The Future of Family Medicine: A Collaborative Project of the Family Medicine Community

The New Model of Family Medicine is a worthy goal to improve the speciality. However, most of it was what I thought we were doing when I was in my residency 30 years ago.

Several new labels have been formulated to describe the New Model, like "personal medical home", "evidence-based medicine", "lifelong learning program", "high quality care", "practice based research", "quality of care", and "team approach to patient care". I thought we were doing these things, or similar things, 30 years ago.

If the New Model is all new, then what have we been doing for the last 3 decades?

It appears that the primary purpose of the New Model is to shape present Family Medicine residency programs for the future. If so, I think that no matter what these recommendations are called, they are still worthwhile.

However, the most important thing that can be done to improve the specialty is to change the way physicians are paid (Not "reimbursed". I never gave an insurance company or the government any monitary sum for which I need to be "reimbursed").

If family physicians were valued and paid commensurate with their value, then their impressive income would be more than enough to lure medical students to the specialty.

I hope that this is what happens.

Competing interests:   None declared

Imagine thousands of social services units all across our nation providing high quality medical care and equal access to patients. How could this be? This existed prior to 1987 in our primary care offices (social services unit) because in each individual office mercy was given to those who could not afford to pay the full charges for service, and those who could and did pay were subsidizing the care of those who were ‘medically poor’. The primary care offices (social service units) were able to pay their increasing business costs by increasing their fees and expecting them to be paid by community members who themselves had ‘received much’. These primary care offices became business units and ceased to be social services units when their finances changed in 1987 by Medicare ruling that balance billing could not continue (Medicare became the social service unit!).

Our government social service unit did it right in this country for our children. For children from poor families as determined by our government (social services unit), our primary care offices receive identification cards that only a discounted payment will be received for services and the remainder will need to be charged off (pre-determined mercy for Medicaid patients). For children from medically indigent families as determined by our government (social services unit), parents are allowed to purchase ‘Kids Care’ for a subsidized monthly amount and the primary care office receives an identification card that only a discounted payment will be received (See prior sentence.) With Medicaid and ‘Kids Care’ the primary care physician knows that the patient has access to specialty care and prescription drug services if needed without providing additional hardship on the family. For children who are neither poor nor medically indigent the primary care office expects full payment for services unless a prior arrangement has been made and agreed to by the primary care office (business unit).

While primary care physicians have a business choice to be in a managed care plan or not, it is not a practical choice to not be a Medicare insurance provider because half of all primary care services are for our patients over 65 years-old. Is there a way Medicare could spend our tax dollars for seniors that would not put primary care offices (business units) out of business or would encourage new physicians to go into primary care?

The solution is ‘Senior Care’. Primary care offices know when a Medicare patient presents with a Medicaid ID card that they can expect total payment from the government for this poor person and that the remainder of the charge will be disallowed (pre-determined mercy for Medicaid patient). What we do not have is a ‘Senior Care’ program for the medically indigent Medicare recipient that would assure specialty and prescription access without additional financial hardship. Instead we have a piece meal program that is confusing to even the professionals and the hardship continues for the medically indigent in our country.

An example of part of the piece meal program that has gone wrong and has exacerbated the financial problems of seniors is that “well” seniors shift to the lower cost no prescription Medicare supplemental plans until they personally need the prescriptions; this raises the cost of the policies for those who do need the prescription plans. Now we have a prescription card fix that is misunderstood and underutilized. If a ‘Senior Care’ program that allowed medically indigent Medicare beneficiaries to buy into Medicaid were combined with allowing only private Medicare supplemental insurance policies with a prescription drug benefit then we would have a simpler and fairer system.

How do the primary care offices benefit from ‘Senior Care’? With ‘Senior Care’ our government (social services unit) will have identified those Americans who mercy needs to be given. For a business to be successful there has to be a way to pass on costs to customers who can afford to pay; if a business charges too much it will have fewer customers and less revenues. Since we are business units Medicare should remove the balance billing restraint on physicians who decide to not accept assignment.

Our specialty societies have to lobby for reversal of the no balance- billing rule and as a minimum accept removal on Evaluation and Management Services. This ‘new’ method of financing primary care will unleash competition and actually increase access to primary care by retaining experienced physicians and recruiting new physicians.

Competing interests:   None declared

The future of family medicine is bright. Healthcare and security are the only two national issues that everyone wants more of. Certainly our specialty is undergoing a serious identity crisis and our diversity makes simple solutions challenging. The FOFM report is a great starting point (1). Questioning the FOFM is a necessary step in finding our common voice amongst the cacophony of ideas, controversies, and visions of our future. There is no question that the FOFM report is complex and filled with many superb ideas and goals, though it lacks the necessary simplicity to stand as a shared vision of our future. If forced, I would call the FOFM report a sharing of visions of potential futures, not a shared vision of our shared future. We need a simpler vision of where we want to go, a simple vision that goes beyond the complexity of the FOFM. I believe William Phillips has begun that process for us in his superb essay in the October issue of the STFM journal Family Medicine: Phillips WR. Questioning the future of family medicine. Fam Med. 2004 Oct; 36 (9): 664-65.

In it he shares his deeply held beliefs about our specialty and the simple dilemmas that underpin our present state which might direct us toward a shared vision of our future. As with all great works of leadership, Dr. Phillips’s essay leads with more questions than positions, more digging than shoveling pet projects, more vision than plans, and more hope than nuts-and-bolts remedies. His is the start of our finding a shared vision of our future beyond the complexity of our current way of looking at ourselves.

I was particularly struck by these three probing questions in his essay (2):

1. Do family physicians have what it takes to be true generalists? Do we know what that is?

2. What exactly does the residency-trained, board-certified family physician bring to primary care that is not done well enough and cheaper by a physician assistant or nurse practitioner?

3. Are family physicians only good enough to care for the underserved? Do only the disadvantaged deserve the advantages of having family physicians?

These questions prick sensitive spots in my own physician-ego. How about yours? I believe in making a serious effort to solve the dilemmas that lie beneath these challenging questions, we can begin to reshape our future with a vision more powerful and successful than that of our predecessors that brought our specialty into being.

References:

1. Future of Family Medicine Project Leadership Committee. The Future of Family Medicine: A Collaborative Project of the Family Medicine Community. Ann Fam Med. 2004;2:S3-32S.

2. Phillips WR. Questioning the future of family medicine. Fam Med. 2004;36 (9) 664-65. Available in PDF at: http://www.stfm.org/fmhub/fm2004/toc.cfm?xmlFileName=fammedvol36issue9.xm

Jeremy Fish, MD Program Director CCRMC Martinez Family Medicine Residency Program

Competing interests:   None declared

I applaud the authors for outlining essential steps in the modernization of family medicine. This will help family medicine transform into a more humane, patient-oriented, evidence-based practice of medicine.

I am dismayed, however, by the lack of material here that is unique to family medicine. Most of what is proposed could be equally well applied to every other primary care specialty, as well as to most subspecialty practices. Does not the urologist, dealing with a terminal prostate cancer patient, have the same issues of family dynamics, accessibility, integration of evidence, etc.?

Our niche is disappearing before our own eyes. When we began in the 1970’s, we were the vanguard of a comprehensive, patient-centered holistic approach to medicine. Today, while not yet widely achieved, these goals are widely recognized as necessary components for all styles of medical practice. Is it possible that our specialty has already served its role to society and the model no longer has the cutting-edge relevance it once held? I cannot help but recall a quote from John Wyndham in The Chrysalids, “All dying species struggle against the inevitable.” The recent 50% decline in family medicine residency matches seems a bellwether of trouble for us all.

If the role of family medicine is to be the vanguard of cultural and organizational change, we should explicitly state that. We would also need to be able to defend that claim, as many others would likely wish to hold the same stake.

If the role of family medicine is to offer services across age ranges and for a wider variety of illnesses, we should state that. Again, in days when family physicians are limiting their ranges of service, unlikely to provide comprehensive women’s care, delegating hospital and surgical care to others, our differentiation from those double boarded in internal medicine and pediatrics is challenged. We need an answer to this challenge, if one exists.

If the role of family medicine is to provide comprehensive access to care in under-served areas, where only one physician is likely to be present and it should therefore be a physician with a broad set of skills, we should state that. Again, in days when family physicians are limiting their own services and other specialties are providing services more comprehensive than their specialty’s history indicates, we need to develop and articulate the distinction.

If we believe that our differentiation is limited to cultural and social values, I submit that the level of variation among us as a group is high enough that this would be difficult to demonstrate to a "non- believer".

If there are other valuable ways in which we differentiate ourselves from the rest of medicine, we should articulate and promote them.

A great many people do not know how family medicine differentiates itself from the rest of medicine. As much as I applaud the innovative directions in this proposal, I do not see them as addressing the fundamental identity problem. This is a good start, provides an excellent direction for all of healthcare, but it does not address the fundamental issue of our identity as family physicians.

Competing interests:   None declared

The Future of Family Medicine has stirred up a tremendous amount of reactivity among our discipline. I would submit these comments:

1. I'm not sure what is new about the "new model." I've always been proud of my heritage as a "descendant" of the original physician, and I continue to feel very centered in the beliefs and values that brought me to this discipline. I'll bet the vast majority of the contributors to the report and the respondents who have commented feel this, as well. Otherwise, they would not have bothered to speak up. My guess is we all have more in common than we do our differences. Although my initial response to the "new model" is that it is something like the Emperor's new clothes, perhaps it is inevitable that we will stumble and be taken aback over word choice and our (apparently) continued need to explain ourselves to others. Now is the time for us to remember our commonality and take a little comfort while we face the current, seemingly huge, challenges of today.

2. A recent article in FP Report stated that students want role models who are the "right stuff." There has always been a balance between our knowledge and our hearts, our practicality and our intuitiveness. Do we STILL enjoy exercising our intellect, the craftsmanship of our hands, and the opportunity to share the good and the bad in our patients' lives? We should not let anyone get in the way of that, and that is our responsibility.

Let's face it, none of us are getting up in the middle of the night to hitch up a buggy and drive around a washed out bridge to see some poor patient whose only benefit will be compassionate hand-holding. We have so many tools to work with, and so much to offer. Our work and our life is what we make of it. It's been my privilege over several decades to know numerous family physicians, both mentors and students, who are the "right stuff." We should not stop fighting for what is right, but we should quit whining. If a major problem facing many family physicians is burnout, surely we can find a way to be emotionally healthier, just as Dr. Fleming has challenged us all to be physically more healthy. What do we tell our patients when they are stressed?

3. The best aspect of this report, in my mind, is that there is a real acknowledgment that we need to seek innovation and consider alternatives, such as four-year residencies. Some of what is said appears too watered down to be meaningful. The practice of Family Medicine is highly variable and reflects individuals and their interactions with communities. A pluralistic approach may not comfort the insurance industry, but it's probably in keeping with the diverse nature of our society. There is no possible way this report could have been written to reflect the entirety of our diversity. I would hope that this report serves as stimulus for dialogue and involvement, not for disenfranchisement. Many of us in Family Medicine education will be trying to respond to the challenges described in this report. We need our connectedness with our colleagues in private practice to do so intelligently. If you believe something, one way or another, get involved. The Family Medicine residency in your community, your state academy, or the clinical department in your hospital is a place to start.

Competing interests:   None declared

Family Medicine’s Future - The Real Story

It looks as if the world is changing for Family Practitioners. The leadership has apparently determined that it is time to roll out a New Model for primary care delivery. Considering the convoluted, inequitable, yet business-oriented medical delivery system, this proposal seems to be a desperate gasp to save the specialty.

Reflecting on survey results published by the Family Medicine Practice Management magazine (November/December 2003 issue), we can appreciate the problems faced by Family Practitioners today. Only 62% of family physicians feel that they chose the right specialty. Up to 40% admit that they would have thought twice about becoming a Family Practitioner if they had known in medical school what they now know. Family physicians tend to value patient’s emotional needs far more than patients’ desire for this service. Americans continue to place greater value on technology than personal relationship building with their family doctors. In fact, most Americans do not even understand the concept of a “family physician”. Being unique has gotten harder with all the ancillary providers.

Referencing The Future of Family Medicine proposal appearing in the Annals of Family Medicine (vol. 2/Supplement 1, 2004), the leadership is calling for a New Model of care delivery which is uniquely patient centered. The conceptualized personal medical home promotes patient entitlement in an environment where care can be received 24/7 in whatever context the patient desires. “ Practice staff will share in decision making regarding patient care with explicit accountability for their performance to patients, to each other, and to each patient’s personal physician. The traditional waiting room will be a thing of the past replaced by a patient resource center with a patient library, computer work stations with ready access to online health education materials, and patient information gathering stations. Practices will be equipped with sufficient technology, staff, and supplies to be able to provide on-site a comprehensive set of diagnostic services, testing for important genetic predispositions, and performance of common therapeutic procedures.” Sounds more boutiquish than Fedcarish. This new model shall be one which emphasizes evidence- based medicine backed up by verifiable quality control measurements delivered by a discipline that is far more art than hard science – an art characterized by the intangible skills of perspective and appreciation for the human dimension. Board Certified practitioners staffing these futuristic offices will be required “to engage their office staff and colleagues in reading materials, audiovisual materials, and computer-based educational training related to the care and management of patients with registry creation to verify consistency with current guidelines” as part of their maintenance of certification. Meanwhile, residency training programs will remain deficient in technological and holistic training as psychosocial and obstetrical training continue to dominate the educator’s attention. The leadership – consistently delusional – proposes an “electronic medical record based world that permits the collection, analysis, and reporting of the clinical decisions and their outcomes that primary care clinicians make every day. According to them, this would support practice-based research, quality improvement, the generation of new knowledge, and practice-based clinical research using electronic audits concerning the costs, processes, and outcomes of care including HEDIS.” Please! We are talking about an industry characterized by low margins and limited capital, yet hoping to promulgate standardization of a dizzying array of software platforms without the political or financial clout to do so. Of course, the leadership promises to work towards introducing a new financing system for primary care delivery services in hopes of making the foregoing grandiosity possible.

All Family Physicians can appreciate the efforts of the AAFP in 1968 when traditional general practice was significantly upgraded to meet the primary care needs of the population at large. Credibility was rendered through the establishment of a three-year residency program plus requirements for recertification every six years after entry into practice. At this juncture, however, I think that the AAFP is trying to recreate itself in hopes of not fading into antiquity. The leadership admits as much, “Unless there are changes in the broader health care system and within the specialty, the position of family medicine in the United States may be untenable in a 10 – to 20 year time frame. “ Unfortunately, the leadership fails to realize that physicians no longer control the healthcare system – business people do. Family docs doing the grunt work see this! Apparently, medical students see clearly as well. Given the cost of medical education and the public’s fascination with technology, no sane medical student would dare pursue primary care. The graying of America, deficit spending, and legislative (social) agendas will increasingly impact governmental spending. This perfect storm will make primary care increasingly untenable. Dearest Leadership – YOU ARE RIGHT! It is time to retool, but YOU MISSED THE BOTTOM LINE - literally!

Competing interests:   None declared

1] I am an optimist and believe that Family Medicine will do well in any system or non-system.

2]All Fam. Med. organizations must actively fight for a Health System which as a " right" will cover the basic health needs of every US citizen. When this happens the importance of Fam med will become apparant as the core of the system. To do this we should join with every organization working for the same outcome. As the chances of a federal change seems remote, we should concentratrate on States. For example, Oregon and Vermont seem primed for Universal coverage of their citizens.

3] To gain more clout, both Politically and Professionally, should we not form a Consortium of all Primary Care disciplines---Fam. Med., General Internal Medicine and General Pediatrics?

