Health Is Primary: Family Medicine for America’s Health

"When you pay for an episode of care in a purely fee-for-service world, the system will tend to deliver services. When you pay for fee-for-service only, you get too much service--over-service."

But do we really believe that we are currently delivering an excess of primary care services, and this is a significant factor in high health care expenses in the United States? Going forward, with an aging population and more insurers, is our goal really to reduce the volume of primary care services delivered?

"If I engage my patients more effectively, if I engage them and the results are better, then I am going to earn more money and my patients will do better."

Based on many years of dealing with United, Aetna, Cigna et al. on a daily basis, I have absolutely no confidence that they will design effective, accurate, evidence-based programs that evaluate quality, value, and outcomes. (I still have insurers who ding me for not ordering PSAs on female IBM retirees!) At least with the industry-wide CPT guidelines, I have black and white evidence of the work that I should be paid for.

Competing interests: None declared

The Health is Primary: Family Medicine for America's Health report calls for bold yet practical changes in the American healthcare system to achieve the Triple Aim (1). However, the responsibility of executing the seven core strategies does not rest solely with the Family Medicine for America's Health implementation committees. Rather, this is an opportunity for the academic medicine community to engage young future family medicine leaders.

At the graduate medical education level, family medicine residency program directors and faculty are in a unique position to explore curricular changes that promote the future of our specialty, such as implementing longitudinal leadership and advocacy programs. We already see this movement happening in a few innovative residency programs. There is also the ongoing need for faculty development -- programs which are offered nationally but also emerge organically in communities. Residency programs should have an infrastructure that, at a minimum, fulfills ACGME requirements but promotes robust and groundbreaking learning communities. Residents are eager to learn about the shift from volume-based to value-based care, primary care payment models, practice management in changing political landscapes, and achieving the Triple Aim. Upon graduation, family medicine physicians should be confident in not only their ability to provide high-quality medical care, but also to be leaders in healthcare transformation.

Residents themselves should embrace their leadership role in implementing the seven core strategies outlined in the Family Medicine for America's Health report. Residents are technology experts who can practice creative forms of communication with patients. They can serve on patient advisory committees at individual practices, then partner with patients in advocacy efforts. Residents should continue their distinctive connections to medical students, whether it is through structured workshops, procedures teaching, volunteer activities in the community, conferences, etc. Even reaching pre-medical students early in their education can have a lasting impact in the decision to pursue primary care. The power of mentorship in family medicine should not be underestimated (2). This is a valuable pipeline for recruitment, and incentives should be in place to encourage community physicians to collaborate with medical schools.

It is no coincidence that the Health is Primary campaign emerges at a time when parallel movements in medical education are occurring. The Institute of Medicine recently called for restructuring of Graduate Medical Education financing to align with national healthcare needs (3). This will require a strategic investment from leaders beyond primary care. However, the recommendation is the consequence of a multitude of trends, such as an increasing focus on data-driven outcomes of quality and efficiency that demand more team-based community care.

Nonetheless, at the heart of family medicine remains the extraordinary relationships we cultivate with our patients. I welcome the bold strategic plan in the Family Medicine for America's Health report so we can move our healthcare system forward.

Natasha Bhuyan, MD, Chief Resident, Banner Good Samaritan Family Medicine Residency, Phoenix, AZ

1. Phillips RL Jr, et al. Health is Primary: Family Medicine for America's Health. Ann Fam Med. 2014;12:S1-12.
2. Indyk D, Deen D, Fornari A, Santos MT, Lu WH, Rucker L. The influence of longitudinal mentoring on medical student selection of primary care residencies. BMC Med Educ. 2011;11(1):27.
3. Eden J, Berwick D, Wilensky G, editors. IOM (Institute of Medicine). Graduate medical education that meets the nation's health needs. Washington, DC: The National Academies Press. 2014.

Competing interests: Member of Family Medicine for America's Health - Insight Group

Word-length not Tepidity

We appreciate the comments of Drs Bradley and Taylor. Their referenced study is an important contribution. We are also most pleased to have researchers from Yale respond since it is one of the few remaining 'orphan' schools that has yet to embrace family medicine.

