Article Figures & Data
Figures
- Figure 1.
1999 distribution of counties with full or partial primary care health personnel shortage designation.
PC = primary care; HPSA = health professional shortage area.
Source: The Robert Gaham Center: Policy Studies in Family Practice and Primary Care.
- Figure 2.
1999 distribution of counties with full or partial primary care health personnel shortage designation without family physicians.
PC = primary care; FP = family physicians; HPSA = health professional shortage area.
Source: The Robert Gaham Center: Policy Studies in Family Practice and Primary Care.
- Figure 3.
The ecology of medical care revisited.
Note: All numbers refer to discrete individual persons and whether or not they received care in each setting in a typical month.
From: Green LA, Fryer GE Jr, Yawn BP, Lanier D, Dovey SM. The ecology of medical care revisited. N Engl J Med. 2001;344:2021–2025.48 Reprinted with permission from the Massachusetts Medical Society.
Tables
Current Approach New Rule Source: Crossing the Quality Chasm: A New Health System for the 21st Century.41 Care is based primarily on visits Care is based on continuous healing relationships Professional autonomy drives variability Care is customized according to patient needs and values Professionals control care The patient is the source of control Information is a record Knowledge is shared and information flows freely Decision making is based on training and experience Decision making is evidence-based Do no harm is an individual responsibility Safety is a system property Secrecy is necessary Transparency is necessary The system reacts to needs Needs are anticipated Cost reduction is sought Waste is continuously decreased Preference is given to professional roles rather than the system Cooperation among clinicians is a priority - Table 2.
Distribution by Specialty of the Usual Source of Care for People With Selected Conditions and a Physician as That Usual Source
Condition Family Medicine % General Internal Medicine % General Pediatrics % All Others % Note: Data are based on 1996 Medical Expenditure Panel Surveys. Atherosclerotic cardiovascular disease 56 31 0.0 14 Stroke 56 34 0.9 9 Hypertension 63 28 0.2 8 Diabetes 67 23 0.6 10 Cancer 60 26 2.3 11 Chronic obstructive pulmonary disease 62 22 5.4 11 Asthma 58 15 20.8 6 Anxiety/depression 62 20 7.0 11 Attribute Description A deep understanding of the dynamics of the whole person This approach leads family physicians to consider all the influences on a person’s health. It helps to integrate rather than fragment care, involving people in the prevention of illness and the care of their problems, diseases, and injuries A generative impact on patients’ lives This terminology comes from Erik Erikson’s work on personality development. Family physicians participate in the birth, growth, and death of their patients and want to make a difference in their lives. While providing services that prevent or treat disease, family physicians foster personal growth in individuals and help with behavior change that may lead to better health and a greater sense of well-being A talent for humanizing the health care experience The intimate relationships family physicians develop with many of their patients over time enable family physicians to connect with people. This ability to connect in a human way with patients allows family physicians to explain complex medical issues in ways that their patients can understand. Family physicians take into account the culture and values of their patients, while helping them get the best care possible A natural command of complexity Family physicians are comfortable with uncertainty and complexity. They are trained to be inclusive, to consider all the factors that lead to health and well-being—not just pills and procedures A commitment to multidimensional accessibility Family physicians are not only physically accessible to patients and their families and friends, they are also able to maintain open, honest and sharing communications with all who are involved in the care process Characteristic Description Personal medical home The practice serves as a personal medical home for each patient, ensuring access to comprehensive, integrated care through an ongoing relationship Patient-centered care Patients are active participants in their health and health care. The practice has a patient-centered, relationship-oriented culture that emphasizes the importance of meeting patients’ needs, reaffirming that the fundamental basis for health care is “people taking care of people”65 Team approach An understanding that health care is not delivered by an individual, but rather by a system,66 which implies a multidisciplinary team approach for delivering and continually improving care for an identified population41,67 Elimination of barriers to access Elimination, to the extent possible, of barriers to access by patients through implementation of open scheduling, expanded office hours, and additional, convenient options for communication between patients and practice staff Advanced information systems The ability to use an information system to deliver and improve care, to provide effective practice administration, to communicate with patients, to network with other practices, and to monitor the health of the community.68 A standardized electronic health record (EHR), adapted to the specific needs of family physicians, constitutes the central nervous system of the practice Redesigned offices Offices should be redesigned to meet changing patient needs and expectations, to accommodate innovative work processes, and to ensure convenience, comfort, and efficiency for patients and clinicians Whole-person orientation A visible commitment to integrated, whole-person care through such mechanisms as developing cooperative alliances with services or organizations that extend beyond the practice setting, but which are essential for meeting the complete range of needs for a given patient population.38 The practice has the ability to help guide a patient through the health care system by integrating care—not simply coordinating it Care provided within a community context A culturally sensitive, community-oriented, population-perspective focus Emphasis on quality and safety Systems are in place for the ongoing assessment of performance and outcomes and for implementation of appropriate changes to enhance quality and safety Enhanced practice finance Improved practice margins are achieved through enhanced operating efficiencies and new revenue streams Commitment to provide family medicine’s basket of services