4] Sub-specialization. For many reasons which I won't go into, I believe the time has come for Fam. Med. to formally allow for sub- specialization activities. This might be done by joint Residency programs as is being done with Psychiatry, or additional years in the other discipline, or sub- divisions in the department, or joint departments. Some subjects that come to mind-- Genetics, Family Health. Geriatrics, Public Health/ Community Health, Sports medicine, Substance abuse, Adolescent Medicine, Womens Health, Research methods/Epidemiology, Bioengineering, Informatics, Nanotechnology, Home Care. etc, etc.

Can this be done without losing sight of our Core Values? I believe we can do it.

Sincerely, Jack Medalie.

Competing interests:   None declared

The report o the future of family medicine lays out,in considerable detail, the future (or a possible future) for Family Medicine However, I believe that it overlooks several critical issues that are (or certainly should be) the provence of family medicice and which really define the unique domain of family medicine.

First, family medicine physicians, along with their collaborating staffs, must be able to treat multiple interacting things at once, each at a different stage of development and each with its own nonlinear path for the future. Family medicne physicians must help patients deal with the interdependencies among a number of conditions, only some of which are medical in nature. It is the ability of the family medicine physician to focus on the patterns of development of the whole system, rather than a highly localized "condition" that makes it reasonable for one to seek a family practice physician to help mangae one's health care.

Second, family medicine physicians must help the patient and clinicians develop a shared sense of "what is gong on here". This is not a question of accurate technical information which is often available on the Internet. Rather, the practitioner of family medicine smust have the requisite skills to help patients, their families, their employers, other MD clinicians involved in any aspect of care, non MD clinicians and others as appropriate, develop a shared sense of, "who am I, now that I have X & Y", "why am I here, when the possible choices of interventions are so many and so uncertain", "what is going on, and what is my role in that unfolding?"

Thirdly, practitioners of famly medicine must clearly know the difference between "correct theraphy" and "plausible theraphy" Evidence based medicine, regardless of its other merits, cannot distinguish between the correct and the plausible in a health care setting. This requires a skilled family medicine physician who can help patients, their families and and other clinicians develop and monitor a path of theraphy designed to enhance the quality of life of the patient in the world in which the patint must live (or die) rather than in the world of the clinical trial.

These three areas define for family medicine domains of medicine and health care that are not the responsibility, at this time, of any other specialty. Each is a gold mine of research opportunites, given how little we know in a scientific sense about any of them. Patients and policy makers can be educated about the value of attention to these matters because each now feels the lack of wholeness in medical care. And certainly young people, who are considering medicine as a career but who want to work with people rather than diseases, or broken bones, or cancers, will find a welcome home in a discipline that attends to the kinds of issues articuulated here.

The report on The Future of Family Medicine articulates many welll defined and worthwhile goals. But the report does not lay any unexpected and interesting directions for the field. The report almost says, fix the finances and we will continue to do what we have always done, only we will do what we do now a little better in return for more equitable treatment.

Certainly Family Medicine deserves better treatment at the reimbursment table. Certaily Family Medicine can and should do some obvious things better. But in the final analysis, the future of Family Medicine rests on what value it can add to the lives of people irrespective of the political economics of the moment.

Competing interests:   None declared

I will not go into all the problems I have with this "Future". So many have already discussed them in great detail. All in all, I believe this is the most disturbing collection of garbage I've read in quite a while. I'm disappointed in this project. I'm ashamed of our board for caving in to the consumer advocacy groups and essentially transforming all of us into lifelong residents. Why would med students choose to be FP's when our own organizations and advocates are making our profession more unpleasant?

Competing interests:   None declared

The Future of Family Medicine (FFM) project has put together the nuts and bolts of the paradigm of family medicine and its 10 recommendations cover the activities that must be around to keep the discipline fighting fit: the new model of care of personal medical home providing a basket of services; medical records; Family Medicine education; life-long learning; research; quality of care; role of academic departments; best practices; communication to promote the new model of care; and leadership and advocacy. Together they form the syllabus for training for the future.

What the FFM project has not addressed are the critical step to take to remain alive and well into the future. It is clear that family medicine is losing grip in the United States judging by the declining number of doctors enrolling in its residency programmes. And America is not alone in this predicament. In faraway Singapore a similar phenomenon is being seen too. So, what can we do about the situation?

Negotiate the turf. The first step is to negotiate the turf. A discipline that has reimbursement issues will face a decline in takers. To that extent, countries like the United Kingdom, Australia, and the European countries are faring better than the United States. Singapore faces the same problem too, although the details are different. In the United States managed care and the advanced practice nurse (APN) erode into the margin of sustainability of the primary care doctors. In Singapore, it is the reimbursement system where employers and insurance companies are unwilling to pay more than acute care rates for primary care doctors’ work that have pared margins to make it tough for primary care doctors to keep going. Patients with chronic medical conditions tend to drift to the specialists because employers and insurance companies will reimburse services provided by the latter. The primary care fraternity may need to consider a future where negotiating with the payors, patients and other providers for a piece of the turf and reimbursement is a major ongoing activity. Shared care amongst the providers – primary care doctor, APN, and hospital specialist; getting managed care and employers to consider not only cost control alone but quality assurance; and best practice in the basket of services becomes of survival importance just as patient-centred care is important.

Minimum standards. The second step is establishing minimum standards of service as a national programme and helping to make these happen. This helps to keep the fraternity together. At least, there will be quality standards that could be used to pull patients and providers together. Such endeavours as life long learning, best practice, and evidence based medicine which are covered within the 10 recommenddations of FFM will find a place here. The American Academy of Family Physicians (AAFP) and the academic departments of family medicine together need to set the minimum standards for the fraternity. The leaders must also achieve a buy-in from the practitioners. The institutions need also to be enablers, advocates, trainers and providers of products and services to make it easy for practitioners to achieve the minimum standards. The AAFP’s publications, Annals of Family Medicine, and other key family medicine publications, the various continuing professional development programmes are steps in the right direction. Practical short courses are invaluable in imparting common core values and skills.

Finding new niches of synergistic work. The third step is finding new niches of synergistic work. Acute care volume is dwindling in most developed communities. Chronic care, elderly care, home care and preventive care are new areas of work. Shared care in oncology and defence against the chronic disablers – the metabolic syndrome, arthritic conditions, respiratory problems, atherothrombosis, strokes and dementia, offer new areas of shared care for primary care doctors to work in synergy with the APN, the hospital speciailist, and paramedical professionals like dietitians and physiotherapists. Working together fosters mutual support and satisfaction as opposed to mutual destruction and paring of reimbursements, and huge amounts of negative energy and cost will be saved. We need to provide the positive energy and embark on the training into these new niches of work. Family Medicine trainers will be busy again.

Reconciling training and service delivery. The fourth and final step to be considered is helping practitioners reconcile training and service delivery. Primary care doctors are trained in the principles of personal, primary, preventive, comprehensive, continuing and community care. Yet, in the real world, not every patient will appreciate nor want the whole basket of services. So the idea of a personal medical home for every one may be doomed to fail with some patients and may at the same time demoralize the practitioner. Some patients do choose to have only selected aspects of service delivery. There may not want patient centered care but rather prefer a doctor who is more paternalistic. The ability to reconcile the scope and the scenario will be important to the professional well- being of the primary care doctor. It must be part of the training agenda into the future.

Competing interests:   None declared

The development of the proposed New Model of Family Medicine evidently involved a tremendous expenditure of time, effort, and money for its formulation. Unfortunately, as I review the published report, all I perceive is a great deal of newspeak, marketing and political correctness thinking and rhetoric, yet very little substance.

The entire premise for the New Model is based on two fallacious concepts. One is that technology--the electronic medical record--will eliminate human error and create an environment conducive to research and improved communications. The other is that funding for the proposed agenda will be available. The cast of characters involved in the Future of Family Medicine Task Force is impressive, but somehow they got sidetracked on ideological concepts and failed to recognize the realities and practicalities of modern medicine, and Family Medicine in particular.

The American Academy of Family Physicians already embraced the concept of the electronic medical record (EMR) and is intent on enforcing its use in the future by all family physicians. The problem with the EMR is that presently the hardware development and the software available is not standardized and is very expensive. For a standing practice to acquire an EMR system and implement it requires a large capital outlay without any guarantee that the present system will meet future standards that might evolve. In fact, we are being asked to subsidize the research and development of the EMR system.

Secondly, the further assumption made is that the EMR will eliminate medical errors resulting from misread handwritten information. How this magic will happen is not entirely clear, since human beings will have to enter the data into the computer, and as long as humans are involved, human error will occur. Perhaps the types of error will be different, but they will nevertheless happen.

Also assumed is that once office records are computerized, family physicians will be able to do "collaborative research that produces new knowledge about the origins of disease and illness, how health is gained and lost, and how the provisions of care can be improved." It all sounds grand, but good research requires money and time, two things that busy family doctors do not have.

No doubt the EMR also figures in the plan for the "Lifelong Learning" that family doctors will have to adopt. The first facet of this process is already being implemented in the new American Board of Family Practice requirements. The details are not defined yet, but it seems that the new plan will require physicians to surrender more time to meet vacuous prerequisites, with no guarantee that the doctors will benefit from it.

Of course, all the recommendations from the task force are couched on a presumption that if we package Family Medicine as a "new" concept, money will pour into our offices and training programs. How this rationale was developed is not clear either. Presently, all third party payers are squeezing health care spending, and there is no evidence that private or public leaders are willing to make changes.

The New Model further expects family doctors to become the leaders of multidisciplinary teams, but does not clarify how these teams will be funded. The Model also fails to clarify how that leadership role will benefit the physician and where he will find the time to coordinate all these professionals. Under the current paradigm of health funding, the doctor will likely have to assume the leading responsibility at his own expense.

Active physicians presently are under attack from many fronts. Attacks that are making the practice of medicine increasingly difficult and that are driving prospective students away from the profession. It would seem that our professional organizations would concentrate their resources in correcting these disparities instead of wasting funds chasing daydreams.

Competing interests:   None declared

The Future of Family Medicine project labors under one of the traditional barriers to a transformed specialty, namely, the total focus on physicians, with only passing reference to the office team. We wrote a renewal plan for our family health center in Nederland, Colorado two months before the publication of the Future of Family Medicine Project. It is strikingly congruent with the FFMP report, except that it reflects a close collaboration between physicians and nurses. Even as family physicians are disrespected by the specialty-laden U.S. health care system, so do office nurses receive less pay and respect from the nursing establishment. The radical reformulation of the role of these committed partners in the delivery of compassionate, evidence-based care to the whole family is absolutely essential to the renewal of family medicine. Physicians must recognize their dependence upon the office team, and must liberate and cultivate the vast array of talent, which remains constrained by traditional office roles.

Competing interests:   None declared

As a family doc "in the trenches", I was disappointed after reading the final FFM report. While it is a very worthwhile academic exercise, it doesn't provide much that is helpful in actual practice. Our specialty is in trouble because we have allowed it to be. Our leadership has not been a voice or a force in the way it should be. Students are not excited about family practice because we are not excited about it.

"The Medical Home" is an excellent concept, but it is the idea we have been trying to get across to our patients, the medical community, and the lay community seemingly forever without anyone recognizing its importance. Instead of continuing to reiterate this excellent concept, we need to some how put real energy and action behind it as a specialty. People want and need family docs; most of them (and most of us!) just don't realize it. We don't need to explain ourselves or justify our existence. We need to act now and show what it is we do and why, and I believe we will have all the respect, reimbursement, and "future" we could ever possibly want.

To paraphrase something I once read: there is nothing wrong with castles in the air. That is where they belong. Now we just need to put foundations under them.

Competing interests:   None declared

Family Medicine has needed a dramatic overhaul for the past decade. I appluad your gargantuan efforts to address our plight. However, after spending 10 years on the frontlines with medical students and residents in the Predoctoral Division and on Faculty at U of TN, and now having joined the ranks of those in Private Practice, it seems to me that the changes suggested in the FFM Project are a nice facelift, but will do absolutely nothing to address the true problems - lack of respect for the specialty, turf wars, declining quality of residency candidates, competition from non -physician providers. I agree with a previous writer, "No, we have not been heard". We have recommended changes for the past decade. These recommendations have, for the most part, fallen on deaf ears.

How do we solve the problems? By changing perception and improving training. Increase the residency to 48 months. Limit clinic involvement during subspecialty rotations and take in house call like everyone else. Change the name to Family Medicine. Raise the bar for those admitted into our residency programs, and make sure they speak English. Make research relavant. Get involved. Be professional. Work hard.

We have the reputation of being bumbling country docs. We know that's not true, but we have to convince the medical community that that is not true. And, yes, it starts in academia - in the ivory tower. Excellence breeds excellence. Anything less will see our demise.

Overhauling our offices, getting EMR, etc... will do little to address the true problems.

Competing interests:   None declared

If we don’t produce a roadmap for our future, someone else will plan it for us. I still remember the day, after having been in practice some five years, when an insurance rep came to my office telling me how managed care would be making my life easier, how it would be “physician friendly”, and that it’s main aim was to direct patients to my office and make sure I received the maximum reimbursement. At the time I didn’t realize that my patients would never again be “my own”, but belong to an insurance plan. In response to these changes I watched a few physicians embrace capitation and managed care, some became employees of the hospital and some just retired early, but most of us have just plodded along hoping for some real answers to a career that is becoming more and more burdensome and less and less rewarding. Through all this I’ve had a progression of “health industry” generated titles; from PCP, to gate-keeper and now back to physician.

I hope “The Future of Family Medicine” generates some concrete answers and does not become another exercise in semantics that can not be implemented in the real world. After reading your report I felt compelled to write down a few observations I’ve made after almost twenty years in private practice.

1) Lets be honest and proud about who we are

I am a family practitioner, the direct descendant of the general practitioner who descended from the allopaths and osteopaths, who descended from the itinerant physicians, who descended from the apothecaries who consulted with the barber surgeons. Whether I am called a “specialist” is irrelevant to who I am or what I do. It may be important in the academic world or in hospital politics or to how insurance companies or funding agencies see us, but it sure doesn’t make a great deal of difference to the people I care for. Every time I’ve been called a general practitioner I’ve always felt obliged to go through a narrative on how we are a specialty that requires three years of training beyond medical school with board certification and continued education, providing and coordinating care from cradle to grave, etc, etc. The usual response is “oh I see”, but in their mind I can sense they’re thinking, “just as I thought, he is a general practitioner”. But that’s not such a bad thing. If we are honest, our true hang up is the fear people will think “family practitioners” are doctors who were not capable of being specialists, and that’s the fallacy we must address. We should take advantage of our unique role as generalists and draw our “best practices” from our own experiences and also follow the “best practices” of the specialists. I accept the fact that “specialists” who concentrate on a particular organ system or discipline may be a step ahead in their care. Each referral I make can be a learning experience for me to better care for my own patients.

2) What are the needs of practicing physicians? What are our immediate concerns?

#1 Economic survival - Many of us are in private practice and face all the hassles and hazards of any other small business with a shrinking margin of profit. I am a physician, yet I cannot find affordable health insurance for my family, no less for my staff. I’ve had to employ an additional person just to deal with referrals, workers comp claims and all the other un-funded responsibilities we’ve taken on. More and more of my income is going to pay increasing malpractice premiums despite the fact that I’ve never had an adverse claim. The very first issue the New Model needs to address is how to decrease the rampant overhead, or there will be an irreversible attrition of well-trained family physicians. Whatever recommendations are made for restructuring the office setting must be sensitive to the finances of the practicing physician, the plaudit that improved office efficiencies will increase revenue is of little comfort when we are being asked to provide and co-ordinate more services.