As one of the coauthors of the cited IOM study on the integration of primary care and public health (ref 7), I completely agree with their desire for FMAHealth to endorse the role of family medicine in being a "hinge between health care and other social services." Besides the quote that they pulled from the article, we also restate the aspiration in the discussion, saying that FMAHealth should be "linked to the social and environmental determinants that have a greater effect on the health of Americans than healthcare." That is still not enough. I recommend that they now read the predecessor article, The Future Role of the Family Physician in the United States: A Rigorous Exercise in Definition (Ann Fam Med 2014;12:250-255), that spells this out in greater detail.

We need their help in making this a reality. Beyond the lack of training they note, we have additional barriers to tackle: 1) no one pays for these "hinge" roles; 2) we lack tools and relationships; 3) we lack time and teams. Our health enterprise is going through a period of what KPMG called, "institutional schizophrenia." We know we need to move to a population health model of care and payment, to leave volume-based care/payment, but few are willing to go first. Population-based models here and around the world support those hinge roles. Family physicians don't have the data systems to help us see who and where we serve to identify trends, opportunities, or potential partners. The ABFM and AAFP's Robert Graham Center are developing such tools based on successful efforts with FQHCs (www.udsmapper.org) and in pilot with OCHIN. Finally, we need teams, time and partners. This also relates to funding, but we need people in family medicine who can help identify the health problems that track back to social determinants and social cohesion, to help us develop the relationships with community partners, and then to work on them. This could happen under Community Health Needs Assessment requirements currently in place for Non-Profit hospitals. It could happen under State Innovation Model or Transforming Clinical Practice Initiative (both CMMI). It could happen in a population-based payment model that invested in robust primary care.

Many thanks to Drs. Bradley and Taylor for highlighting this issue, neglected in our article due to space, not tepidity. We hope you will join the effort as advisers to our Practice Tactic Team, just getting underway. We also welcome your help in introducing Yale University to the "well-worn" understanding of the role of primary care in improving health and containing health care costs. Yale currently graduates less than 10% of its residents into primary care practice (http://www.graham-center.org/online/graham/home/tools-resources/gme-mapper.html), and does not produce family physicians.

Competing interests: co-author of study

I am very grateful to all those who have worked hard over the past 2 or more years to create "Health is Primary and Family Medicine for America's Health". This collaborative effort has already stimulated constructive dialogue among a wide variety of professionals and citizens who are committed to shifting our health care delivery and health professions educational systems in a primary care, prevention oriented, team-based direction. Nonetheless, I agree with the critique by Dr Elizabeth H. Bradley that as stated now we have not emphasized enough the need to connect to community-based services and struggle with the patients' social determinants of health. As Dr Bradley suggests, family medicine can lead the effort among physicians to be the link to community resources and advocacy for improved basic requirements for health such as education, equity, economic opportunity, safety, etc.

However, we won't be effective if we start with such a broadly defined purpose. The current documents define a strategy. The overall goal of reaching the Triple Aim remains. At this point in the struggle we need to ensure there are more family physicians in training programs and fewer family physicians (and other primary care providers) giving up their ideals and their practices due to their discouragement. All of the strategies within "Health is Primary and Family Medicine for America's Health" lay out reasonable steps in a positive direction vs more of the same ineffective efforts to shift away from procedure-based, hospital-centric care.

This is a serious struggle for minds, resources and people. I believe we have chosen about the right amount of conflict to manage. Going further right now is not a sign of timidity but of good judgment. With the focus chosen, we can work with others to succeed in moving more quickly to the Triple and Quadruple Aim (Bodenheimer, et al, Annals of FM, 2014).

Competing interests: None declared

We were pleased to see the strong endorsement of primary care by the Family Medicine for America's Health Working Group. The paper reviews the classic, now well-worn literature on the role of primary care in improving health and containing health care costs. The values of patient-centeredness, responsiveness, and accessibility are admirable and if the vision set forth in the paper could become a reality, we have little doubt that the health care sector would be transformed for the better.

Nonetheless, the paper is less audacious than needed. It does not actively embrace family medicine as a hinge between health care and other social services that promote health for patients. Although the authors state that patients can expect family physicians to "understand the effects of the community-level factors and social determinants of health on their patients' well-being, and identify community resources available to meet their health needs," this statement is buried as the 7th of 8 expectations (Table 3) and is excluded from the roles of family physicians or expectations of the discipline. Recent research suggests that better coordination between health care providers and social service providers (e.g., housing, education, nutrition support, and other social services) could temper health care costs escalation and promote health (Bradley and Taylor, 2013). The discipline of family medicine could refashion itself to be the bridge between health care and social service providers; the Family Medicine for America's Health Working Group falls short of that vision.

