ASKING HARD QUESTIONS: THE ROLE OF ANNALS OF FAMILY MEDICINE IN ADVANCING OUR DISCIPLINE

Annals of Family Medicine celebrates its 16th anniversary this year; as a community, we celebrate Kurt Stange’s accomplishments as Founding Editor. As it happens, the transition in Annals’ leadership happens at the same time as the 50th anniversary of the American Board of Family Medicine (ABFM) and the specialty in this country. Such times provide an opportunity to reflect on where we have come from and to consider where we need to go.

Annals was a product of the Future of Family Medicine project and is a collaboration of the “family” of family medicine—the organizations that, collectively, shepherd the discipline. This was, in part, a response to the termination of Archives of Family Medicine, which was taken as a message that we lacked sufficient intellectual distinction to be worthy of a journal. Under the leadership of Kurt Stange and his editorial team, Annals has established itself as a leader in primary care research with impressive impact, a longstanding commitment to interdisciplinary work, and a growing international following. Our specialty needs to be both proud and grateful.

Where now? A direction can be glimpsed in the original Future of Family Medicine report. In March 2004, the leaders of the initiative issued a famous prophecy: “without major changes in both the discipline and the health care system, family medicine may be extinct in a generation.”¹ Now, a half a generation later, where are we as a specialty?

The picture is mixed. The Patient Protection and Affordable Care Act (ACA) has increased access to care for many. Chronic care management, electronic health records (EHRs), and quality metrics are an integral part of our practice and there has been a proliferation of new practice models. But we are far still short of where we need to be. Rapid health system consolidation, employment of physicians, and the rapid spread of high deductible insurance plans may undermine robust primary care. US medical student interest has grown only modestly. At the practice level, EHRs take attention away from the patient, burnout is epidemic, and meaningful improvements in quality and equity have often been local, modest, and temporary.

In this context, the ABFM believes that the specialty must act with urgency, thoughtfulness, and passion. In the fall of 2018, we began a new strategic planning process. Over the last 17 years, the ABFM, guided by its Board of Directors and Dr James Puffer, implemented a variety of innovations to improve the certification process, transformed the organization into a digital enterprise, and helped drive innovation in family medicine residency training.^2,3 Dr Puffer also launched a robust research enterprise⁴ that has documented positive correlations between participation in continuous certification and knowledge base, quality of care provided, and lower incidence of adverse medical license actions. ABFM has also documented dramatic changes in our scope of care, developed a national graduate survey to provide feedback to residencies on their outcomes, and begun to develop quality measures that capture the core of what primary care does. We look forward to reporting soon our directions for the next 5 years.

As the specialty responds to the changing environment of health care, how should the Annals guide us? Of course, the core of what Annals and other journals do is to cultivate scholarship in our field—the day-to-day working with authors, helping them to develop, and raising the bar for scholarship in family medicine. Equally important is its role in providing guidance to the discipline, assessing the current status of our research, and identifying important directions that should demand our attention now and in the future. This includes inquiring about the state of family medicine research today—who is doing it, what has been its impact, and how will it be funded? What are the “next big things” for research in primary care, as pragmatic clinical trials become a new “bright shiny object”?

But this is what all excellent journals do. What should Annals do specifically for the discipline? In March 2019, as we anticipate the ideas of a new editor and editorial team, the American Board of Family Medicine urges the editors to emphasize the asking of hard questions, not only of the delivery of health care, but also of ourselves. This means underscoring robust methodology, publishing the best available evidence, and emphasizing team science and interdisciplinary work. But it also means looking inward and questioning what the specialty is doing today and where it appears to be going—and looking at outcomes.

Examples of this kind of questioning span the work of the specialty. In clinical redesign, it might include a focus on the hard work of spread and sustainability of clinical redesign efforts, as well as the long term outcomes of interventions directed at social drivers of health outcomes. In education, it might mean asking why interest in family medicine has grown only modestly compared to psychiatry, which also suffers from lower compensation, as well as the stigma of association with mental health conditions. Additionally, it might prompt a reevaluation of our longstanding methods of delivering continuing medical education, which remains a largely passive endeavor with little evidence of improvement of clinical outcomes. In research, it might mean greater attention to the data sources we use to measure quality and the infrastructure needed to support development and evaluation of new models of care. And for the discipline as a whole, it means coming to grips with the reality that the large majority of family physicians are employed, and many in large clinically integrated systems. How will this change our ethos—and shape our ability to improve the health of the public? These examples are meant to be illustrative: we have no doubt that readers will add many others. The overall point is the importance of asking questions that are both hard and important.

A related issue is: how will our specialty organize, or reorganize, to conduct the science our specialty needs? As documented in a recent National Academies report,⁵ there remain large numbers of important, daily, and unanswered questions about care in the primary care and family medicine settings where the majority of health care takes place in the United States. Moreover, despite many individual successes, the overall track record of family medicine publications and NIH grant funding remains substantially below other specialties and other professions. The causes are both complicated and complex—from the social construct of what is important science, to the core infrastructure and number of trained researchers, to availability of funding for primary care and population health research. We look for Annals and family medicine’s research leaders to weigh in. In an era of big data, team science, and global markets, Annals’ emphasis on interdisciplinary science and international research is an important contribution today and a desired future direction. We are also very supportive of any efforts to replace lost support for training programs for clinical researchers from Robert Wood Johnson, HRSA, and others, with new initiatives, such as the new Physician Scientist residency track. We also appreciate that the Family Medicine Review Committee’s enhanced requirements for scholarship in residency has set the right tone for the specialty.

We urge, however, more systematic thinking about how our specialty is organized for research. Perhaps an early initiative might be to ask NIH, AHRQ, and PCORI to fund an issue addressing what primary care research is. Part of a direction can be seen in the work of the Family Medicine for America’s Health research tactic team,⁶ with its strategic focus on how to measure and pay for family medicine and primary care. More broadly, how can we develop robust centers of excellence in primary care research, like those that have been so successful in cancer and other disciplines? How will we support the development of data bases that will allow pragmatic clinical trials and robust studies of the questions relevant to family physicians as they work within systems and extend practice into new populations? How will we, and the institutions in which our faculty do their work, organize and fund the interdisciplinary teams necessary to the research that is needed for the discipline?

ABFM is committed to doing its part—to supporting Annals of Family Medicine and the Journal of the American Board of Family Medicine (JABFM), collaborating with researchers across the country, and helping to train residents, fellows, and faculty in policy-focused research. Other members of the “family” of family medicine also have important contributions to make toward this future, as they have done in the past.

The science of primary care is too important to be left to others. Thank you, Annals, for all you have done. We now look for you to mark the path forward.

• © 2019 Annals of Family Medicine, Inc.