#2 Career long learning and improvement – For me one of the benefits of being in private practice was a feeling of controlling my own destiny. I thought that once I ran the gauntlet through medical school and residency I would be recognized as having the knowledge and discipline to conduct my practice in the best way suited to care for my patients and to be personality fulfilling. I had the freedom to explore facets of medical knowledge that held a special interest or where I felt deficient. Now that many aspects of care have been taken over by third parties I’ve found that I am scrutinized on multiple levels. I am required by the State to maintain a certain number of CME’s every three years; the hospital has continuing medical education requirements, chart reviews, and quality assurance as well as board re-certification. Each of the insurance companies reviews my office and charts, referrals and prescribing patterns, and gives me a quarterly report card. I spend so much time making sure all the “bullets” are addressed in my office notes for coding purposes that I lose sight that their true function is for communication between my colleges and myself. Now I must not only take the boards every seven years but I must advance through a series of yearly modules for which I have the privilege of paying. I truly understand the need to be competent, but there comes a point when all this scrutiny becomes demeaning.

If the vision of the future is to add another tier of “education and assessment”, it must replace or simplify some of the scrutiny we already receive. If modules are given they must reflect the nuts and bolts of primary care that can readily be assimilated into practice. If we are to go through modules, then eliminate the redundancy and drudgery of the board exam every seven years. If the board exams continue then at least make them more relevant to my daily practice and provide more guidance on key points to study – the field of medicine for the generalist has become too vast to just say; know it all, and here are some sample questions to review. Professional growth has to be an enjoyable and enriching experience and not one more onerous task.

3) We must make Family Medicine appealing to future physicians.

I entered family medicine envisioning a career I would want my children to aspire to and perhaps carry on when I retired. Because of the hassles I face I no longer feel that way. It’s no mystery why family practice residences don’t fill their positions. The prospect of a life with little personal time, increasing responsibilities and scrutiny, decreasing finances and constant fear of lawsuit has to make any graduating medical student think twice. If the New Model does not create a future that is economically and personally fulfilling we will find our numbers dwindling at the very time an aging population creates an unprecedented need for primary care physicians.

4) We cannot let our profession be exploited

It started when the first ad on television said, “ask your doctor about---“, and we all laughed and mumbled to ourselves, “no, please don’t ask your doctor”, but since then, that tactic has snowballed. In a clever and subtle way the pharmaceutical industry has enlisted us into their sales force. These television ads have become so commonplace that we don’t even think about them any more, but even more insidious is the flood of discount coupons, drug cards and discount programs we are asked to “pitch” to our patients. We are often placed in an untenable position. Every day a patient with limited means or without drug coverage asks for samples and in some cases the patient’s compliance depends on what periodic help we can give them. Yet the gimmicks, ads and promos that take up our time and imply endorsement of a drug should not have a place in a doctor’s office. There is no reason that these marketing promotions could not be done at the level of the pharmacies; but for the fact that the drug companies appreciate the power of our prescription pads. If we want real clout and make an impact on the drug industry we should follow prescribing patterns directed by a formulary generated by our Academy, based on drugs that fulfill two requirements; that they are therapeutically safe and effective, and just as important, that they are cost effective. There is no point in prescribing a medication if the cost negates compliance. We shouldn’t be so wedded to the drug industry that we can’t recommend to our patients that they seek a safe and cheaper source – even if that means they go to Canada. It seems absurd that anyone can go on line and obtain anything from Viagra to Xanax, yet my diabetic who is finally controlled on a certain oral agent has to consider insulin because it may be cheaper in the short run. We must become aware of the power of our prescription pad and use our clout without being exploited.

5) Above all create no bureaucracies

Ten years ago I wrote an article where I stated, “ I wish I could get bureaucracy classified as an illness because then I could just treat the insurance companies and not have to see my patients”. Above all please DO NOT add another level of bureaucracy to an already burdened system. The New Model must constantly seek ways to streamline and simplify our lives and not become another intrusion.

6) Family Physicians also have families and a finite amount of time for their own lives.

For some reason the assumptions been made that we live only to be family doctors. The New Model will fail if it expects us to be superhuman. If we are expected to run a business, maintain professional excellence, study and be tested on practice modules, orchestrate a multidisciplinary team approach, maintain an electronic medical record, provide a “personal medical home” and a patient centered relationship, answer patient’s emails and voice mails, deal with third party payers, see patients in the office, hospital and nursing homes, be on call, attend CME’s, attend hospital committees and meetings, practice defensive medicine, perform community services etc, etc. there will be no room for the things that keep us sane, our families and our personal time. I have reached a stage in my life where I cherish the time I have with my family and have discovered interests and talents outside the realm of medicine. I have always enjoyed patient care because it was a positive expression of myself that included some insights that came with time and experience. The relationship a doctor has with his patients can not be contrived or learned in a module or condensed into an electronic medical record. When the future of Family Medicine becomes a reality I hope it recognizes the needs and limits of the person who also happens to be a family physician.

William J. Schultz MD

Ohio Family Physician Year 2000

Sugarcreek, Ohio

April 19th, 2004

Competing interests:   None declared

Let's not forget there are two problems here: both medicine in general and family medicine in particular are under attack. We find ourselves in the awkward position of attempting to justify our very existence not only to the system as a whole but also to our colleagues and even to ourselves. This is dangerous ground and given the current climate we need to hunker down and wait it out, to make ourselves resilient enough to weather the present situation and to survive to fight another day. For example:

1. Cut the GME slots to meet demand (or even make it a competitive specialty!)

2. Increase residency training to four (or even more years) to obtain greater procedural expertise (see N. Schleidler, "Proceduralism would boost interest in the specialty", Letters to the Editor, FPM, May 2004).

3. Aggressively advance MEANINGFUL primary care research

4. Aggressively address reimbursement.

Are all or any of these necessary to the essence of family medicine? Some will argue that they're not, but remember, PERCEPTION IS REALITY, and if our colleagues and insurance companies see us as little more than costly alternatives to PAs and NPs, then it's UP TO US to change that perception.

Competing interests:   None declared

I commend the members of the Project Leadership Committee for undertaking this task of The Future of Family Medicine, though after examining the results, I believe this could be more accurately called “The Leadership Role of Family Medicine In The Future of Medicine in the United States.”

The results clearly reveal that Family Medicine with its current concepts and attributes have a place in the current and future of medical systems in the United States. Diagnostic technology is quickly advancing and will call for even a greater need for physicians who can take this wealth of diagnostic information and apply with specific knowledge of the patient to help the patient decide on the best course of medical care for them.

While disagreeing with some of the descriptions of “Traditional Model of Practice” current Family Medicine, i.e., not patients centered, etc., I do believe the attributes stated desired in Family Medicine are accurate. It seems clear that in order to achieve these goals for the future of medicine and the ideas of access to medical care, consistency in care, competency, patient safety, continuing education, enhanced practice finance, as well as research, all depend heavily on a universal electronic health record.

I believe it is most vital in order to realize stated goals for the future of medicine and the leadership therein of Family Medicine for the organizations of Family Medicine to put their greatest focus and resources into the development and availability of this universal electronic health record.

Thank you for undertaking this project.

Competing interests:   None declared

The following questions and summary of the online discussion will appear as part of the On TRACK feature of the May/Jun issue of Annals, which will be published later this month. I am posting it now in the hope that it will help to move forward the very thoughtful and passionate discussion that readers have been having. I am grateful to the online discussants who gave me feedback on my early attempt at a synthesis, and have modified this summary based on the many helpful comments.

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." The Table below depicts some of the early themes apparent in the ongoing discussion about the Project report, which was published as a supplement to the previous issue of Annals. We encourage readers to participate and invite diverse others to join in. Invite patients, people without access to becoming patients, other health care professionals, policymakers, and others to bring their voices and insights.

The early online TRACK discussion personalizes the sense 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, Indiana: "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.

Times are changing (e.g. as articulated by Hashim, 4/20/04)

Change and the current health care reality is causing great frustration

• Among family physicians, patients, others
• Loss of relationships, system fragmentation
• Financial crisis, malpractice crisis
• Pain from being part of a dysfunctional system
• Distress is an impetus for calls for retrenchment or further change
• Some feel isolated from the report and its proponent organizations, some are energized
• A sense that the reports, and therefore the organizations, in trying to see beyond the current frustration are not adequately acknowledging the current reality

The call is about something larger, a crusade about which family medicine is only a part

• Restructuring and greater equity in health care financing and reimbursement
• Health care for all
• A medical home for high quality, integrated medical care

Diverse strategies are emerging

• Local practice and system innovation
  • Appreciative medicine (Franklin, 4/20/04)
• A viable economic model can provide "breathing space" to pursue innovation, but with current financing, this can involve sacrificing access for all to primary care
  • Concierge practice
  • Safety net projects
• National advocacy and partnerships for health care, financial and tort reform

Frameworks for understanding and fostering change

• Return to old values and approaches
• Retain some core values and develop new approaches
• Take the offensive based on the unique and valuable generalist role (Starfield, 4/6/04)
• A complexity science perspective (Lamberts, 4/6/04)
  • Anticipate non-linear results & unintended consequences
  • Well-planned social interaction can result in a partial agreement
  • Initial conditions and evolving relationships are key

Challenges for individuals and organizations

• Adapting to (and thus enabling) a dysfunctional system while working to change the system
• Engaging and activating traditional and new partners
• Being true to core ideals AND open to new ideas
• Getting enough margin to make proactive changes
  • Costs (e.g. electronic health record) of transition to any new model
• To be effective in fostering the big changes their members need, organizations need to engage outside groups who are not sympathetic to the financial concerns of doctors, while not losing the support of their members
• Managing the short term, in which things may have to get worse before they get better

The early discussion leaves us with at least three overarching questions and many sub-questions 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? How can they be engaged?
     • The family medicine organizations and their members?
     • Others engaged in providing and paying for health care?
     • Policymakers who can envision primary care as essential?
     • The community of those who need health care.
   • 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 look like for these efforts?
     • Organizational
     • Individual
     • Grass roots
   • To what degree do things have to get worse, if they are to get better in the end?
   • Can an appreciative inquiry approach[1] 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 to 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 are three or four things 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, policymakers, health care professionals in other fields, payers and other potential partners and antagonists to enrich the debate and action.

References
1. Cooperrider DL, Sorensen PF, Yaeger TF, Whitney D. Appreciative Inquiry: an emerging direction for organization development. Champaign: Stipes; 2001.

Competing interests:   Annals Editor

Competing interests:   None declared

I read the future of Family Medicine supplement with enthusiasm and admiration.(1) Family medicine and society should benefit from the enormous amount of energy and effort used to create the report. One issue that was not addressed is how patient behavior is often contrary to patient expressed interest regarding a patient centered approach to decision-making. Patients verbalize an interest in shared decision-making, yet they often are unwilling to accept responsibility for their decisions. The current malpractice climate, where a perfect outcome is the expectation, reflects a patient belief system where physicians and the healthcare system are financially responsible for unpredictable poor outcomes.

Patient behaviors that document the difference between spoken desire and actual desire, include demanding direct access to sub-specialist care and high utilization for unproven technology. These behaviors appear to show patients want physicians to search for zebras. Society appears to want errors of commission. Errors of omission, like not recommending a PSA in a patient who is ultimately diagnosed with prostate cancer, are unacceptable.(2) The family medicine philosophy of treating the horses under the bell shaped curve and accepting, but not immediately searching for, the zebras that are two standard deviations from the mean, is at odds with patients who believe a head CT is needed to evaluate all headaches.(3)

The medical home, with the hope of improved trust and communication between physician and patient, may help patients understand the morbidity associated with false positive tests. However, unless patients accept the limitations of physicians and technology, the patient centered approach decreases physician autonomy and increases physician risk for patient retaliation when the standard of care is followed but the outcome is suboptimal. Despite its limitations, the patient centered approach is a worthwhile goal. For the patient centered approach to work, decision- making and responsibility for the decision need to be shared between the healthcare system, the physician, and the patient.

References:

1. http://www.annfammed.org/content/vol2/suppl_1/

2. http://www.afip.org/Departments/legalmed/openfile97/prostateca97.pdf 3. http://www.massgeneralimaging.org/newsletter/september_2003/september.pdf

Competing interests:   None declared

The article about "The Future of Family Medicine" was quite refreshing. I've long held that physicians should lead the charge in designing a health care delivery system that addresses the needs of patients from our point of view. Left without our vital lead, the government will undoubtedly impose what they feel is the best method to deliver medical care to the public. Hospitalists and Managed Care have redefined the specialty of family medicine which is why I'd like to see us actively involved in transforming our specialty of family medicine that serves our patients in ways described in this article. I don't see this happening if there isn't a tremendous amount of grassroots support from the Family Physicians currently serving the needs of patients. I would like to know more about getting behind this effort, and about how we might assist in researching and implementing this transformation.

Competing interests:   None declared

Any casually aware med student could have told the two high priced consulting firms, and the 5 committees, what is going wrong with our profession.

There will be no future of Family Medicine, at least as practiced by real medical doctors, without addressing three fundamental issues.

Reimbursement. FP’s are at the bottom of the pay scale for medical doctors. To avoid being paid less than the PA, they see 25 –30 patients a day in harried, cramped, understaffed offices, easily working more than 50 hours each week. This is in large part our own fault. We have not represented ourselves to payors, peers or patients as highly educated physicians providing a unique, and therefore valuable, service that only we can do. This is what the specialists have done. Out of intellectual laziness, fear of litigation, or just lack of time, we refer way too much. We have opted for quantity over quality care. As in Dr. Flemings’ example, we send diabetics to our “subspecialist colleagues” to do the real medicine, while we busy ourselves filling out referral forms and rushing off to the next ten minute office visit. We hire PA’s and NP’s, tell insurance companies, peers and patients that they provide the same service we do, and then wonder why reimbursement is low. Insurance companies pay for specialized expertise and procedures. We have been actively reinforcing the notion that we have nothing special to offer other than our compassion, and you don’t have to go to med school to provide that.

Respect. Let’s face it, we all have egos and this one counts. The Project states our “identity as a discipline…(is) grounded in the core values of continuing, comprehensive, compassionate, and personal care”. How about grounding our medical profession in expert, competent care? How about having patients and peers see us as a repository of expert knowledge in a wide range of health care subjects? The Project states that the family physician is an expert in “…a process: the patient-physician relationship and problem definition/prioritization”. I’m not even sure what that means but it doesn’t sound like a doctor who knows his medicine. In this profession, respect comes from being recognized as a professional and competent expert. Peers think of us as less than expert because that is how we represent ourselves, and that is how we practice. Again, we have equated ourselves with PA’s and NP’s so long that patients think we’re all one and the same. The outpatient office happily treats us all as equals, preferring the ambiguous term “family practitioner” to the term “family physician”. We all know practices where the NP or PA has their own patient panel, and supervision is at a minimum. No need to go through med school when you can get the same job in a fraction of the time! We have been instrumental in devaluing our own education and training. NP’s, PA’s, patients, hospital administrators, privileging boards, and our alleged subspecialist peers all hold a diminished view of our intellectual acumen, but most are too polite to say. (After all, they need our referrals!) The perceptive med student is not oblivious to this bias, and soon adopts the same attitude. The reason the patient survey said patients value us for our caring and compassion is that they don’t even think of us as experts. That is what they want from us because that’s what they think our job is! They assume we are not experts and that our job is to hold their hand and send them to a specialist. My job may in part be to “humanize” the experience as the Project says, but my primary job is to provide the best expert medical care that I can. I am not a professional hand holder!