Some may argue there is good reason for the Working Group's tepidity. The field of family medicine clearly recognizes that health care accounts for less than 20% of premature deaths averted, and that social, behavioral, and environmental factors account for the vast majority of our health outcomes (McGinnis, 2002). It stands to reason that family physicians may fear the responsibility of managing the diffuse social determinants of health when most are primarily trained to deliver high-quality clinical care. What's more, the thought of advocating for the role of social services may appear particularly unattractive in a "medicalized" America, where neither consumers nor politicians appear quite ready to forego the quickest (also most expensive) approach to attaining health - even if it delivers sub-optimal results. An historical review of American health care reveals a propensity to conflate health and health care. Re-educating the populous about the difference will require more than family medicine physicians, but the conversation could be rooted in primary care settings if the profession saw its mission as promoting health, not health care.

References
Bradley EH and Taylor LA. Paradox and Promise in American Health Care. Why Spending More is Getting us Less. Public Affairs Press: NYC, 2013.
McGinnis, J.M., P. Williams-Russo, and J.R. Knickman. The case for more active policy attention to health promotion. Health Affairs, 2002. 21(2): p. 78-93.

Competing interests: None declared

This is a major article that should become iconic in the annals of family medicine literature. The value of family medicine and primary care is spelled out in well supported detail. The subtitle "Family Medicine for America's Health" is vital to the overall title.

I am concerned that the promotional materials, posters, etc. of the Health is Primary effort are overally focused on this expression. The fine print underneath is "Brought to you by America's Family Physicians". When explained, "Health is Primary" has some deep meaning but at a glance it is just an obvious statement. Health is Priamry does not have the "blink" value to go viral.

The family medicine organizations will need to follow through with many activities for this effort to be successful. Fundamentally it must be about change, how we family physicians care for populations in the 21st century, and not just a validation of past models of care.

Competing interests: None declared

In order to expand and transform family medicine (Phillip's core strategy #6) [1] we believe training should include skills of palliative medicine.

In recent years palliative care has received formal specialty status by the American Board of Medical Specialties which now has more than 6,520 diplomats and 301 Accreditation Council for Graduate Medical Education - approved fellowship slots. Specialist palliative care consultations improve the quality of care for patients and families, affordability and in some cases longevity.[2-4] But with the present training programs, graduating fellows will only be able to replace the retiring palliative care specialist as we attempt to care for the ballooning number of baby boomers with serious illness and often life limiting medical illness. Patients who receive specialty palliative care along with disease-focused specialties demonstrate favorable patient centered outcomes.[2,5] People live longer with modern medicine, yet they often receive more complex care, bear more burden of illness and treatment and are more ill when they die.

Palliative care interventions are often categorized by symptom management, psychological support, ethical decision-making, coordination of care, spiritual support, prognostication, and goals of care conversations.[6] A new paradigm in health care has been proposed to infuse core principles of palliative care into the disease treatment model.[7,8] We believe teaching more palliative care within the specialty of Family Medicine would yield similar results. Currently only 3% of Family Medicine board certification material focuses on palliative medicine principles.[9]

Quill and Abernethy delineate "primary palliative care" and "specialist palliative care" and suggest that robust primary palliative care is a way to ensure that all patients receive high quality palliative care.[10] Newman and others offer a visual representation of this covenantal relationship between health care provider and patient and family to foster a caring relationship.[11] The primary care team is well poised to deliver primary palliative care to all patients, both established and new.[12] Palliative care initiatives in primary care have improved clinician and patient outcomes.[13]

Palliative Care has demonstrated improvement in quality of life of individuals that are the sickest 5% accounting for half of all healthcare spending by focusing on pain, symptoms, shared decision making, goals of care clarification and spiritual suffering. There is a strong causal link between better quality and lower costs.[14] Family Medicine is uniquely situated to develop, foster and drive this link between quality and cost by training and supporting the emerging skills of family physicians who are actively integrating primary palliative care into their present practice.

The 6th core strategy could include a dedicated approach to three core primary palliative care content areas for seriously ill primary care patients: advance care planning, symptom assessment and management, and biopsychosocial-spiritual assessment and management.[15] We believe this will improve the care of patients and strengthen Family Medicine's commitment to whole person care.

