and implementing this transformation. Competing interests: None declared |
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Robert A. Brockmann, Englewood. Colo physician
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Any casually aware med student could have told the two high priced consulting firms, and the 5 committees, what is going wrong with our | |||
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