Scope of Practice. Our shrinking scope of practice is evident. Hospitals are limiting our inpatient privileges, and the paraprofessionals have claimed the outpatient practice of family medicine. The Dean of a prominent nursing school teaches that NP’s provide equivalent care to patients in the outpatient setting, and PA’s have suggested changing their designation from physician assistant to physician associate. Some PA’s I know describe themselves as “the closest thing to being a doctor without going to med school”. Our leadership has done nothing to preserve our reputation as educated medical doctors distinct from paraprofessionals, and in fact has supported their advancement into our profession. Hospitals are routinely denying deck privileges, ICU privileges, and procedure privileges on the grounds we don’t have adequate training, unlike the “real” doctors on the medical staff. One local hospital is considering denying all admitting privileges to FP’s. The Project states “depending on local circumstances, they (that’s us) may not always assume full or primary responsibility for patient care in the inpatient setting”. Why is our leadership conceding ground on all fronts? Why would a med student opt for a shrinking and ill-defined profession?

So what will be the valuable, irreplaceable service we will provide in the future? A “medical home”? A place where the healthcare experience will be “humanized”? A warm and fuzzy office setting? Is this truly the best we have to offer?

It’s no wonder med students shun family medicine, looking instead for a tangible specialty that offers financial security, respect, and a scope of practice that reflects his training and interest in practicing real medicine. Our profession must recognize these issues and meet them head on, with clear action plans, and not hide behind a report filled with “consultantspeak”. We must actively protect and promote our professional niche and our livelihood, and insist that family physicians are unique, valuable, indispensable, and irreplaceable.

Competing interests:   None declared

First, let me thank everyone for their hard work on the future of Family Medicine Project. While the recommendations and predictions sound exciting - I feel the most critical element to ensure any future for Family Practice was left out. I predict that without significant and rapid improvment in reimbursment for primary care services our organization's very existence is in jeopardy. The average debt of medical students is climbing, the discrepancy between salaries of family physicians and specialist is increasing, overhead cost are rising and contractual insurance "write offs" essentially limit our ability to keep up. Many of my collegues cannot make ends meet, espically in todays rural communities that are also being hit hard by manufactoring closings. Our residency fill rates are down even though we utilize FMG candidates more and more.(42% of positons filled in 2003). Sometimes I feel that the policy makers must feel that primary care services can be equally provided by FNPs and PAs. When one looks at the number of Family Physicans who will be retiring in the next decade, their experience and their locations - and then looks at the supply of physicans to coose from to replace them the picture looks bleak. I feel reimbursement should be the primary focus of any program that makes any predictions or recommendations about our future. Thank you for allowing me to share my opinion. Clay Richardson, MD

Competing interests:   None declared

The philosophy of the recommendations from the first 5 Task Forces, I hope, would continually DETER medical students from entering Family Medicine, until an uniform recognition of the specialty of Family Medicine is appropriately bestowed upon, financially, politically, economically, socially, and philanthropically. In essence, this report has institutionallized what is supsicious, word-of-mouth from practitioners to medical students for the past 7 years! Yes, it is bad, bad, bad, and now the experts have said it! The question I think, is not whether we will have a job as a Family Practioner, for we do too many things for too many people, and too may other specialties, hospitals, pharmaceutical companies, administrators are dependant on us at the front line. The issue at hand, is whether ELEVEN YEARS of supervised schooling and training is worth the time, the loan incurred, to go out there and practice what reality does not afford us to do to our fullest potential and be rewared just the same as our peers.

Competing interests:   None declared

The project report was well written and well organized and had many nice words, verbosity, redundancy and cutely coined phrases such as "personal medical home". (Yes, by all means, put the patient in a home!) But it certainly doesn't indicate the Gateway to Modern Scientific Medical Care that the family physician has always offered since the inception of the our specialty over 40 years ago; developed from the comprehensive role formerly played by the General Practitioner and so aptly portrayed by Marcus Welby of TV fame. Most who entered our primary care specialty for humanitarian reasons have been more than gratified with their success. Now there is a real demand because family doctors are in such short supply. Medical students should have the opportunity to meet these medical heroes if they have not previously been acquainted with a role model. Expediting this should be the main task of the Dept. of FP at the medical school level. Compassionate and caring students should be identified and encouraged to enter our rewarding field. Those students motivated by money or supposed prestige should be channeled into other easier, more lucrative specialties without our agonizing over their choice...the trial lawyers who "follow the money trail" will make sure they get their unfortunate reward.

Teachers of FP should be recruited from those who have actually practiced it; not the ersatz variety that are all too prevalent. The one ideal should be to maximize the availability of the family doctor to his patients. Dr's helpers such as Doctor's Assistants, Nurse practitioners, Chiropracters and other "Alternatives" may increase the revenue but dilute the quality of care.

I applaud the Academy for initiating the demand for lifetime learning over 40 years ago. I applaud the inovations resulting from vital research in the field. I applaud the Academie's efforts to make funding sources realize that the general field of medicine is much more difficult to practice than any specialty and should be appropriately compensated. I still applaud the "Old Model" of General Practice present during the bulk of the twentieth century when Doctors were number one in the hearts and minds of the people of the United States. Sure, the movement is facing an uphill battle, But WE ARE IN THE RIGHT!

by Dr. Robert S. Heck; former COB of the Illinois Academy; founder and former Director of the Christ Family Practice Residency.

Competing interests:   None declared

I was very disappointed to read the report on the Future of Family Medicine. First, of course, it defined me, as a solo practitioner as passé. It then went on to say that the essence of Family Medicine was continuous, relational medicine, with a family orientation, but, without any evidence, says that this will best be delivered by large, corporate style practices, (sounding suspiciously like present academic Family Practice Units), with EMR's, web sites, and lots of electronically imposed "evidence-based" guidelines. These will miraculously be paid for with "savings" from corporatization.

15 years ago, all the local hospitals and insurers were buying up practices to do everything touted in the report. Amazingly (though some of us predicted exactly that), the corporate and administrative imperatives produced higher costs, less continuity and relational medicine, and eventually they all disbanded or sold off the practices to the individual MDs. Where is the evidence that such practices lead to the stated goals? How will lots of Web interface promote continuity, rather than discontinuity, since it is not a person talking with another? And if it is done real time, why not on the phone, and or will it be another cheap, poorly trained staff member one has to hire?

As one who is struggling financially, where will the money come from to implement EMR? If it can be found, the records I see are both devoid of content, individualizing the patients care (and I've been told of VA residents cutting and pasting others charts to save time); they are unable to be scanned quickly, they have problem lists that include everything from URI to cancer; one cannot make a drawing, or a comment in another language about the spouse's STD, suspected abuse, etc. What will happen not only to the old chart information, but to the present format when there is new technology or software, incompatible with the old?

Finally, with regard to "evidence-based Medicine," as one who for 20 years refused to give HRT, because it was biologically implausible, and who is now living through my third wave of "diuretics are best," and again hypokalemia, gout, gastritis, and who, with a large African-American population, never bought into ACE-inhibitors as great, I wonder where is the room for skepticism, for local, practice-based, epidemiologic knowledge? What about for experiment? Even more for outcome measures, rather than process measures, over long periods? Worse yet, how will electronic guidelines (changed how often, by whose authority, based on how much evidence, and at what cost), always based on one problem and variable, be applicable to this individual patient with multiple problems, some ill-defined?

I wonder if we are not defining ourselves out of existence, and missing the most salient points. Do patients, in fact, want a much more individualized medicine that, with our telephone triage systems, and cheapest, least paid staff answering, when they do manage to reach a body, we are already overly "modernized" to preclude? Are residents not going into Family Medicine simply because it takes too much time to do relational and continuous medicine, and because that is not what they are seeing in the Academic corporate units? And, worst, do they have too much debt and see too little reimbursement and too much malpractice cost and risk, to make Family Medicine appealing?

Competing interests:   None declared

Here is an early synthesis of the TRACK discussion so far. The editors welcome your further reactions.

From the TRACK discussion so far, we have gained a greater appreciation on how:

Times are changing (e.g. as articulated by Hashim, 4/20/04)

Change and the current health care reality is causing great suffering

• Among family physicians, patients, and others less represented in the discussion
• Financial crisis, malpractice crisis, system fragmentation, and loss of relationships
• Suffering is an impetus for calls for retrenchment or further change

Not everyone is suffering greatly

• The old model still works for some
• Some are finding new ways to flourish and contribute

Challenges for individuals and organizations

• Being true to core ideals AND open to new ideas
• Managing the short term, in which things may have to get worse before they get better, and so many practices have no margin now
• Costs (e.g. electronic health record) of transition to any new model
• Engaging new partners

The call is about something larger, a crusade about which family medicine is only a part

• Health care for all
• A medical home

Frameworks for understanding and fostering change

• Retrench
• Embrace the current Zeitgeist
• Go it alone or/and collaborate
• Take the offensive (Starfield, 4/6/04)
• A complexity science perspective (Lamberts, 4/6/04)
  • Anticipate non-linear results & unintended consequences
  • Well-planned social interaction can result in a partial agreement
  • Initial conditions and evolving relationships are key

Diverse strategies are emerging

• Consistent with the report’s call for a “period of active experimentation”
• A viable economic model can provide “breathing space” to pursue innovation
  • Concierge practice
  • Safety net projects
• Appreciative medicine (Franklin, 4/20/04)
• Complementary nature of local innovation, national advocacy, and partnership
• Real health care and financial reform
  • Do things need to get worse and collapse before a viable macro solution can emerge?
  • What would it take to make equity a higher value than autonomy?
  • Political courage is needed to do the right thing instead of just the politically expedient thing
• “In summary, we are privileged to be medical doctors, gifted with careers that reward us with a humbling life experience. It is up to us to take that first step.” (Franklin, 4/20/04)

Competing interests:   Editor, Annals of Family Medicine

I have read the article and so has my wife (who after 29 years of marriage, putting me through med school, and being the book keeper for my office for 21 years, is very well qualified to have on opinion). We both agree that the article is just so much "smoke and mirrors." It never addresses the core problems with our specialty. First, we have markedly declining and inappropriately low reimbursement for work done. Mine has plummeted in the past 10 years. This warrants barely a paragraph in the article and is absolutely central to any discussion of preserving the specialty. Without a marked increase in pay, the specialty will never attract bright and ambitious students to the field. Next, is the severe disconnect between patient's feeling of unlimited entitlement and unending high expectations in our era of limited resources and funding, while at the same time having an explosion of technology and information. This is true not only in the health system at large, but also in my office. Who or what is going to pay for the new high tech office and information services mentioned in the article. Those resources should first be devoted to increasing pay. I found the article, with its naive avoidance of the core issue of reimbursement, to be largely an exercise in academic self- stimulation. Thirdly, is the issue of life-style for the physician. Tell the average med student that they can go through 11 years of post high school education and training to work a 100 hour week for an average of $25.00 per hour and they will likely decline the privilege-indeed they already are. Have it become known that you can work a 55 hour week for $165,000 a year taking care of families and their health concerns and be able to have your own family, and you will have folks flock to the field. In conclusion, the report was "pie in the sky" not at all getting "down and dirty” to the real dollars and sense (not cents) issues at the core of the specialty's problems and why it is in decline. I don't think 29 pages of filler are needed to outline the problem and the solution. Higher pay and quality of life issues says it all and your report does nothing to address these. We are most certainly doomed. Kindest regards from the trenches, Allen W. Ditto, M.D

Competing interests:   None declared

After reading "The Future of Family Medicine", and discussing it with colleagues who, like me are veteran FPs who are not set in their ways, close-minded or prone to automatically embrace the latest trends, several thoughts come to mind.

1)It seems to many of us that the AAFP is gradually losing touch with many of its members. So many "real-world" issues seem to be ignored, while reports like this that seem to be loaded with catch-phrases and all the academic lingo (are you really serious about the term "personal medical home"?) eat up time and resources. I agree with the posted comment that the AAFP may eventually fragment.

2)There are many things that must be resolved before any of your ideas can go forward. First must be the liability crisis. Many of us practice in states where we honestly don't know if we will be in practice in the future. Some naively feel this will never happen, but as President of our county medical society, I have watched two FPS be within hours of closing their practices, and am soon to watch a doctor of another specialty move out of state due to being unable to get insurance. This is happening now, and is real, and will not be solved by discussing ideas like "Continuous Personal, Professinal and Practice Development in Family Medicine."

3)Many seem to think that by all of us implementing Electronic Medical Records in our offices, many of our problems will be solved. This seems to be not only an assumption that this will magicallly make our patients healthier, but is totally unrealistic. Having been through various computer systems since 1986, I was quoted a price of $60,000 by my vendor last month to fully implement EMR. A two FP practice (that does not employ lottery winners) does not have that kind of capital. I doubt many do. Please do not lecture me about shopping for vendors. My staff is well trained on our current system, and the upheaval of changing vendors would cost thousands of dollars also.

4)Why are so many in academia enamored of using Email to communicate with our patients? Most of us have found that the best way, the most accurate way, and the way certainly with the least liability to communicate with our patients is face to face. Why would we consider moving away from that?

5)As a specialty, we have tremendous disagreement about what a Family Physician really is. We seem to be moving toward a basic division of whether we attend patients in hospitals or are only office physicians. That debate has raged and will continue, but it is basic to the future of this specialty. We are being forced from even considering including obstetrics in our practices, but this specialty runs the gamut from FPs who do C-sections to docs who never leave their office. Can we expect our colleagues and our patients to ever take us seriously as "specialists" if we can't even to begin to define what it is we do?

6)No amount of planning, discussion or attempts at implementation will ever outweigh the forces of economics on this specialty and every specialty. We can try to make changes in our national health policy, and many of your goals are noble. Realizing them, however, will depend much more on economics than noble intentions, or even careful thought and planning.

I cannot predict how the pratice of Family Medicine will change in the future. I feel like I have "re-invented" my pratice at least once in the 21 years since I finished residency, more by necessity than anything else. My guess is changes in the future will be driven again by necessity more than grand plans.

Competing interests:   None declared

I read with great interest the report "The Future of Family Medicine" and agree in principle with the ambitious recommendations. However, until the woefully inadequate reimbursement that family practitioners receive is addressed, Family Medicine will not survive as a viable specialty. The one small paragraph in the report that addressed reimbursement emphasized increased efficiency as a means to improve practice margins. I believe most of us practicing family physicians will find this statement to be rather naive. Out of necessity, we have already adapted and significantly improved efficiency on our own in order to survive. While new technology and "New Model" practices may offer some additional efficiency, it is unrealistic to think that will be enough to save Family Medicine. I hope the Task Force 6 report will more adequately address these issues as I believe the biggest threat to Family Medicine as a specialty is the inequitable reimbursement we receive compared to other professions and other specialties.

Competing interests:   None declared

Moving from chaos to sense
Is difficult, daunting, and dense.
In research and in practice,
The dominant fact is
We dance to the dollars and cents.

Competing interests:   I serve as Senior Associate Editor of the Annals of Family Medicine.

There needs to be more development of the "access to health care for all Americans" advocacy on the part of participating organizations in the Future of Family Medicine.

People cannot have a personal medical home until they have a method of accessing the health care system. The tens of millions of uninsured and underinsured Americans, many children, have little or no practical means of establishing a personal medical home until they can access some form of health care insurance.

This issue is not just one of equity and social justice for those without, it is also in the self-interest of those who have health care insurance of whatever form from a public health perspective of disease tranmission, and from a cost perspective to taxpayers, employers, health care industry.