Sincerely,
Cory Ingram, M.D., M.S., FAAHPM, Corresponding Author. Assistant Professor of Family and Palliative Medicine; Practice Chair of Community Palliative Medicine; Director of Palliative Medicine, Office of Population Health Management, Mayo Clinic.
Andy Bock, MD, Instructor of Family Medicine.
Kari Bunkers, MD, Medical Director of the Office of Population Health Management, Mayo Clinic College of Medicine, Rochester, Minnesota.
Brian Grimard, MD, Instructor of Family Medicine.
Robert P. Shannon, M.D., FAAHPM, Assistant Professor of Family Medicine and Palliative Medicine, Mayo Clinic College of Medicine, Jacksonville, Florida.
James Deming, M.D., FAAFP, Palliative Medicine, Mayo Clinic Health System - Eau Claire, Wisconsin.

References
1. Phillips, R.L., Jr., et al., Health Is Primary: Family Medicine for America's Health. Ann Fam Med, 2014. 12 Suppl 1: p. S1-S12.
2. Temel J.S. et al. Early Palliative Care for Patients with Metastatic Non-Small-Cell Lung Cancer. New England Journal of Medicine. 2010; 363:8:733-742.
3. Bakitas M. et al. Effects of a Palliative Care Intervention on Clinical Outcomes in Patients with Advanced Cancer. JAMA. 2009;302(7):741-749.
4. Morrison R.S. et al. Cost Savings Associated with US Hospital Palliative Care Consultation Programs. Arch Intern Med. 2008;168(16):1783-1790.
5. Institute of Medicine. Crossing the Quality Chasm, 2001.
6. De Roo M.L. et al. Quality Indicators for Palliative Care: Update of a Systematic Review. Journal of Pain and Symptom Management, 2013, in press.
7. Mount B. Healing, Quality of Life, and the Need for a Paradigm Shift in Health Care. Journal of Palliative Care. 2013;29:1:45-48.
8. Ingram C. A Paradigm Shift: Healing, Quality of Life and a Professional Choice. Journal of Pain and Symptom Management. 2013, accepted for publication.
9. https://www.theabfm.org/moc/examcontents.aspx
10. Quill T, Abernethy A. Generalist plus Specialist Palliative Care - Creating a More Sustainable Model. N Engl J Med. 2013;368:1173-1175.
11. Newman Bhang T, Iregui JC. Creating a Climate for Healing: A Visual Model for Goals of Care Discussions. Journal of Palliative Medicine 2013: 16(7):718.
12. Matlock D. Do We Really Want to Grow the Field of Palliative Medicine? Journal of Palliative Medicine 2013: 16(9):998-999.
13. Pelayo-Alvarez, M. et al. Clinical Effectiveness of Online Training in Palliative Care of Primary Care Physicians. Journal of Palliative Medicine 2013: 16(10):1-9.
14. Smith S, Brick A, O'Hara S et al. Evidence on the cost and cost-effectiveness of palliative care: A literature review. Palliative Medicine 2014: 28: 130-150.
15. Sulmasy, D. A Biopsychosocial-Spiritual Model for the Care of Patients at the End of Life. The Gerontologist 2002: 42(Special issue III):24-33.

Competing interests: None declared

The recent publication of Health Is Primary: Family Medicine For America's Health (HiP) is an important step forward in the evolution of American family medicine.[1] There is much to be commended in this document. HiP more bluntly calls for payment reform than the original Future Family Medicine report (FFM) and better states the importance of comprehensive care by family physicians. And at least now we're not counting on Electronic Medical Records to save us from all that ails us.

However, the vision of HiP is still misdirected and incomplete. This statement by family physician leaders again fails to explain to the American people what the true value of family medicine is, though they acknowledge there is "...confusion of the public about the role of family physicians." There are many parts of this document I don't agree completely with, but I will focus on two major areas.

Family Physician Value
The first glaring deficiency of HiP is it fails to explain how family physicians deliver better health and lower costs. Because generations of Americans have grown up not knowing what it's like for the entire family to see a family physician for the majority of their healthcare needs, HiP is an opportunity to explain ourselves. The key missing word is judgment, which is found nowhere in the document.

