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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Thoughts on AHC's and Family Medicine
Shaping the Future of Academic Health Centers
Is it realistic in the USA?
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Larry S Fields, Ashland USA Physician, Board chair AAFP
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I very much appreciate being asked to comment on the Annal's supplement dealing with Academic Health Centers. I found the issue fascinating and insightful, both in framing the opportunities we face in such an environment and in finding "best practice" solutions. Using Dr. Newton's lead article as a frame work, there are several thoughts I want to submit. Our current model for training students is based on a report in the second decade of the last century which called for increasing specialization of medicine. Fifty years later the public reeled against this approach and demanded a return to the idea of a generalist physician, thus the specialty of Family Medicine was born. The public and lawmakers general embraced this development while AHC's had a more uneven response. Regardless, our specialty enjoyed a heyday of rapid expansion which lasted for the better part of two decades. We now are in the position of renewing and revitalizing Family Medicine in the light of declining numbers of students choosing the specialty and the aging workforce of practicing family docs. AHCs play a determining role in what type of workforce is trained and therefore our engagement with these institutions is critical to Family Medicine's success. It is perfectly clear at this point that Family Medicine provides a significant benefit to populations, societies and individuals by delivering health care that is of higher quality and more cost effective. Opinions to the contrary, no one who can read a scientific study in an unbiased manor can argue against the volumes of data that show how valuable primary care in general, and family medicine in particular, is to any health care system that hopes to achieve high quality at an affordable cost. Our current system of medical education has fundamentally misaligned the incentives to train the type of physicians the country wants and needs verses those that bring in large dollars to the AHC from research and procedures. This must change. The opportunity for FM departments to take the lead in, and get big money from, translational research is real, is better than ever before, and must be acted on now before leadership at NIH changes and this part of medical inquiry is deemphasized. Through the AAFP's National Research Network, the many Practice Based Research Networks, and NAPCRG, our specialty is uniquely positioned to conduct real landmark studies that will make a difference in people's lives. We must persuade our deans that the "planning" approach to workforce is just as flawed as the "supply-demand" model of Cooper and both should be replaced by a needs-based approach like the AAFP took in its recent workforce study. That is, determine what the country needs as a workforce to provide a cost effective, high quality health care system, and train that type of physicians. We must dissuade the deans from the bizzare opinion that many of them now hold that any expansion of medical school class size needs to come with the purpose of increasing the number of sub-specialists. There could not be an idea which is more certain to produce high cost and less quality than this one! The primary care based model works well for care of populations which are underserved, on Medicaid, are disadvantaged, or who suffer from disparirites in health care. Studies show that increasing the amount of primary care in a population wipes out disparities caused by socoieconomic status. This is a powerful fact. We need look no further than North Carolina's Mediciad system to see the positive effect on chronic disease and cost that the medical home has. Disease management is best done by physicians who are trained in both primary and secondary prevention and who are masters of complexity science -family docs. The initiative with Academic Health Centers is a major cornerstone in shaping the future of health care in America. This effort by the Annals to get a handle on what needs to be done and how it may be done is exceptional work and the editors, contributing authors and staff are to be highly commended. To achieve high quality health care for everyone in the United States, we must have our training institutions putting out the kind of physicians Americans both want and need-Family Docs! Larry S. Fields MD, FAAFP Board Chair, American Academy of Family Physicians Competing interests: None declared |
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Cynda A. Johnson, Greenville, NC USA Dean, Brody School of Medicine
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The role of Family Medicine in shaping the Future of Academic Health Centers (AHC) begins with our presence inside the AHC. In their lead off article in the September/October Supplement of Annals of Family Medicine, Newton and DeBard note that 11 medical schools have yet to create a Department of Family Medicine. What that means is 115 schools have a Department of Family Medicine. Of that we can be very proud. So we are at this table; now what? Newton and DeBard suggest five areas of contribution from Departments of Family Medicine. I will comment on three of these, from the perspective of dean at a community-based medical school: ambulatory and primary care; education; and work-force. Departments of Family Medicine should have their grounding in premiere practices of ambulatory and primary care. The “model family practice clinic” of our past should become the “model of an ideal practice” of the future, with a focus on patient-centeredness, efficacy and effectiveness. We should be seen as leaders in chronic disease management, knowledgeable, available to the patients for whom we are providing a medical home, and responsive as chief collaborators in a complex system of medical care. I believe our educational contributions to the AHCs are key – this is what many stakeholders in the Academic Health Centers expect of us and so they should. There is much to teach and many to teach it to, but perhaps at times we have been too diffuse in our educational pursuits. We must be intentional – with careful attention to our students and residents and choosing our other activities carefully so that we are seen us skillful educators, fully realizing our commitments. Perhaps Family Medicine as a discipline has been most remarkable in its contributions to the workforce – training physicians who have the skills set to practice in all settings – including those that are rural and/or underserved. Within our AHC we must promote admission policies and curricula that support Family Medicine principles. Our residency training programs must have increasing flexibility to train family physicians to practice in varied settings while having credible markers of competency. The future in Academic Health Centers is ours – we must not let it slip away. Competing interests: None declared |
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François E. Lehmann, Montreal, Canada Chair, department of Family Medicine, University of Montreal
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Newton is to be commended for a very thoughtful look at Academic Health Centers. He writes about social accountability and this may be the major contribution of Family Medicine: referring to Starfield's work, Newton points out that health is better in a country with strong primary care. If Academic Health Centers truly want to have an impact on health, they must train more primary care practitioners. But are they willing to do this when the glamor and the money is in technology? When touching on research, Newton does not seem to give much importance to the aquisition of new knowledge through research about primary care problems : are episiotomies useful, how often does one need to see a hypertensive patient so as to optimise blood pressure control? These are just 2 examples of recent contributions by family medicine researchers. Newton is concerned with indigents. I would broaden this to the poor in general. Family Medicine departments are the ones who can best train doctors in how to get pleasure and satisfaction from treating the underprivileged. They can do that by training residents in the community and by giving them excellent role models. Newton seems to think that Academic Health Centers can also make high quality health care affordable to the poor. The New Mexico experience described in this issue is commendable, but so limited and so local. Having practiced before and after the introduction of socialised medicine to Canada, and practicing at that time exclusively with the underprivileged, I can testify to the fact that overnight people became equal in their access to medical care. That did not come about through efforts of Academic Health Centers but through the decision of the Canadian people and their governments to create a system which permitted equality. Competing interests: None declared |
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