The Future of Family Medicine recognizes the need for health care access for all (albeit in just one paragraph (p.S-25)). It acknowledges the need for family medicine to exert a leadership role in advocating for health care coverage for all (in one sentence (same paragraph, p. S-25))-- but then gives no concrete recommendations on efforts Family Medicine leadership can and should take to do this.

This is a huge weakness of the report.

The "New Model", which purports to be designed to serve "all indivuduals--regardless of...socioeconomic status" (p. S-28), must be more concrete and detailed in this advocacy role for family medicine leadership in creating a new model that really does provide a personal medical home "for all".

Thank you for your consideration,

Andrew Deckert, MD, MPH member of AAFP

Competing interests:   None declared

Table 3 command of complexity "... health and well-being - not just pills and procedures." This phrasing denigrates the use of pills and procedures further distancing family physicians from science and technology. We need to do pills and procedures and do them well ... and do so much more. This may seem like nit-picking but can we complain that we are not respected in academia or seen to be technologically savvy when all of our key attributes are about the art and none are about the science of medicine. On the other hand the italicized statement in the area of the text referring to Table 3, "Family physicians are committed to fostering health and integrating health care for the whole person by humanizing medicine and providing science-based high-quality care", seems to capture what we should be about.

Competing interests:   None declared

After reading the report and several of the letters regarding the report, I am overwhelmed by the number and diverse thoughts and feelings engendered. Let me enumerate a few: (1)Even though there is mention of the dysfunction of health care financing, this seems to me to be the major problem in medicine generally and family medicine specifically. Patients either can't afford to see anybody and then, without a primary care doctor relationship, default to expensive ERs or Urgent Care settings or, if they have health insurance, are subject to the whims and vagaries of changing plans and their changing panels of physicians. And insofar as payors and reimbursement systems retain the procedural bias, young doctors interested in better remuneration logically choose more lucrative specialties. (2) I am sure that the motivating factors in choosing family practice vary as broadly as the breadth of our specialty, but for me I chose Family Practice because I thought it would give me the flexibility to practice in either urban or rural settings and in practices varying from full-service, continuous family practice to more narrowly-focused practices. I have, in fact, worked in urgent care, pediatrics, hospice, hospital and health plan medical management(in addition to traditional family practice) and now occupational medicine.

(3)Although the HMO-driven "gatekeeper" system seems to have fallen by the wayside, in a sense, that was a mechanism through which our specialty could have achieved recognizable stature and helped boost incomes and attract new graduates. If health care financing schemes are revised--they have to be--hopefully we can revisit the value in our serving as the captains (or pilots) of the individual patient's health care ship. (4) The tenuous and awkward relationship of family practice in the academic medical center as mentioned in the report begs a discussion and, I hope, some eventual changes.

Finally, although I was initially predisposed to lambaste the effort and the recommendations, by and large, it is a comprehensive, readable and well-reasoned report. I hope it helps the effort to improve American health care.

Competing interests:   None declared

Here are a few concerns:

Does this "New Model" create new openings and theories for medicolegal liability? If the patient's personal health record is headquartered in the family physicain's office, are we now responsible for knowing every piece of information that flows through? For example, say a radiologist sent a report to a surgeon and the surgeon missed an important finding. If all this communication is going through our offices, it seems we could be drug into any lawsuit that results. Who is going to pay for the time it will take to review all this information?

Next, I have yet to see a shred of evidence that primary care office- based electronic medical records improve quality or safety. It sounds possible, but the leaders of the FFM project are making a big leap of faith (while at the same time touting evidence-based medicine). Two recent studies encourage caution: A study based in San Diego found that a hospital computerized order entry system was eventually scrapped, because it was so difficult to use. Another study found that 90% of drug interaction warnings generated by an EHR were ignored by the physicians. EHRs are no panacea.

I think the idea of physicians using EHRs to run QI reports for their practices is excellent. It would be great if we could periodically run reports on how many of our diabetics got their eyes checked or how many of our CHF patients are on ACEs. The current problem with doing this is not just the lack of good and affordable EHR systems, it is the opportunity cost of spending the time to do these analyses. The time it takes to do this self-analysis is time that is not spent generating more income for the practice. Someone has to come up with a mechanism to pay for this time to at least make up the opportunity cost, and ideally to actually incentivize the exercise so that family physicians would actually look forward to analyzing their own practices.

Next, there is nothing in this report about the cost of health care, the demand for health care, or setting limits. The demand for health care is infinite and greater access will lead to greater demand. I think payment systems should be created that discourage patients from visiting their family physicians for runny noses. I think the $5 co-pay was the worst thing that ever happened to family medicine, because it sent the message that $5 is what our time is worth.

The cost and unaffordability of health care is glowing brighter on the political radar screen. Clearly, if family physicians are demanding higher incomes, someone will have to pay for it. This pricetag could be even higher if the payers are expected to not only increase our incomes, but also pay for the increased infrastructure of EHRs and patient resource centers. If extra resources come our way, then someone else will have to give up something or the overall cost of health care will have to increase that much faster. I don't see either scenario being very popular.

There is nothing in the FFM report about making difficult policy decisions. Most other developed countries have implicitly or explicitly made decisions about setting health care limits (yes, rationing care). Overall, these decisions seem to very slowly becoming more explicit. I can only look to the Oregon Medicaid experiment to find anywhere in the U.S. where setting health care limits to keep budgets managable has been openly debated. Family medicine should be leading this discussion, not cowering in the corner.

Next, I am all for the notion of increased research in family medicine. Two thoughts about that:

First, the report is absolutely correct that the funding for AHRQ should be geometrically increased. One anecdote: an outstanding family medicine researcher I know has created a research niche for himself by studying adult survivors of childhood cancers. This is top level research funded by the National Cancer Institute of the NIH. He will probably be able to sustain the rest of his career on grants he will write on this subject. Earlier in his career, he tinkered with studying bronchitis. Not to denegrate his current work, but if you polled family physicians about which topic would be more useful to them, I suspect new knowledge about bronchitis would win hands down. This researcher did what he had to do to sustain a successful research career the way the game is currently played. He went where the money was, which was in a specialty branch of the NIH. Best I can tell, there was not nearly the same amount of funding available to study a common condition such as bronchitis. This inequity needs to be fixed, and more funding for AHRQ seems the best way to acheive that.

Second, it is time for family medicine to change its attitude about research. This attitudinal change should start at the top with the AFMO organizations. It always has been, and is even more so now, completely stupid that practicing family physicians are separated from family medicine researchers. Every other medical society I am aware of includes its discipline's research with its annual meetings, yet the AAFP and NAPCRG meetings are always held separately. This year will be a refreshing change, but the coalescing of these 2 groups needs to be even more complete. Excellent research is being carried out by today's family medicine researchers and the practicing family physicians need to see it; and the researchers need to hear the comments and concerns of the physicians in the trenches. The only way this is going to happen is if they meet at the same time at the same place.

Lastly, there is nothing in this report about taking care of sick patients. I think the FFM report reflects too much the coastal version of family medicine. Who is going to go to the hospital on a Sunday night to help a patient with COPD and CHF breathe easier? Who is going to sort through the complexities of a patient with 5 chronic diseases who is taking 10 different medications? Who is going to take ultimate responsibilty when sick, complicated, inconvenient patients need our help? I find that too many family physicians are quick to shuttle those responsibilites to other physicians.

I went to medical school to learn how to help sick people get better. I am completely comfortable with other health care providers helping me with this task, but I am disappointed that the "New Model" state that the "Multidisciplinary team is the source of care". The family physician should be the source of care, no matter how sick the patient is.

I hope these comments are helpful.

Competing interests:   None declared

It was great to see the Future of Family Medicine report in print. The message that it sends is thought provoking. My thanks and graditude for all the time and considerations placed on the topic by the Task Force members and the Academy.

If the Personal Medical Home is to become a reality I believe that a certification process must be created. Without such a label the message and intent of the project may be lost. Until an appropriate committee or other group formalizes the requirements which must be met to qualify as a Personal Medical Home an intermediate step is needed. I feel that an award similar to the Good Housekeeping Seal of Approval could be created for those practices which epitomize the true spirit of the Personal Medical Home. A questionaire or similar device could be written to capture data from a practice's 'basket of services' and then ,as appropriate, a site visit be made. The state academy or the AAFP could present the seal for display prominently in the office.

I hope this idea helps stimulate discussion towards the implementation of the Personal Medical Home.

Gregory H. Blake

Competing interests:   None declared

Traditional attributes of general practice such as continuity and comprehensive care have decreasing relevance to primary care today. Patients change providers frequently and specialties overlap increasingly in areas of service. Primary care itself is becoming a competitive field with different specialists, independent mid-level providers, and alternative medicine specialists providing first contact care with increasing prescribing authority.

Providers who do not adapt to the new realities of the field are likely to find the practice of medicine increasingly frustrating with fewer personal and financial rewards.

Qualities that are becoming more desirable include:

1. Cost-conscious care

Providers who provide effective care at a lower cost have a competitive edge that is attractive to patients, third party payers and employers with managed care contracts. As patients share an increasing burden of costs directly, even with medical insurance, they appreciate physicians who are versed with healthcare costs, lower cost alternatives, and low-risk watchful waiting for medical problems. Regardless of the form cost- containment takes, managed care or private pay, physicians will be asked to discuss costs in medical decision-making.

2. Guideline-based disease management

Research has shown that providers are poor at providing optimum evidence-based care. Too often effective therapies are prescribed infrequently while treatments which have no proven value continue to be used as part of traditional practice. Use of clinical guidelines requires self-discipline and a structured approach that contrasts with an informal style that relies on the vagaries of mental recall. Reminders to physicians such as checklists and flowsheets (in paper-based or electronic records) need to be implemented. Physicians who resent these ‘encroachments on physician autonomy’ will be not appreciated. Third party payers will seek providers who demonstrate higher adherence to guidelines based on billing data.

3. Efficiency in workflow

Physicians must learn efficient workflow – a skill rarely taught in clinical medicine. Office design, handling of patient requests, and paperwork flow must be streamlined to allow fast processing with least effort. Efficient division of labor in personnel according to skill should extend from clerical to clinical areas. Medical assistants, nurses and physician assistants should be utilized appropriately. Support of this teamwork should be the hallmark of family physicians as team leaders. They should be adaptable and be ready to explore new timesaving techniques.

4. Administrative finance acumen

Physicians should be familiar with billing criteria and strive to maximize the billable value to their patient care time. In other words, clinical work should be as detailed as possible. Subsequent discounts should be allowed for indigent patients. Physicians should be aware of budgets within their clinics even if they are in a salaried position and look for ways to optimize the use of resources. In this way, physicians can contribute to their net value as team members.

5. Patient-centered care

Family physicians have been patient-friendly with emphasis on psychosocial aspects of health - they have to build on this tradition. Family physicians should lead in patient education initiatives such as shared decision-making with communication of risks and probabilities. Improved access using the open-access same-day scheduling model is another example. Availability via electronic mail and personalized care plans using interactive websites should be explored. Family physicians should continue to learn treatments for emerging patient concerns such as herbal supplements and minor cosmetic procedures. The term family physician should conjure an image of a friendly, accessible physician who listens and cares for his patients.

6. Clinical research

Family physicians have to participate in clinical research to improve credibility and generate clinical authority in their field. Most clinical research data comes from tertiary care centers, which may not be applicable to primary care. ‘Research’ work that involves writing reviews, guidelines, case reports or uncontrolled case series does not carry much weight. Family physicians should familiarize themselves with the basics of study design, data collection, and statistical analysis. At a minimum they should join a practice-based research network and participate in clinical data collection.

7. Balanced work and family life

Physicians must learn to balance work and family life and should set limits to their number of patients per day, work hours per week, after- hours access by pager, and hospital call. They should observe good lifestyle habits being role models for patients. Well-rested, healthy physicians add to the healing process for their patients. Physicians should be wary of signs of ‘burnout’ such as mood irritability and learn to cut back on clinical duties.

Both the clinical and the non-clinical components of family medicine residency teaching should reflect these new demands. Physicians should yield to certain limitations in their practice such reduced time per patient visit and delegate counseling to staff such as dieticians and nurses. Patients are increasingly relying on physicians to help them make informed decisions about complex medical decisions in face of uncertainty – for more mundane tasks such as lifestyle counseling they are relying on other sources of expert information. Patients and healthcare employers will seek physicians who take up these attributes for high quality, low cost healthcare.

Competing interests:   None declared

The editor asked me to respond to some of the concerns being raised as "doability" of the recommendations.My responses:

1.The Academy's leadership in EHR is resulting in political advocacy to "push" for national standards.

2.The Academy's Partners for Patients has encouraged many EHR vendors to adopt Academy principles and work with FP's

3.The Task Force #6 initial dialogue strongly supports some type of payment mechanism(s) to financially support the new model

4.A confluence of external events(less expensive technology,payor interest,rising cost of healthcare(and premiums and cost shift to patients)and increased underinsured(and no realistic plans for transformation before the FFM recs)and the quality concerns and the need for NIH to do translational research all will move the transition forward.

We must acknowledge the leadership role(and all that it entails)to move this agenda,as demonstrated(and requested) by the research from our communities,our subspecialty colleagues,and the organizations providing reaction to the report .

Competing interests:   None declared

Doctor Blanchard's comments on retainer medicine touch on a most important issue that will determine the success of the Future of Family Medicine (FFM) project: Can viable financial models be developed that will make for thriving practices to serve as effective medical homes? All five Task Forces and the Project Leadership Committee of the FFM project recognized the criticality of this issue. Task Force Six (TF6), which is part way through its work, was created to address that very issue. As a member of TF6, I can assure you that we are examining any and all forms of practice reimbursement, including retainers, capitation, salary, fee-for-service, quality bonuses, and so on.

Family physicians are distributed more evenly across America than any other specialist - there are about 30 family physicians per 100,000 population, no matter whether the community is smaller than 2500, greater than 3 million, or somewhere in between (1). There are about 200 million patient visits annually to family doctors, more than any other type of physician (2). Clearly, Americans depend on family physicians like no other specialty. Yet, not every American has a medical home.

Assuring that every American has a medical home is good not only for family physicians; it is good for the health and wealth of Americans. A growing body of evidence shows that when health care is organized around family doctors, it results in care that has higher quality, lower mortality, and lower cost (3-5). Our increasingly fragmented, limited specialist-centric health care system means that as complexity and costs go up, more people suffer worse health outcomes and are shut out of the system.

Until we are willing to step over the bodies of the stricken denied entrance to emergency departments – and I hope that day never comes – we will continue to pay more for fewer to receive less effective care, unless we redesign our system so that every American has a medical home. Having a medical home increases the chance that every American can realize the promise made by Poor Richard, as modified by this poor Richard: an ounce of prevention is worth a pound of cure, and saves a ton of money.

So our challenge becomes this: how do we redesign and finance a health care system so that everyone has a medical home? Some of the solutions must occur at the macro level (e.g., coverage for a medical home for all Americans); some at the micro level (e.g., reimbursement models that sustain thriving medical homes).

One concern many family physicians express about the use of a retainer as a primary method of practice payment is that we see ourselves as a resource to everyone in our community. What do we do when few in our community are able to pay the requisite retainer while trying to remain true to our commitment that everyone should have access to primary and preventive care?

As an attorney, I know that the use of retainers by lawyers became a less common practice because they kept legal services unaffordable for many. As a family physician, I am eager to explore every financial model that enhances the vitality of my practice as an effective medical home, but only so long as it promotes the health of all Americans, not only the wealthy among us. Over time, given our systematic cost shifting, providing elite service to a diminishing few will mean that we will all be worse off. Health care must be about equity as well as quality.