Statements are made in HiP that are sometimes in opposition. In table 3, the document states that family physicians provide the right care, at the right time, at the right cost. In table 4, the statement is made that FPs will continuously improve each patient's experience of and access to care, emphasizing the patient's definition of both. What is missing is an understanding that sometimes these principles are in direct opposition to each other. What am I supposed to do when a patient demands antibiotics for a cold, do the right thing or please the patient/customer? I must exercise judgment.

Other concepts are jumbled. HiP calls for integration with public health. Perhaps this was the driving spirit of the comments by Glen Stream, MD, MBI, board chair of Family Medicine for America's Health, who wrote an email to STFM members after HiP was released. The first specific goal stated was to "increase ... smoking prevention and cessation." While this is one aspect of a family physician's day in practice, smoking cessation increases overall healthcare costs,[2] thus counteracting the goals of the triple aim.

HiP does not state that the primary reason family physicians deliver better care at a lower cost is that we are different people from other physicians, including internists.[3-5] We believe we possess a different set of attitudes, values, and skills than all other physicians.[6] We are comfortable with uncertainty, ambiguity, and even death. We are more comfortable making diagnoses based on a conversation and physical exam only. We are more comfortable including costs in our medical decision making. We actually believe early detection often does not change the final outcome.

Some observers have concluded that many Americans are harmed by too many tests and too many interventions,[7] especially at the end of life.[8] We are the solution.

We exercise judgment dozens of times a day. Every time we hear the phrase "pain in my belly" we do not order CT scans. Every time we hear the phrase "chest pain" we do not order heart catheterizations. We deliver better care at a lower cost because we do not treat all patients the same. We often deliver outstanding care by not following simplistic cookbook guidelines. We do deliver excellent care by making dozens of judgment calls a day.

The Institute of Medicine has estimated that the U.S. wastes over $750 billion in unnecessary medical care.[9] We are the solution.

None of these important concepts are found in HiP.

Paying for Value
The second major problem with HiP is its silence on naming two of the foundational forces that have suppressed medical student interest in family medicine and comprehensive family medicine growth in the United States. These forces are the AMA CPT current procedural terminology book [10] and the Center for Medicare and Medicaid services evaluation and management (E&M) rules.[11]

The average number of issues addressed in a visit to family physicians depends on the population served. In a relatively healthy insured population, studies have measured that family physicians address between 2.5 to 3 issues per visit.[12-13] In diabetic patients the number is 4.6 issues per visit,[13] and geriatrics it's been measured at 6 issues per visit.[14] The AMA's CPT book lists no E&M examples that cover more than four issues (and that example is for a 99205 code, which comes with its own burden of unnecessary documentation to legally bill the fee). The practicalities of the CMS fee schedule, and its reliance on the AMA CPT codes, are that family physicians are not paid for any work beyond addressing two issues in one patient visit. And this does not even begin to get into the other related issues such as lack of payment for email or telephone visits (which, to its credit, HiP implies should be fixed in its statement about enhancing technology).

Fee-for-service payment is not the fundamental problem with the existing payment system. Other healthcare systems in developed countries use varieties of payment mechanisms, yet they have similar health and cost outcomes. Britain and Sweden use a primarily capitated or salary payment system for their general practitioners. The Netherlands and Australia use a fee-for-service system.

The fundamental problem in the U.S. physician payment system is the disparity in how healthcare services are valued. For example, the time required to perform a cataract operation is paid at 8 times more per hour than the time required to care for a complex primary care patient.[15]

There is no perfect payment system. U.S. family physicians have already lived through a global payment/capitated payment model -- the managed care era -- which was a disaster for family medicine. No one has invented a system that can appropriately adjust for pertinent risk factors of a complex non-employed patient population. If we're not careful, patient populations such as Medicaid patients, disabled patients, and the elderly will have built-in disincentives for family physicians to care for them, which is the opposite direction our healthcare policy should move.

Family physicians in at least one region of the country believe a better payment system fundamentally includes the concept that brief or simple work should be paid less than time-consuming or complex work.[16] Many subjects expressed doubts that global payments would work, because of the built-in incentive to work less.