A commitment to provide patients with family medicine’s full basket of services—either directly or indirectly through established relationships with other clinicians Health care provided to children and adults Integration of personal health care (coordinate and facilitate care) Health assessment (evaluate health and risk status) Disease prevention (early detection of asymptomatic disease) Health promotion (primary prevention and health behavior/lifestyle modification) Patient education and support for self-care Diagnosis and management of acute injuries and illnesses Diagnosis and management of chronic diseases Supportive care, including end-of-life care Maternity care; hospital care Primary mental health care Consultation and referral services as necessary Advocacy for the patient within the health care system Quality improvement and practice-based research Traditional Model of Practice New Model of Practice Systems often disrupt the patient-physician relationship Systems support continuous healing relationships Care is provided to both sexes and all ages; includes all stages of the individual and family life cycles in continuous, healing relationships Care is provided to both sexes and all ages; includes all stages of the individual and family life cycles in continuous, healing relationships Physician is center stage Patient is center stage Unnecessary barriers to access by patients Open access by patients Care is mostly reactive Care is both responsive and prospective Care is often fragmented Care is integrated Paper medical record Electronic health record Unpredictable package of services is offered Commitment to providing directly and/or coordinating a defined basket of services Individual patient oriented Individual and community oriented Communication with practice is synchronous (in person or by telephone) Communication with the practice is both synchronous and asynchronous (e-mail, Web portal, voice mail) Quality and safety of care are assumed Processes are in place for ongoing measurement and improvement of quality and safety Physician is the main source of care Multidisciplinary team is the source of care Individual physician-patient visits Individual and group visits involving several patients and members of the health care team Consumes knowledge Generates new knowledge through practice-based research Experience based Evidence based Haphazard chronic disease management Purposeful, organized chronic disease management Struggles financially, undercapitalized Positive financial margin, adequately capitalized - Table 7.
Suggested Program Guidelines to Further the Vision and Mission of Family Medicine Resident Education
Guideline Description Flexibility/responsiveness Ability to provide education in areas needed to meet geographical and community needs Innovation/active experimentation Programs encouraged to try new methods of education, including 4-year curriculum pilot programs, and to teach the cutting edge of evidence-based medical knowledge Consistency/reliability Programs provide a basic core of knowledge and produce family physicians who exemplify the values of the health care system articulated by the Institute of Medicine Individualized to learners’ needs and the needs of the communities in which they plan to serve Programs offer enhanced educational opportunities in areas needed by graduates, such as maternity care, orthopedics, and emergency care Supportive of critical thinking Programs encourage and/or require research and expect a thorough understanding of evidence-based medical practice Competency-based education Programs stress a new paradigm for evaluation of resident performance based on competency assessments Scholarship- and practice-based learning Programs integrate scholarship and quality improvement through analysis and interventions built around patient care activities in the continuity setting Integration of evidence-based and patient-centered knowledge Programs model knowledge acquisition and processing from both perspectives in the patient care setting Medical informatics Programs go beyond just using an electronic health record (EHR) to modeling the broad-based acquisition, processing, and documentation potential within state-of-the-art informatics resources Biopsychosocial integration An emphasis on the interdependence and interplay among different levels of the system—whether it is the cardiovascular system, the individual, the family, the community, or the larger social context Professionalism Programs move beyond the simple objectives of the Accreditation Council for Graduate Medical Education professionalism curriculum requirements into a comprehensive monitoring and feedback system to residents during the critical developmental period of residency training Collaborative and interdisciplinary approaches to all learning Programs provide both support and role modeling for the effective use of teams and interdisciplinary approaches to patient care, including the involvement of other trainees in the process
Supplemental Appendix
Methods
Files in this Data Supplement:
- Supplemental data: Appendix - PDF file, 5 pages, 1.13 MB.
In Brief
In response to the flaws and fragmentation of the US health care system, the leadership of 7 family medicine organizations have released a blueprint for improved, patient focused care. The Future of Family Medicine Project report calls for large-scale changes to the US health care system, medical education and clinical practice. It proposes a new model of patient-centered care in which all Americans would have a "personal medical home." Based on interviews and focus groups, the report offers an objective understanding of what patients want and need from their personal physicians and from America�s health care system, and it identifies challenges and opportunities for the specialty of family medicine.
In this issue
Jump to section
- Article
- Abstract
- PREFACE
- INTRODUCTION
- RESEARCH
- FOUNDATION FOR A REINVIGORATED DISCIPLINE
- BRINGING ABOUT CHANGES IN CLINICAL PRACTICE
- Patient-Centered Care
- Whole-Person Orientation
- Team Approach
- Elimination of Barriers to Access
- Information Systems
- Redesigned Offices
- Focus on Quality and Safety
- Enhanced Practice Finance
- The Basket of Services in the New Model
- BRINGING ABOUT CHANGES IN TRAINING AND CONTINUING DEVELOPMENT
- BRINGING ABOUT CHANGES IN THE US HEALTH CARE SYSTEM
- MOVING FORWARD: THE LEADERSHIP AND COMMUNICATION CHALLENGE
- RECOMMENDATIONS
- Acknowledgments
- Footnotes
- REFERENCES
- Figures & Data
- eLetters
- Info & Metrics
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