The Future of Family Medicine? Reflections from the Front Lines Reveal Frustration and Opportunity

THE FUTURE OF FAMILY MEDICINE

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.”¹ Table 1⇓ below depicts some of the early themes apparent in the ongoing discussion about the project’s report, which was published as a supplement to the previous issue of Annals.² By the time this On TRACK feature is published, the ongoing discussion will likely reflect additional ideas on the future of family medicine. We encourage readers to participate and invite diverse others to join in at http://www.annfammed.org. Invite patients, people without access to becoming patients, other health care professionals, policy makers, and others to bring their voices and insights.

The early online TRACK discussion personalizes the sense of 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, Ind,³ “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.

The early discussion leaves us with at least 3 overarching questions and many subquestions that call for further debate, and ultimately, action. We invite readers to weigh in and to pose other questions:

1. How do we move from our current frustration to a better place for patients, family physicians, and the larger health care system?

   • What will it take for us to change this situation?

   • What does each of us want to do?

   • How do we want to work together?

   • What support do we each need?

   • How could we organize ourselves locally and nationally?

2. How can the larger health care system be reformed?

   • How can the energy from the current pain, frustration, and anger be channeled toward finding solutions?

   • How do we move the discussion from being just about family medicine to focusing on equity, accessibility, affordability, personalization, and quality of health care for all people?

   • What is an emerging and essential role for family medicine in this larger vision?

   • Who are potential allies? The family medicine organizations and their members? Others engaged in providing and paying for health care? Policy makers who can envision primary care as essential? The community of those who need health care?. How can they be engaged?

   • How do we build resilience and capacity for when the current “system” collapses?

3. What do we do in the short term and at the local level, while advocating for long-term and macro-level solutions?

   • How can we get just a bit of slack—to move from day-to-day survival in a painfully dysfunctional system to a place where we can start to imagine and implement a better way?

   • What short-term sacrifices will we have to consider to see a brighter future?

   • What will leadership—organizational, individual, grass roots—look like for these efforts?

   • To what degree do things have to get worse, if they are to get better in the end?

   • Can an appreciative inquiry approach⁴ engage diverse potential partners around an important common goal? How can we discover that which gives meaning, life and joy, dream what might be, design together what should be, and then make our destiny together by working on our own part of the solution?

   • What changes do we want? What comes to mind when you think of practicing family medicine happily? What is the meaning of family medicine in your life? What 3 or 4 things do you like best about family medicine and shouldn’t be lost? What do you do for joy?

Please continue to use the Annals TRACK forum to share your insights, frustrations, and joys. Give the Web address to others and invite patients, policy makers, health care professionals in other fields, payers, and other potential partners and antagonists to enrich the debate and action.

TRACK DISCUSSION OF RESEARCH REPORTS

The discussion of the research articles in the March/April, 2004 issue of Annals also was vigorous. Community-oriented primary care (COPC) generated great enthusiasm as a model for integrating public health and primary medical care to solve population health ills and health disparities. Commenters on the study by Plescia and Groblews-ki⁵ and the editorial by Williams⁶ described their own experience and identified the challenges of applying this appealing model within the current system.^7–,¹³ We encourage others with real-world experience with COPC application to share the process and outcome.

The authors of the natural history study of asthma¹⁴ provide a thoughtful response¹⁵ to questions about the diagnostic criteria^16,17 and data sources¹⁸ for their primary care cohort study. The study identifies a positive prognosis for primary care practice patients with an initial diagnosis of asthma and a lack of predictive value for bronchial hyperresponsiveness testing.

The study of management of hepatitis C patients¹⁹ brought calls for advocacy and safety nets to facilitate care^20,21 and useful additional clinical information for increasing our awareness and efficacy in case finding in primary care.^22,23

The study of medical errors by Elder et al²³ spawned a research agenda²⁴ and an articulation of the challenges of measuring errors of omission.^25,26 The need for a classification system and definitions for errors in the outpatient setting was identified by several discussants.^27–,²⁹ The authors’ response,³⁰ and the tenor of the discussion show that there is a highly engaged group of critical thinkers openly sharing new knowledge in this nascent but rapidly emerging field of inquiry. A cluster of papers in a forthcoming issue of Annals will further this discussion, and we encourage readers to continue sharing ideas online.

The study finding low levels of reported physician effectiveness in screening for inherited cancer risk³¹ brought a reflective commentary on why we don’t consistently do what we are “supposed” to do.³² Two family physician genetics researchers urge us either to seize the “teachable moment” to incorporate genetics into our practices³³ or to do more research to understand how to do this effectively.³⁴

The related studies that identify mortality risk from elevated serum transferrin saturation³⁵ and dietary iron intake³⁶ brought important perspectives from an advocacy group^37,38 questioning the practice of iron fortification of foods. In addition, researchers identify a possibly related gene locus³⁹ and free radicals as a likely causal pathway for the observed association.⁴⁰ The Annals’ statistical editor points to these studies as examples of the fruitful hypothesis-driven analysis of nationally representative data to answer an important clinical question.⁴¹

The novel and intriguing finding by Keeley et al⁴² that a specific combination of parental attitudes is a predictor of birth weight is supported by French,⁴³ who raises additional questions for further research.

Gask’s study of powerlessness among HMO-based family physicians⁴⁴ generated a call for team approaches to practice,⁴⁵ and the hypothesis that the younger generation of physicians may have a different experience.⁴⁶ Another writer hypothesized that it would be valuable to bring some aspects of decision making back to the physician “connected to the ground level practice realities of caring for patients.”⁴⁷

Comments on the US Preventive Services Task Force finding of insufficient evidence to support screening for intimate partner violence⁴⁸ reflected frustration with the limited evidence identified by this systematic review and recommendation. Observations included a call for additional questioning and research,⁴⁹ the presentation of emerging data on terrorism and other disasters as a risk factor for intimate partner violence,⁵⁰ and questioning the methods and data used for the systematic review and recommendation.^51,52

In critiquing the meta-analysis that failed to show value to partner support in increasing smoking cessation,⁵³ McIlvain⁵⁴ wonders whether the question is too broad. Because there is such diversity in “partners” and in the meaning and quality of such relationships, she concludes that without further definition, the answer is likely to remain “it depends.”

The very personal story shared by Rosenblatt⁵⁵ generated intellectual and personal responses^56,57 but a lack of surprise at the impersonal care he received. What are others’ experiences and expectations of health “care”?

In addition to these postings related to the last issue of Annals, thoughtful commentary continued on articles in previous issues, including a critique⁵⁸ of the immunization study by Schillaci,⁵⁹ and author response to previous and continuing^60,61 critique of the study on religion, spirituality, and health status in geriatric patients.⁶² Jerant responded to critique⁶³ of his TLC model of palliative care in the elderly.⁶⁴ A retired public health physician⁶⁵ provided some thought-provoking (if speculative) data on the magnitude of iatrogenic risk for mortality.

Finally, the Annals Open Forum was used to introduce the “Campaign to Revitalise Academic Medicine,” offering an option for readers to contribute their views on this international effort.⁶⁶ Previously, the Open Forum generated a spirited international discussion of the importance of classification systems relevant to primary care. This discussion was in response to posting of the Banff Declaration on this topic.⁶⁷

We thank you for your thoughtful engagement.