The more important and patient-centered approach to family physician payment would incentivize family physicians to address all of the issues that their patients are concerned about. This could include anything from acute concerns, chronic diseases, or even questions about the health of family and friends. It should include providing a wide variety of cognitive and procedural services (which was actually mentioned in FFM under the Basket of Services, but was rarely discussed again). By using this approach, the inherent disease burden of any physician's patient population will not be a factor in trying to calculate a global payment. Sicker populations will have more concerns and issues to be dealt with per patient, healthier patients will have less. Family physicians should actually have incentives to own the majority of the care of their complex patients, which a capitated system may not promote.

A Better Way Forward
How do family physicians deliver better care at a lower cost? We do it by providing comprehensive care to complex patients, applying a set of values, attitudes, and skills unique from other physicians. It has nothing to do with prevention, wellness, care coordination, or promoting public health. We deliver excellent results by not treating every patient the same way. Our value is not achieved by rigidly adhering to chronic disease guidelines that often do not make sense for an individual patient. We deliver value by making judgment call after judgment call after judgment call. None of these concepts are listed in HiP.

Unless the HiP leadership corrects the deficiencies, America will continue to misunderstand why we're so valuable for America's future, and just as we did with FFM, we will once again set ourselves up for failure. And the real losers will be the American people.

Richard Young, MD, Director of Research, JPS Hospital Family Medicine Residency Program, 1500 S. Main Fort Worth, TX 76104, 817-927-1412, ryoung01@jpshealth.org

References
1. Robert L. Phillips, Jr, Perry A. Pugno, John W. Saultz, Michael L. Tuggy, Jeffrey M. Borkan, Grant S. Hoekzema, Jennifer E. DeVoe, Jane A. Weida, Lars E. Peterson, Lauren S. Hughes, Jerry E. Kruse, and James C. Puffer. Health Is Primary: Family Medicine for America's Health. Ann Fam Med October 2014 12:S1-S12; doi:10.1370/afm.1699
2. Barendregt, J. J., L. Bonneux, et al. (1997). "The health care costs of smoking." N Engl J Med 337(15): 1052-1057.
3. Phillips, R. L., M. S. Dodoo, et al. (2009). "Usual source of care: an important source of variation in health care spending." Health Aff (Millwood) 28(2): 567-577.
4. Conry CM, Pace WD, Main DS. Practice style differences between family physicians and internists. The Journal of the American Board of Family Practice 1991;4:399-406.
5. Fiscella K, Franks P, Zwanziger J, Mooney C, Sorbero M, Williams GC. "Risk aversion and costs: a comparison of family physicians and general internists." The Journal of family practice. 2000 Jan; 49(1):12-7.
6. Young RA, Bayles B, Benold TB, Hill JH, Kumar KA, Burge S. Family physicians' perceptions on how they deliver cost-effective care: A qualitative study from the Residency Research Network of Texas (RRNeT). Family Medicine 2013;45(5):311-8.
7. http://www.iom.edu/Reports/2011/The-Healthcare-Imperative-Lowering-Costs-and-Improving-Outcomes.aspx. Accessed Nov 5, 2014.
8. http://www.iom.edu/Reports/2014/Dying-In-America-Improving-Quality-and-Honoring-Individual-Preferences-Near-the-End-of-Life.aspx. Accessed Nov 5, 2014.
9. http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America/Report-Brief.aspx. Accessed Nov 5, 2014.
10. American Medical Association (2014). CPT 2014 Standard Edition (Current Procedural Terminology). Chicago, Il.
11. http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf. Accessed Nov 5, 2014.
12. Stange KC, Zyzanski SJ, Jaen CR, et al. Illuminating the 'black box'. A description of 4454 patient visits to 138 family physicians. J Fam Pract. May 1998;46(5):377-389.
13. Beasley, J. W., T. H. Hankey, et al. (2004). "How many problems do family physicians manage at each encounter? A WReN study." Ann Fam Med 2(5): 405-410.
14. Tai-Seale, M., T. G. McGuire, et al. (2007). "Time allocation in primary care office visits." Health Serv Res 42(5): 1871-1894.
15. http://healthaffairs.org/blog/2011/08/01/rethinking-the-value-of-medical-services/comment-page-1/. Accessed Nov 5, 2014.
16. Young RA, Bayles B, Hill JH, Kumar KA, Burge S. Family Physicians' Suggestions to Improve the Documentation, Coding, and Billing System: A Study from the Residency Research Network of Texas. Fam Med 2014;46(6):470-2.

Competing interests: I was paid a stipend to participate in the CMS Innovation Advisors Program.