Richard G. Roberts, MD, JD

(1) United States Council on Graduate Medical Education. Physician Workforce Update, August 2000. Accessed at http://www.cogme.gov/00_8726.pdf.

(2) United State Department of Health and Human Services. National Center for Health Statistics. Division of Health Care Statistics. 2001 National Ambulatory Medical Care Survey. Accessed at http://www.cdc.gov/nchs/data/ad/ad337.pdf.

(3) Baicker K, Chandra A. Medicare spending, the physician workforce, and beneficiaries’ quality of care. Health Affairs 7 April 2004;W4:184-197.

(4) Shi L. Primary care, specialty care, and life chances. International Journal of Health Services 1994;24:431-458.

(5) Franks P, Fiscella K. Primary care physicians and specialists as personal physicians: health care expenditures and mortality experience. Journal of Family Practice 1998;47:106-109.

Competing interests:   Member of FFM Project Leadership Committee and Task Force 5 & 6.

I read with great interest the article "The Future of Family Medicine". I think it is a great idea, but the reality is that it just can't happen without great changes in the American health care system.

To be able to finance an office described in the article will require a huge influx of money from third party payers. This is just not going to happen. Medicare reimbursement has been flat for the last several years and the future doesn't look that great for improved reimbursement. The recent Medicare law was very irresponsible and will further stress Medicare which is over 50% of most family physicians' income.

Payment from the Blues and other third parties is often less than Medicare and since the health insurance companies have merged, reimbursement has dropped.

Medicare is going to be further stressed with the onslaught of the baby boomers. The reality is that there will be less money to go around for family doctors as hospital costs, drug costs, and everything else rises.

I am a self employed solo board certified family physician who is 55 years old and have practiced in the same location for 28 years. I have used an EMR record system since 1998 (Soapware is simple and works)and cannot concieve of spending the money which is being tossed about in the article.

For the concepts described in the article to succeed, the entire method of reimbursement to physicians has to change and I just don't see Medicare, Anthem, Sagamore, or anyone else doing that in the near future. I hope that I am wrong, but the plan just seems too complicated to be successful.

Competing interests:   None declared

A Patient-Oriented Approach Based on “Appreciative Medicine”

Terry L. Franklin, M.D.

I. The State of Medicine Today

Every day we hear about breakthrough technologies that support conventional medicine, such as MRI, PET and CT scans that detail the inner workings of the human body or sensational new wonder drugs. This is in keeping with a health care system primarily based on allopathy, typically defined as a “substitutive therapy…in which a disease is treated by producing a second condition that is incompatible with or antagonistic to the first.”*1.

Although most health care today is focused around the allopathic management of chronic disease, acute care centers exist to handle cases of major illness, such as chest pain, cerebral-vascular accidents or traumatic motor vehicle collisions. Many times, the emergency department is still the optimal setting to stabilize and save life.

At the same time, patients often feel less than satisfied with the scope of conventional medicine. For routine care, more people are gravitating toward the holistic, natural treatments promised by practitioners of “alternative medicine.” Patient response in this direction has fueled what is now a 40 billion dollar industry.*2 We commonly encounter the terms wellness – health –optimal well-being – peak performance. Are these concepts more than a convenient marketing tool? Some alternative methods are clearly gimmicks, but research shows that others truly complement allopathic care.

Regardless of the healing modality one may choose, two questions still remain: 1) As a physician, how can I better advise my patients to create an improved state of functioning? 2) As a person (remember that doctors are patients, too), how do I achieve optimal health? Patients and physicians alike want to enjoy more life in their day. We all see the limitations of the disease model and want our patients to experience improved well-being.

II. Is “Alternative Medicine” Really an Alternative?

No doubt, alternative medicine in combination with conventional allopathic care has brought comfort, healing and good health to literally millions around the globe. Nevertheless, alternative integrative health systems are not always a true alternative. Many health care approaches may utilize holistic treatment options, but they often encompass the same philosophical approach to patient care--the problem-oriented approach.*3

Many in our profession have tried to redefine their role as a physician by modifying their scope of practice or even changing the traditional doctor-patient relationship.*4 At the same time, there is an exodus from mainstream medicine to a diverse mix of venues, propelled by the frustration and obstacles present in today’s system. For medicine to be a true alternative, physicians need to consider a new paradigm in patient care. That is, we can redefine health challenges as wellness solutions and provide partnership models in the patient-doctor relationship. These activities will parallel the worldwide paradigm shift currently taking place in other scientific as well as professional spheres as we become more aware of the interaction of our physiology, human emotions and the essence of being.*5

I believe we can achieve the inner vision of wellness for which we all quest. Even though an optimal quality of life often appears to be just out of reach, amazing “secrets” of health are revealing themselves to us at this progressive moment in history. To hasten the process, I suggest each person create a personalized “road map” of wellness, a unique vision of health offering the highest quality of life on all levels. I next explore the advantages to medicine of such an approach.

III. Patient-Centered Health Care: An Integrated Approach

We physicians have all questioned our methods when experiencing, after examining a patient, that something was left missing or not accomplished during a particular encounter. Could there be a more constructive way to interact with patients? I took a course in acupuncture, thinking it might provide some value for patients. But even after integrating medical acupuncture into my traditional allopathic practice, I felt the need for something more. I identified what was missing as the need for creative dialogue with patients. So I attended numerous workshops and seminars, but none offered a satisfactory alternative approach to patient care that included the communication patterns I believed necessary.

Now, after a three-year search for the essentials of holistic dialogue, I have developed an integrated patient-centered approach, which I call “appreciative medicine.”*6 It includes a four-part, interactive guide to assist health seekers through the maze of care options.*7 Using the question and answer format, patients enter a process leading to a fundamental change in how they view their health challenges. Appreciative medicine also restructures the physician’s role to that of a partner, working with patients to create new healing dynamics.

The principles of appreciative medicine encourage patients to become proactive, take responsibility and assist in developing their own optimal health plans. On a regular schedule, they review their progress with their primary care physician and critique goals as they plan the next step. This system utilizes medical technological advances appropriately and to the fullest while building upon doctor-patient relationships of trust to provide the most appropriate choices. Appreciative medicine opens the door to a full range of healing strategies that include complementary medicine options, some of which have become almost routine, such as acupuncture for back pain or yoga to help lower blood pressure.

At the heart of appreciative medicine is a personalized approach that highlights patients’ unique, positive characteristics and targets solutions for optimal healing. Patients are empowered to access directions of choice by journaling, with the help of prepared guidelines in a question-answer format. This process of reflection and journaling benefits both patients and practitioners in subsequent office interactions. Written responses are carefully reviewed with practitioners, often propelling patients beyond their previous limitations.

IV. Implementing an Appreciative Medicine Program

As in all new beginnings, professionals in the practice of medicine must learn how to implement new tools for change. It begins with us—one patient at a time. Appreciative medicine is not for all patients, but this inclusive approach can create a bridge that links the entire continuum of health care services, ushering in an era of health options based on partnerships and teams. Best of all, appreciative medicine offers an opportunity for us to understand the uniqueness of our patients and, at the same time, to recapture our enthusiasm for the healing arts.

Designing and implementing an appreciative medicine program is relatively simple:

· Physicians and other practitioners are briefed on the “appreciative dialogue” method, including a journal-oriented workbook; they learn how to share the approach and resources with patients, schedule review conferences and measure results.

· Select patients receive the workbooks, along with invitational letters from their physicians or a program coordinator, which explain appreciative medicine and encourage patients to participate.

· Patients are asked to complete the basic workbook pages (objectives, modalities to explore, and summary), bringing their responses to health care providers for discussion and development of individualized treatment plans.

· Because the workbook allows for ongoing entries, patients are encouraged to continuously reflect on their progress and evaluate the efficacy of the treatment plans from their own perspective.

· After six to eight weeks, patients meet with physicians to review and monitor their progress and receive further direction in their treatment plans.

· Results of the program can be assessed by participating physicians and patients, accomplished in reviews and evaluations set up by an appreciative medicine coordinator. This role is best serviced by patients’ primary healthcare provider.

Appreciative medicine thus meets challenges that have long beset the health care delivery system: separation, isolation and fragmentation of services and healing modalities. This is a perspective that seeks to resolve several issues: separation between patient and physician, between practitioners in specialized areas, and between allopathic medicine and complementary disciplines. At the core of appreciative medicine are three basic principles:

1) deeper participation by those seeking health care;

2) increased efforts of primary care physicians to unify all treatments, guiding consultations through integrated and supportive protocols, and

3) a focus on creating wellness—a patient’s innate healing systems are activated not from treatments per se, but by the process of being healed from within.

This is a solution-based, proactive way to achieve the goal of optimal health. Patients progress when they envision total wellness with the help of many professionals working together. Further, both patients and their health care providers benefit from positive outcomes that make a difference in the quality of life for all concerned.

V. Meeting the Challenge of Widespread Chronic Illness

The time for change is upon us. Clearly, patients and physicians alike are looking for a more human-centered path to health care. Patients say they want choices, especially when it comes to chronic illness. But our health care system has become overwhelmed with costs, utilization and redundancy. We don’t deny that today’s medicine can excel in an acute health crisis. For instance, our approach can stabilize, cure and save the lives of patients who suffer acute myocardial infarction, appendicitis or even sepsis. However, when it comes to chronic health concerns, such as low back pain, diabetes mellitus, allergies, depression or anxiety, conventional health care would have to receive a failing grade.

Physicians often end up placing patients in a maze, where they feel isolated and lost in an array of costly lab tests, x-rays, consultations with specialists and over prescribed pharmaceuticals. Our intentions may be pure, but our approach is flawed, often perpetuating “problems” inherent in the system. But we can go beyond particular “complaints” and adopt a better way that maximizes health.

I know of no better way to promote healthier living than by lifestyle modification. Yet, too often we are recruited to patch a problem rather than as partners in making a significant healthy lifestyle change. Patients’ problems have become their “ticket” to see a doctor, leading them from one illness to the next. Over a million interactions occur daily within the health system—doctor appointments, emergency visits and countless ancillary care procedures head the list. In contrast, appreciative medicine empowers patients to become more independent; but actively involved in making positive lifestyle choices, which often translates to improved compliance.

After an appreciative medicine orientation, what did patients themselves report of most value in achieving renewed vitality? What did they do to gain balance and be able to enjoy life again? The following are typical of selections from patient journal entries, written in the context of the appreciative medicine approach: “In my quest for optimal health, I…

1. Am silent and listen. 2. Listen and trust; I believe in myself.

3. Understand how my body digests and utilizes food. 4. Walk, move, stretch every day. 5. Spend time in nature; I let it saturate my soul. 6. Avoid all negativity. I avoid all negativity. I avoid all negativity. 7. Optimize my innate healing systems. 8. Pray every day. 9. Celebrate my life. 10. Love--and don’t miss an opportunity to share it. 11. Breathe (fresh clean air). 12. Acknowledge what I feel. 13. Learn; every day presents new lessons. 14. Turn off the television. 15. Respect animals—to adopt one is to receive 100-fold payback. 16. Protect the environment; I am a trusted steward. 17. Volunteer; I have something unique to give. 18. Take the word procrastinate out of my vocabulary. 19. Respect myself, as well as all people, animals, and things. 20. Keep a journal and write in it often. 21. Use all of my senses—touch, sight, hearing, taste and smell. 22. Forgive myself (as well as others); I strive to be nonjudgmental. 23. Love art in all its forms. 24. Am grateful; I am thankful. 25. Am open to new experiences, ideas, and relationships. 26. Feel that family time is a priority. 27. Drink pure water. 28. Eat food for a healthy body. 29. Plant a garden. 30. Smile (a lot).

VI. Understanding the S.O.A.R. Model For the most part, health care providers currently assess patients with a formula used for many years, a template called “S.O.A.P” (Subjective, Objective, Assessment, and Plan). This familiar, problem-treatment approach may work well enough for certain acute conditions, but I recommend the more comprehensive “S-O-A-R” model (Solution, Objective, Assessment, Action, Reinforcement of possible solutions), especially in chronic conditions.

For example, Marcus Smith is a 44-year-old patient with a history of chronic lower back pain. He has seen his primary care physician at least four times a year with exacerbated pain, and he was told a few years ago that his cholesterol was high but is confused about what that means. He cannot remember ever having a physical exam as an adult. What might be missing from Mr. Smith’s treatment plan?

Clearly, this case would look different had the patient interacted with a practitioner using the principles of appreciative medicine. Figure 1 outlines some of the differences between the well-known S-O-A-P protocol and the suggested S-O-A-R method introduced here. Even so, there are additional activities inherent in the S-O-A-R model, which need further explanation. First, patients derive the solution (e.g., an affirming statement) through in-depth reflection. In other words, it is not necessarily the foremost medical opinion of the attending physician. Second, the objective supports what patients themselves see as being true, not necessarily what practitioners may observe as problems to correct. Third, health care providers and patients achieve the assessment phase together, in which they agree on what action to be taken. Finally, reinforcement supports patient-doctor collaboration and does not automatically, or of itself, dismiss or supersede conventional methods of treatment.

In the S-O-A-R process, several outcomes are achieved: a) The vicious cycle of problems—always dwelling on another complaint—is suddenly broken; b) Patients are in a unique position to be more motivated to carry through with their treatment programs; and c) Patients are empowered to act, truly vested in the agreed upon regimen.

Figure 1. The Case of Marcus Smith—Conventional Versus Appreciative Medicine

Allopathic/Alternative Medicine VS. Appreciative Medicine

S-O-A-P S-O-A-R S SubjectiveLow back pain S Solution“My back pain has resolved. I feel stronger than ever. How can I keep feeling strong and flexible?” O ObjectiveMultiple trigger points; decreased range of motion; reflexes intact O ObjectiveRange of motion normal; strength good; flexibility increased. A AssessmentLumbar strain AA AssessmentContinue with back strengthening exercises. Recommend stretching and swim therapy.ActionTake a course in yoga. Be conscious of posture. P Plan R ReinforcementWalk daily. Learn more about the Mediterranean diet. Update tetanus-diphtheria. Schedule yearly physical and have appropriate blood testing.

In summary, we are privileged to be medical doctors, gifted with careers that reward us with a humbling life experience. It is up to us to take that first step, to learn about the new infrastructure provided by appreciative medicine. We can learn to partner with our patients on a true healing quest. I appeal to all physicians to bring forth their resources for the common good. Pursue creative dialogue with patients and develop personalized health plans that focus on wellness. Together we can not only effect a system of change but also assist health care itself to take a quantum leap forward.

Notes:

*1. Stedman’s Medical Dictionary—25th Edition. (1990). “Allopathy.” Baltimore, MD: Williams & Wilkins.

*2. Eisenberg, D. M., Davis, R. B., Ettner, S. L., Appel, S., Wilkey, S., Van Rompay, M., & Kessler, R. C. (1998). “Trends in Alternative Medicine Use in the United States, 1980-1997.” Journal of the American Medical Association, 280, 1569-1575.

*3. Hurst, J. W., & Walker, H. K. (Eds). (1972). The Problem- Oriented System. New York: Medcom Press.

*4. Smith, S. 2003, Sept/Oct. “The Boutique Medicine Boom: Perspectives on the Growth of a Controversial Trend.” Practice Builders, 2(9) 1,2.

