The Future Role of the Family Physician in the United States: A Rigorous Exercise in Definition

The article by Phillips et al. describes an elegant and robust approach to defining the field of family medicine so as to establish a widely endorsed, attractive and influential role for the family physician in the U.S. health care delivery system. As it stands, this is a useful exercise.

But I am personally more interested in the "foil" description. If the "foil" role is the likely scenario without a re-definition as proposed, then how is the new, more attractive role going to avoid suffering the apparent failure of the last role-defining exercise, Keystone III? And why is it that Family Medicine seems to have so much trouble defining itself?

I do not see this kind of exercise being conducted in other specialties or disciplines, with the possible exception of General Internal Medicine. However, GIM appears to have simply given up trying to be something that few of its members want to be. Most other specialties and medical disciplines are defined by organ systems, technologies or narrow demographic definitions of their target population. They evolve as science and technology evolves, both the science of medicine and the science of medical care delivery. Family Medicine seems to have some nostalgic notion of its post-WWII roots that carried on into the Marcus Welby era, but it seems to me we are stuck there. We seem to identify more with the technology and demography of those particular times rather than understanding at a more fundamental level who we are, what we do, and how new biomedical and information technologies change the answers to those questions. We seem to have trouble understanding what our core purpose and values are, and therefore how those core values are manifest with new demographic, biomedical, political and financial influences.

The new role described by Phillips et al. is attractive. How will we get there and stay there?

Competing interests: None declared

I love the definition. Leading with "personal doctors" sets the tone that being a family physician is about the relationship with the patient and family, and does not depend on a certain set of procedures. We are defined by who we are more than by what we do. Or better yet, what we do is defined by who we are. The follow-up detail in the role definition is rich and will serve us well.

Competing interests: None declared

Well done. Thoughtful and elegant. I especially appreciate the distinction between the check box care coordination programs, and the real daily work of shepherding patients across a broken system. To move away from the foil where we are often simply the file cabinet of the health care system, we need many tools including payment reform and functional systems to help us in our up hill battles to get people what they need.

Competing interests: ?? None declared

The document just released by the Role Definition Group rides on the shoulders of previous efforts to place the family physician in America's evolving health care system. No matter how impressive the result, it is destined to die a familiar fate. For there is no one role, one definition of the family physician; we are a collection whose careers respond to the needs of our families, communities, and personal interests, and will never conform to a job description or salary line that others have prescribed for us.

The process of creating this document was studied and deliberate. Can we reasonably conclude that it was intended for a higher purpose? Is it a blueprint for residency education? Is it the mold for replicating highly productive (and thus highly remunerated) primary care practices? Is it a checklist for certifying the family physician of tomorrow?

For the seasoned (read "older") practitioners who cut their teeth on the writings of Gayle Stephens, TF Fox, and Rosemary Stevens, the RDG definition seems thin gruel. Where are solid, reliable words like "generalist," "friendship," "personal responsibility," and "relationship." Substituting "enduring partnerships" brings to mind a business contract that concludes when our mutual self-interests have been satisfied. Relationships- we know too well- have no such endings. Patients look to us for opinions, guidance, and authority in the face of their paralyzing circumstance. Many seek our company when medical interventions are no longer helpful or desired. And those in greatest need- the marginalized members of society- would never know a partnership were it not for our ethical obligation to reach out to them.

Could others offer a better description of the family doctor? Possibly not. But there are simpler ones, and those that create a bigger tent. Here is my suggestion: family doctors are generalist-trained, relationship-centered, and community-oriented. We believe that conversation, friendship, and hope can transform lives. Our approach to patient care is governed by the moral imperative to always do the right thing.

Phillips and others are right to suggest that family doctors take a leading role in health care redesign. Our current disadvantage derives not so much from the failure of present leadership as from our collective silence. The authors also deserve credit for rekindling a critical discussion about how we think about ourselves as family doctors. Thought turns to serious talk about values, motivation, and a practical wisdom that can be plowed back into the practice of our profession. Words matter. Let's choose them carefully, share stories that bind us, and create the kind of workspace that allows us to effectively care for all those we love.

Competing interests: ?? None declared