As a family physician myself and also as an astute observer of the specialty of family medicine in general I must admit that we have not all been "all that we could be" for our patients.

This sad truth is partly our own fault, but partly the fault of the long-broken system in which we must do our work. Physicians are mis-incentivised, time-pressured, over-regulated, and medicolegally timid. We make short-sighted decisions in an attempt to find any way to make our day easier in order to buy ourselves one more minute of high-yield "relationship time" with any patient - our true purpose when we awake each morning. This strategy causes individual physician burn-out and is burning out our specialty as a whole. There is no respite care program for the field of family medicine. Like a carnival game of "Whack-a-mole", any attempt to make one aspect of our work easier inevitably makes another area more challenging and we often end up shortchanging someone - or most commonly, everyone.

In our hearts we want to do better - to be better - to have the healing relationships we once enjoyed with out patients. Family Medicine for America's Health appears on paper to be the kind of catalyst needed to direct the family of family medicine in ways that can help us be all that we can be for our patients, for ourselves, and for our own families.

I know that the leadership of these organizations will be able to envision what that better future looks like. Family Medicine for America's Health will give them a framework in which to build the walls and floors of a new construct for our specialty. In the end, however, it is individual family physicians who must be willing to make the changes necessary to see that brighter vision of the future. Once we do that in our own practices, it will be easier to change the larger system. Thankfully, Family Medicine for America's Health is prepared to address changes in the system AND provide meaningful assistance to help individual physicians transform themselves from what they are into what they've always wanted to be.

To other family docs out there reading this article I say, "hang in there." The next 5-10 years should be a wonderful (and probably wild) ride for our specialty and you won't want to miss it.

Competing interests: None declared

One of the struggles that many primary care physicians have considering what a fully transformed practice looks like and how it functions is that we are trapped in our own experiences and skepticism. Dr. Sinsky's response is welcome because it pushes out the typical mental boundaries for what we need to become. Even if healthcare business models and payments flipped to support population health tomorrow, we would still have our own anxieties and roadblocks to transforming our practices into what the public needs us to become.

Dr. Sinsky's ability to describe what high-functioning, joyous primary care practices look like is critical to Family Medicine for America's Health. We need the visionaries, and even more, we need the evaluators who have seen such practices in action and can point to them. I hope that Dr. Sinsky will join the effort, just launched, to craft specific strategies to help enable her vision. We welcome others who share her impatience for getting the change started, and those who can show us what it looks like when we arrive.

Competing interests: member of the FMAHealth Board of Directors and lead author

Patient care is at a crossroads in a rapidly changing healthcare landscape. Going forward, will the majority of patients receive most of their care from a highly trained, well-supported primary care physician and team they know and trust? Or, in contrast, will patients receive care through a series of loosely connected episodes, from a wide array of narrowly focused providers? Who will adjudicate care for the whole person across competing conditions and multiple settings--the primary care team, the individual patient or even a new type of entrepreneurial navigator?

From the professionals' perspective, will primary care be a specialty that allows professionals to develop relationship and continuity with their patients, manage complexity and do meaningful work; or will it become the specialty where the core work consists of triage, information management and documentation?

My view on these central questions is a mixture of optimism and caution. I am optimistic that patients can receive personalized, coordinated, consolidated care that matches their needs and preferences. For the professionals, primary care can be one of the best of specialties, contributing greatly to individual patients' and communities' health, while also being rewarding as a life's vocation.

Imagine the possibilities when family physicians, general internists and other primary care professionals (PCPs) are able to spend the majority of their workdays adding high value to patient care. Imagine a wider ecosystem set up to support PCPs doing this work. Where, for example, policy explicitly limits the current crushing weight of clerical work distracting physicians from their mission. Where, by another example, subspecialists' core work includes supporting the PCP in managing patients further into each subspecialty, allowing patients to get most of their care "at home" rather than shuttling between multiple providers.

Imagine the possibilities when healthcare resources support primary care in meeting patients' social and behavioral needs, where the primary care team includes health coaches, pharmacists and social workers on location, ready to work collaboratively and on-the-spot with patients and PCPs.

Primary care can be the lynch pin in a high quality, cost-conscious, patient-centered healthcare system, and the Health Is Primary initiative can contribute to bringing this vision to life.

Competing interests: None declared