*5. Cooperrider, D. L., Sorensen, Jr., P. F., Yaeger, T. F., & Whitney, D. (Eds.). (2001). Appreciative Inquiry: An Emerging Direction for Organization Development, Champaign, IL: Stipes Publishing.

*6. Franklin, T. L. (2004). Expect a Miracle; You Won’t Be Disappointed! Berkeley, CA: Celestial Arts.

*7. “Step 1: Change your mindset. Immerse yourself with goodness, love, and joy. Dwell on the creative, positive instinct in your life. Develop a vision of optimal well-being. Focus on the positive realm of goodness and health within you.

Step 2: Discover the tools for harnessing the vital energetic force that creates healing. This includes the entire spectrum for healing, from conventional approaches to alternative treatment modalities.

Step 3: Reflect on your accomplishments. Note the benchmarks along the way. When you see where you've been, you become clearer on where you're going.

Step 4: Obtain true insight into who you are and where you want to go. The road to self-actualization will take you to the state of wellness, where all your dreams and hopes for the future can be realized.”

Competing interests:   None declared

As a 20 year residency trained and boarded member of the ABFP, fellow of the AAFP, I have read and wish to comment on the Annals of Family Medicine "Future of Family Medicine". My intent on entering the medical field was to be a traditionalist rural family physician. Due to social and financial pressures and constraints, I have evolved through a number of roles as a family physician, never really achieving my original goal. From solo private practice, I have journeyed through several employed clinical positions, some part time academic work, urgent care, Alaskan Native health service, Emergency room (where I have for the present landed) and who knows what tomorrow may bring?

My fear is that as "Family Medicine" evolves, I approach the outer limits of the wheel, where at last the centripedal forces will eventually thrust me in to the void. Where do we traditionalists who have become fragmented from the fold find ourselves in this evolving picture?

Competing interests:   None declared

When I read the hypothetical scenario described by Michael Fleming M.D. which accompnied the "Future of Family Medicine" supplement,in which he describes a hypothetical diabetic's encounter with her physician,I thought Dr. Fleming was being sarcastic.

I was dismayed to realise that he was perfectly serious in that the delivery of this kind of "medical care" is a goal towards which doctors should strive.

I would be more upset if I thought that the changes outlined in this supplement had the slightest chance of being implemented, but I am comforted by the thought that the flaws will be obvious and fatal.

My specific objections are too lenghty to be expressed in this forum, but I would welcome the opportunity to discuss them with anybody who may be interested in my viewpoint.

My credentials, of which I am proud, and which are almost unique, are that for 19 years I have been in private Family Practice ,in my own office in San Diego, where I practice with my wife.We participate in no insurance plans (no PPO's,HMO's nor Medicare), even though all our patient have these kinds of insurance.

We provide traditional medical care with no "exotic" nor "alternative" therapies, but in a manner for which patients are quite willing to pay full, non-discounted fees, out of their own pockets, when they leave our office.

I am not suggesting that our model of practice could be implemented everywhere, by every physician. My point is simply that I have enough successful, practical experience in Family Practice that my ideas may be worth considering.

Sincerely,

Competing interests:   None declared

Well said -- I wish more people in our specialty thought like this. I fear (no, I am nearly convinced) Family Medicine will die because the public is sold on the notion that a specialist is the only doctor to treat a specific problem. The only practical way we will stay alive is on 'word of mouth' referrals from patients. Good luck, and don't give up.

Sincerely, (from just south of you) Scott J. Samuelson, M.D. Fort Collins, CO

Competing interests:   None declared

A hearty congratulations, and - just what they need - another pat on the back for the authors of the Future of Family Medicine project. I am forced to agree with the eternal optimists that the glass is still one eighth full.

It does not surprise me at all that 85% of patients in the multimillion-dollar focus groups want an FP as their personal medical advocate and resource. THEY JUST DON'T WANT TO PAY FOR IT. Apparently, neither does the government, or the HMO's. I'm sure glad they have figured out ways we can become more efficient, so we can lower our overhead, and increase our operating margins that way (especially since my practice currently breaks even or loses money on one-half of our patients).

Unfortunately, until so-called "organized medicine" and physicians ourselves take a stand, and learn to say "NO!," the future of Family Practice is clear. We will remain as THE DOORMAT of medicine, and continue to be walked upon. We will also usher in our replacements as the stepping stone for the mid-level providers, continuing to sign their charts and back them up as they "skim the cream" and go home early, as we stay ever later to maintain our existence.

So, enjoy the warm fuzzy glow while you can, with backslapping all around while gazing at the pie-in-the-sky. But make no mistake, without a strong movement to advocate THE PHYSICIAN in the here and now, there is no future for Family Medicine. How about a focus group on that . . . ?

Competing interests:   None declared

It is no surprise to me that the numbers of students interested in family medicine residency prorams is in decline. I am a preceptor of students from the nearby medical school, and the reasons for students lack of interest is obvious.

Family practice is at the bottom rung of the pay scale for physicians. Why go through these years of education to be paid less than all of your colleagues? Medicare just cut reimbursement rates to our state, one of the poorest states in the country. Pay is not the only issue, however, for many of us went into medicine not for the salary, but for our altruistic beliefs. What happened to this? A recent letter in The Sun was from a doctor whose disillusionment made him wish that he were not a doctor after 24 years of practice. Medical malpractice is on the increase and primary care is at the very top of the list of what field of medicine is most likely to be sued. The doctor-patient relationship has eroded to nonexistance as time constraints increase (how much of a relationship can you develop in three minutes?), and as changing insurance forces patients to see different doctors in different plans. Patients have become more demanding (due to various reasons such as the information age, "news", advertising and lack of doctor-patient relationship) and health plans are requiring "patient satisfaction" be part of a physicians evaluation which is in turn related to pay. This leads to "jack-in-the- box" medicine, i.e. just give the patient whatever they want in order to get them out of the door and happy, even if it is not good or even adequate medicine (not to mention sky-rocketting antibiotic resistance). The American Board of Family Practice has just instituted a yearly recredentialling process, which is in excess of any other specialty. This is not only more work, but more fees on an already lowest-paid specialty. Don't think that students don't know all this when they are choosing a specialty. In choosing family practice, they are choosing a career in customer service, with the least pay and most liability. How attractive is this to a student?

The section "Addressing the Declining Interest in Family medicine among Medical Students" suggests that it is the departments of family medicine that must work to attract student interest. In talking with medical students, this is perhaps the last place that would influence a student to pursue a career in family medicine. They don't look to residency programs to decide on a specialty. They look to their peers, the internet, their parents, their experiences, community doctors (who may be disillusioned) and statistics(not necessarily in this order) before they discuss their career with a residency program. Only after a student has decided on a specialty will they discuss it with a residency program. The issues mentioned above need to be corrected before there will be any increase in students interested in family medicine. The altruistic no longer are interested in family medicine, they go into public health, or environment, or politics.

Competing interests:   None declared

As a Board Certified Family Physician, I see little need for this grandiose set of changes being proposed, and stand firmly opposed to it being institutionalized by the organization designed to represent us rather than exercise tyranny over us. I find medicine by email to be a rather sterile entity; many FP's are employees of multispecialty groups and cannot necessarily dictate the total management setup of the whole group. Other small offices are beset with already staggering overhead to make these sweeping changes. I believe these changes can evolve where relevant and appropriate within the local milieus without a national organization dictating from above and afar. We can advocate but have not the power to decide how health coverage is provided. I think our national organization should be pointing out the strengths of our specialty as it stands rather than adding it's voice to the FEW naysayers. Please get a reality check. Thanks, Don Elder MD

Competing interests:   None declared

I am submitting my reaction to the proposed changes to family medicine. I feel qualified to comment because my experience is based not only on my own nearly 30 years, but my father's 30 before me (when it was GPs who did surgery and delivered) and my 2 sons after me (both FPs in Paoli Inidiana Fps who deliver and even do C sections). If you alter the landscape, you will be doing an experiment with the lives of all present family docs (who entered the profession without consenting to these changes like computerization and interconnection)and without being able to fully see what all the ramifications will be for our lives. Patient centered medicine is fine to a point, but when it is driven by phamaceutical companies and unfiltered internet, it makes a mockery of our education. Already they change physicians frequently and not just for insurance, but because they feel that a specific concern (that Donahue or other TV raised) was not addressed. They diagnose and request exact meds and become vehement that they know best when not given the antibiotic they want. They refuse meds like statins because "we're poisoning them to get rich" etc. I believe my patients may be a little more demanding but I see other docs confirming my impression. You are opening Pandora's box by suggesting total availability and patient driven medicine. You cannot begin to comprehend (nor can I) what all the future will hold. But it will be a decidely less pleasant and gratifiying speciality. Of course the specialists are glad to let us experiement. It is no skin off their noses. They will watch what happens before they change. Wasn't certification-- and recertification going to make us respected? If it didn't why do you think this will work? And where in your model is the FAMILY part of FP anyway? I almost hesitate to write a response because I am an unimportant inconsequential person. But here is my thought anyway.

Competing interests: None declared

We cannot even begin moving toward the "new model" outlined in your report without first having a major overhall to the financing of health care in our country. For those of us practicing retainer medicine we have been practicing the "new model" since 1996. Retainer practices put the power back in patients hands by giving them the opportunity to purchase out of pocket access to a practice that offers the "new model". Many of us practicing retainer medicine see this as an opportunity to positively impact the problem of the uninsured in our country. Physicians practicing retainer medicine find they increase care for the uninsured compared to their traditional practices because of the more favorable profit margins. The movement toward retainer medicine that we are seeing accross the country is driven by patient demand in the market place for the "new model" of health care. The "new model" as you describe it in the report is not new to those of us practicing retainer medicine and we are living the future today.

John Blanchard MD

President

American Society OF Concierge Physicians

www.conciergephysicians.com

Competing interests:   None declared

How can one expect family physicians who have the least reimbursement and highest overhead to fund the recommended transformation of their practice to a model that embraces new facilities, EMRs, patient resource centers, etc?

For all that patients say they want, we know they are not willing to pay for it. We have learned that the relationship is meaningless if the managed care plan changes and the patient must decide between that relationship and less cost for medical care.

The managed care plans themselves place a premium on proceduralists but poorly reimburse cognitive skills. They really don't want what the family doctor offers or they would pay for it. Consistently they reimburse specialists at 150%-200% of Medicare but allow family physicians 75%-100% of Medicare allowable.

I recommend the initial changes be those that take advantage of the current system to help us get a better deal. I think the inpatient arena is lost to the specialists not only because of poor reimbursement for inpatient cognitive skills but also because of the well entrenched specialists. We should become the acute and preventive care resource for outpatients. That won't happen unless our organizations support us by not only lobbying congress for improvements in primary care reimbursement, but also by immediately identifying and promoting opportunities for enhancement of practice income. If our organizations truly believe EMR is the future, then use your resources to develop a reasonably priced EMR that meets the needs of the family doctor.

It is no surprise why less medical school graduates choose family medicine. First and foremost, it's about the money. Why spend the same amount of time in a residency that will ultimately pay only half what a dermatologist can make and provide a lesser quality of life regarding call and time available for family?

I love family medicine and I hate to see this happening. This article and the attachments describe a "pie in the sky" solution that doesn't address the real issue which is poor reimbursement for what we do. The patient may love his family doctor but he'll leave you for a nickel.

Competing interests:   None declared

The specialty of Family Practice has taken a trip down the rabbit hole with Alice in Wonderland. Instead of tying to be nicer to Family Physicians under siege with reimbursements, malpractice, etc.. we are now told that taking an examination every six years is not enough! Please spend more time and money proving you're good enough for less each year. Up is down and down is up. Gosh, if we can't be kinder to ourselves, it's no wonder we are talking about how our specialty will survive. Stop the madness and go back to the ABFP test every six years. This will be a step in the right direction.

Competing interests:   None declared

I read with great interest the report on The Future of Family Medicine: A Collaborative Project of the Family Medicine Community in this month’s issue of Annals of Family Medicine, and I appreciate the opportunity to participate in this online discussion. I share the authors’ concerns over the current state of health care in America. As a physician myself, a psychiatrist by training, I have been keenly interested throughout my political career in the promises and challenges posed by the health care system in our country.

The specialty of Family Medicine, created almost 40 years ago, has developed alongside revolutionary advances in medical science and technology. However, despite our best efforts, these advances remain inaccessible to many in our society, and the promises of medical science are limited by large disparities in access across racial, ethnic, social, economic and geographic boundaries. These disparities will be highlighted in a revised report to be issued by the Department of Health and Human Services and remain a challenge we must all strive to overcome. This is a particularly timely issue, since April is National Minority Health Month, and this week is National Public Health Week. The American Public Health Association has chosen to focus on health disparities, with the theme of the week being "Eliminating Health Disparities: Communities moving from statistics to solutions." Family physicians can play an important role in eliminating such disparities by promoting diversity in the health care work force, developing models of culturally competent care, and continuing their leadership role in reaching out to underserved communities.

The Future of Family Medicine report proposes a “New Model” of practice that would “meet the needs of patients in a changing health care environment.” This model incorporates many of the values I advocate: universal access, coordinated and continuous care, an emphasis on high quality and evidence-based medicine, and financial sustainability. These values, echoed in the Institute of Medicine’s 2001 report on primary care, Crossing the Quality Chasm, are central to most discussions on health care reform, yet their implementation remains an elusive goal.

It is clear that family physicians and other primary care providers will play a crucial role in meeting the health care needs of the future. As discussed in this report, today’s family doctors face many challenges in our fragmented health care system. Because they provide the spectrum of care to patients in diverse geographic, economic and social settings, and have a long history of commitment to safety net care, care in rural and isolated areas, and care to many underserved groups, family physicians are uniquely poised to play a central role in meeting the health care needs of the future. Collectively they must play an active role in shaping the discussion on health care reform. The family physician’s emphasis on patient-centered care and a coordinated team approach will be necessary to develop a rational model of health care that is comprehensive, cost- effective and equitable.

In my proposal for universal health care, The American Health Security Act (HR 1200), I recognize the role played by family physicians and other primary care providers, and specifically recommend the promotion of primary care. I will continue to work towards transforming health care in our country into the high quality, cohesive and equitable system that Americans want and deserve, and I look forward to working with family physicians towards this shared vision.

Competing interests:   None declared

The successful future of family medicine and the future of US healthcare must be inextricably linked. The complexity of healthcare choices and treatments demands a generalist in each person’s medical home. This is not the old, hated, gatekeeper model, but a model of the physician as guide and consultant.

We are challenged to use technology in our practices. Data show that care by generalists produces excellent outcomes while using fewer resources, but our patients want the high tech medicine they see on TV. In my practice we use a web-based prescribing program that allows instant access in the exam room to the latest evidence based information about drug usage and preventive health strategies. When a patient requests “the latest drug” we can show them the medical information supporting or not supporting its use. We can be “high tech” without being expensive.

We are challenged to provide, “culturally and linguistically appropriate” care. However, I recently read the article on this year’s residency match in AAFP Direct. The author stated that the “2004 match data still contain some cautionary elements. The percentage of family medicine positions filled by U.S. medical school seniors slipped by 0.2 percent, from 42 percent in 2003 to 41.8 percent this year.” If we want to promote diversity in our specialty and culturally and linguistically appropriate care, why apologize for filling residency slots with non-US medical graduates?

To me, the key statement was, “….as a discipline, family medicine has yet to formulate and deliver a compelling message.” As Family Physicians we must become the health promotion, disease prevention “gurus” of medicine. We have ceded that role to the alternative health practitioners, and while they may be important in promoting wellness, we need to take back the leadership there. With growing evidence that some interventions (e.g. coronary angioplasty) may not be as effective as previously thought, we need to be leaders in the movement for true disease prevention by promotion of healthy lifestyles. Our patients, students and residents need to be assured of physicians and teachers who are technologically savvy, promote health, practice evidence based medicine, and who still remember the JOY of practicing Family Medicine.

Competing interests:   None declared

The statement of the Future of family Medicine Project Leadership Committee, published in the Annals of Family Medicine, March/April 2004 is bold but not brave. It says all the right things; the problem is what it doesn't say.

All of the proposals, although important and necessary, might be made by many if not most of the non-primary care specialties, who also will soon recognize changing need and claim their intention to meet them. The crux of the matter lies in the definition of comprehensiveness. It is not helpful to to define comprehensiveness as the range of services as provided by the Canadian family physicians; at least some specialties could and would claim a similar range in their practice. Not is it helpful to claim responsibility for 'most problems. "most problems' logically refers to most problems in the International Classification and since most of these are rare, it is specialists, in aggregate, who care for them. Furthermore, coordination of care, important as it is, is interpretable asas a low-level activity that can be done, possibly better, by non- physician practitioners. A brave stance regarding the role of family medicine requires confronting two realities: the public's perception that specialists have more competence and provide better care for specific problems, and the iron grip that specialist and academic health centers have on health policy decisions.

An appropriate role for specialists is different from a primary care role. It is 1) care for uncommon conditions whereas primary care deals with all but uncommon conditions 2) provides advice and guidance to physicians (no patients) about diagnosis and management 3) provides long-term care for problems too uncommon and too complex to be managed by primary care physicians

Claiming a critical role for primary care requires confronting that perceptions of the superiority of specialty care. Specialty care is very important in a health services system but it does not provide superior care when patients have primary care needs, and especially when they have co-morbidity (which is the rule, not the exception).

Defensive stances are insufficient in promoting the future of primary care; the offense is necessary.

Competing interests:   None declared

‘The Future of Family Medicine: a collaborative project of the Family Medicine Community in the United States’ is a clear, consistent and visionary document. I know from experience how difficult it is to reach a consensus with ‘meat on the bone’ between leaders of different organizations with their own vested interests. Over the past four decades I have read numerous national and international reports on the future of (research in) family medicine, including, obviously, the 1996 IOM Report. This experience has taught me to anticipate non-linear results, and the need to apply the strategies of complexity theory when implementing recommendations. In any attempt to bringing about change, complexity increases with a low certainty of how outcome relates to input, and with low agreement between the actors who provide the input.1 And it is especially the latter that worries me after reading this Report.

Sen states that it is highly unlikely that the aggregation of preferences and values of individuals will result in a coherent framework for ‘reasoned social assessment’.2 Difficult as it must have been for the family medicine leadership to find common ground for their personal values (and their personal interests), it is even less likely that each individual family physician (FP) will readily consider this Report’s goals as moral requirements. In fact, ‘majority rules’ can almost never be considered as the aggregate of individual preferences. Still, well planned social interaction can result in a partial agreement, because individual preferences and norms may over time develop in the ‘good’ direction. Unintended consequences of recommendation are, however, often more outspoken than intended changes - and this is the core of applied complexity science.

An important source of lack of consensus between FPs might well be the fact that the Report considers ‘beneficence’ as a core value in the patient physician encounter (‘continuous healing relationship’). In several countries, an external morality for family practice is gradually replacing the internal morality of beneficence in which many of us were trained. Veatch argues ‘the impossibility of a morality internal to medicine’, based on an earlier publication 'Doctor does not know best: why in a new century physicians must stop trying to benefit patients'.3,4 He concludes - and I agree - that physicians should see themselves as having a new, more limited duty to assist patients in pursuing their own understanding of their interests. In this vision, physicians are not allowed to pursue their own understanding of their patients well-being instead of or opposed to the patients own understanding. An external morality for family practice is, consequently, mainly a social construct; and the Report very adequately lists the relevant social, political and economical elements.

It is likely that US FPs will have (very) different perspectives on this issue and there factual reactions to the implementation of the recommendations will probably be equally diverse.5,6 My congratulations for this landmark Report are, therefore, accompanied by the wish that US family medicine leadership will be prepared to actively deal with complexity, and enjoy the surprise of unintended consequences.

References 1. Sweeney K, Griffiths F. Complexity and Healthcare: an introduction. Oxon: Radcliffe Medical Press, 2002. 2. Sen A. Development as Freedom. New York: Anchor Books Random House Inc, 1999. 3. Veatch RM. The impossibility of a morality internal to medicine. Journal of Medicine and Philosophy 2001;26:621-42. 4. Veatch RM. Doctor does not know best: why in the new century physicians must stop trying to benefit patients. Journal of Medicine and Philosophy 2000;25:701-21. 5. Pellegrino ED. The internal morality of clinical medicine: a paradigm for the ethics of the helping and healing professions. Journal of Medicine and Philosophy 2001;26:559-79. 6. Miller FG, Brody H. The internal morality of medicine: an evolutionary perspective. Journal of Medicine and Philosophy 2001;26:581-99

Competing interests:   None declared

Dear Authors and Editorial Team: Thank you for the opportunity to comment on the "Future of Family Medicine" article. You have done a marvelous job. I am very concerned with the future of our specialty. For example, our group is the only group in one hospital where we actually see our own patients in the hospital rather than use hospitalists. We are seeing an erosion of Family Medicine internally (doctors less committed to their patients) and externally (less political clout, less pay, less respect, more insurance hassles, etc.) This is such a multifacetted topic, it could be discussed for days. One specific comment about electronic medical information, is that it is a huge and unguided journey with large dollar tags attached. I wish you well as this project is attempted to be implemented. Hopefully, it will go better than the AAFP's attempt at a coordinated electronic medical records system!

Yours truly,

John Saxer, M.D.

Competing interests:   None declared

Over the past 20 years, most Family Physicians left residency anticipating a thriving practice with patients they would share a long- term relationship with. That continuity allowed them to personalize the care to the individual and their family. Multiple forces have fragmented that care to the point that many physicians spend more of their time processing patients through the system than providing care. Other forces including medical liability have altered the scope of care provided by many family physicians. Many patients now find the system impersonal and difficult to access and a large number of people are uncertain of the role a family physician plays.

The Future of Family Medicine Project addresses these concerns and outlines the role Family Physicians will play in the future. The report incorporates many of the changes already occurring and yet it is only the beginning.

ENCORE by Kelly Greene appears in the Wall Street Journal’s quarterly guide to Retirement. Number 7 on her list of Top 10 Health Mistakes is: “Not having a single primary care physician who oversees your treatment.” In the future, patients will return as the driving force in the health care market. The Family Physician becomes the guide in an increasingly complicated jungle of health care services.

Family Physicians will incorporate technologies into their practices that improve communication, documentation, and evaluation. Family Physicians will have new advanced diagnostic technologies available at the point of service. The market will reward those who offer the latest advances in evaluation and treatment with easy access in formats patients can understand.

The report also addresses concerns that Family Physicians share regarding the moral obligation to provide basic health care to all individuals. Society can find the solutions to this dilemma by investing in Primary Care. By encouraging the concept of a “medical home,” society works to ensure that patients receive the most specific and appropriate care without excessive waste of their time or health care resources.

The ultimate test will arise in the area of future funding. In the present managed system, more of the premium lands in the administration’s pocket than those delivering primary care. When the patient can designate payment directly with allocated dollars for a specific “basket” of services, a paradigm shift in funding should occur. This will attract new services and persuade more individuals interested in medicine as a career to select Family Medicine.

Competing interests:   None declared

I read with interest your report on the future family medicine. I submit to you that a few innovative primary-care physicians are currently pioneering a way to achieve these goals. We are doing this under the auspices of patient supported practices.

These are practices where the patients pay an annual fee for the services of their primary-care physician. No insurance company is charged for any service, thus eliminating the need for complicated and expensive coding and billing systems. In return for their annual fee the patients are given greatly improved access to relationship-centered personal medical care. Physicians in patient supported practices typically limit the size of their patient panels to between 500 and 800 patients. This allows much more time per office visit to attend to the patient's multiple medical and emotional needs as well as address important health maintenance issues and coordinate specialty care. My patients are somewhat taken aback when I end each visit with the question "Is there anything more I can help you with today?"

The physical space of my office has been redesigned to enhance the comfort of my patients. I decided to eliminate the waiting room and in its place I put in a kitchen. There are usually healthy snacks on the table in the center of the room and the smell from the breadmaker each morning is quite pleasant. My patients know to help themselves from the refrigerator for something to drink and I frequently sip tea in my office while interviewing my patients. As 80% of all diagnoses are made by the history alone I interview all my patients in the relaxed environment of my office. My patients prefer this approach over my previous office where most histories were obtained from half dressed patients sitting on the end of a cold exam table.

In this improved environment I am learning the stories of people's lives and I love it. One patient commented that he and his wife felt they became better acquainted with me in their first visit to my new practice than they have in all the past 15 years of coming to me as patients.

The reduced volume of patients allows me to channel my energy into improving the efficiency of the practice. One main area of focus is implementing an electronic medical record. I am in the process of transitioning away from the paper chart and for the last two months all visits are now exclusively documented in the electronic medical record. This electronic medical record system also allows me to improve my communication with my subspecialty colleagues. With a few mouse clicks I can generate a complete referral letter including past medical history and current medications to send with my patients when they visit the referring specialist. This certainly enhances my patients care.

I can say with certainty that in my previous practice I had no time to spend learning a new system of record keeping. I felt as if I were running around all day just putting out fires. I am writing this letter to you on a voice-recognition system as my typing skills leave a lot to be desired. At $.11 a line for dictation this voice-recognition system has already paid for itself in two months. Learning this system has taken time which I didn't have in my previous practice.

I am new to this type of practice. The office opened on January 12, 2004. I based my practice model on a practice in Seattle, Washington. Two courageous physicians six years ago created the idea of a totally patient supported practice and I owe much to them for their guidance and support. After 2 1/2 months of practice my patient panel is such that I now can support my overhead. I'm still not earning a salary but for each new patient that signs up from here on out it puts me that much farther in the black. Most importantly, my patients are extremely happy and well served.

If you would like to know a bit more about this practice you can visit my newly designed web site through the AAFP at www.familydoctor.org/familydoctorscare/ or e-mail me at

familydoctorscare@earthlink.net

This type of practice is not for everyone. Not every doctor relishes the idea of spending an hour with a patient. In addition, newly minted physicians just out of residency probably need the increased volume of patients of a typical office or clinic setting to gain valuable practice experience. What a patient supported practice allows for is the creation of what I would like to call a "Master level practice". The physicians obtain their apprenticeship during residency and then need to have a journeymen experience for 12 to 15 years where they refine and hone their craft prior to proceeding onto the master level of practice.

Thank you for giving me the opportunity to express my thoughts and relate my experience.

Competing interests:   None declared

I wanted to raise the issue that is of utmost concern to practicing physicians and is so blatantly not being addressed in the article on the future of family physicians. The issue of malpractice and tort reform needs to be resolved before we find ourselves unable to provide care to our patients. This has been a concern but never really an urgent issue for me as my malpractice premiums have always been low compared to other specialties. I have 20 years of practice and have not had a claim against me. However recently my malpractice insurance was cancelled. I have to scramble to find another carrier and I am sure a new policy will cost dearly. This comes at a time when reimbursements are declining and we had to lay off staff to meet our bills. The physicians in our group recently took a severe wage reduction to reduce overhead.

The academy needs to be assisting in supporting tort reform or we may find that many good physicians will be persueing other careers and there will not be a need for an academy. The fees we pay to the academy may go the way of cost savings and overhead reduction for the members.

Competing interests:   None declared

Despite our dedication to our patients and the long hours we devote to our profession, the current “system” is incapable of delivering the health care we so desperately want and need. Redoubled effort won’t result in an office practice that can deliver on the new rules from the Institute of Medicine’s Chasm report of 2001.

The richest health care system in the world leaves at least 40 million Americans without basic health insurance. A growing population of Americans is being forced to pay out of pocket for basic services due to double digit premium increases driven in large part through neglect of primary care. It is highly unlikely that we’re going to get more money to fix our problems.

We must re-tool our profession; transform what we do and how we do it. For this to occur, we need a clear and unambiguous statement of what we are, what we care about, and where we want to go.

The Future of Family Medicine Project Leadership Committee has done an excellent job articulating the need for our specialty to transform itself based on the needs of those who come to us for help, future family medicine physicians, and ourselves.

On 2/26/01 I opened a solo practice all by myself to test the feasibility of the Chasm rule set. Now I’m practicing the kind of medicine that drew me to become a doctor, and I love it. Linda Lee, James Sturgis, Michelle Eads, Jeff Arp-Sandel, Gary Seto, Larry Lyons, Rian Mintek and numerous others have taken the leap as well.

Clinton Family Health Center in Rochester NY, a part of the Safety Net project (www.rsafetynetproject.com) is showing that these principles can be applied to an established inner city practice serving a vulnerable population. In three months they have achieved same day access, dropped their no-show rate from 45% to less than 10%, increased revenue while still getting home on time, are implementing primary care case management, group visits, and starting their diabetes registry.

The Safety Net project sponsors are investigating how to change the way health care is reimbursed so that the primary care clinicians and office staff will be rewarded for achieving critical process and outcome targets. We are changing policies and rules, we are creating structured community partnerships to support patients in primary care.

It is possible to re-tool. The salvation of health care in the U.S. is depending on our willingness to accept this challenge.

Competing interests:   None declared

Instead of challenging the current medical establishment and current patient thinking about health care and how FP's can be a patient's best source of medical care, you are proposing we put our tail between our legs and beg for scraps of food like a hungry dog!

I predict there will be two organizations for FP's in the future, and the current one will be for physicians who want to be nothing but middle people adding to the cost of medicine and actually doing no medical care.

The new organization will be for the FP's who still believe we are a patient's best source of most medical care. It will lead these FP's in the continued battle for privleges in hospitals to perform deliveries, c- sections, endoscopy, cardiac stress testing, etc.

It's time we challenge patient thinking on all avenues and have them understand it doesn't require a specialist to treat acne, htn, diabetes, asthma and ......( you get it ).

Donald Kirk, M.D. Afton WY, dkirk@sv-mc.org

Competing interests:   None declared

The report of the Future of Family Medicine project is very accurate and on track. The report represents a tremendous work from the family medicine community and means a lot of future work for many people in the family of family medicine. I congratulate the leaders of our community for their work and insight on this difficult topic. I wish to make several points:

First, problems are not solved at the same level at which they are created. We, in Family Medicine, although not a cause of the problem, are in the problem. We, therefore, are at the same level as the problem and, thus, are not the best one to solve the problem. Our first response as family physicians is to try to fix the problem, whatever it is. However, we must resist that initial impulse. We are emotional about the problem. After all, this is our chosen specialty. We need to hire our marketing consultants, Siegel & Gale, to help us through the problem and not rely on our emotional responses. Business strategy is hardly our forte. Let us allow them to help us out of this quagmire. This will be expensive, but worthwhile.

Second, the major enemy is within, not without. Although our specialty faces some tough times, especially for those now entering the specialty, we have some members who are satisfied with the current situation. Fat cats don’t hunt. All of us need to think about the specialty as a whole, including those entering the profession, and make some changes for the benefit of all. For some of us this may mean entering an uncomfortable area of the new practice.

Third, here is a golden opportunity to influence the health of the nation in a very positive manner. Let us all make the most of this opportunity. Lache pas la patate.

Competing interests:   None declared