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Research ArticleFinal Report

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

Future of Family Medicine Project Leadership Committee
The Annals of Family Medicine March 2004, 2 (suppl 1) S3-S32; DOI: https://doi.org/10.1370/afm.130
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Figures

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  • Figure 1.
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    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.
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    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.
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    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

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    Table 1.

    Simple Rules for the 21st Century Health Care System

    Current ApproachNew Rule
    Source: Crossing the Quality Chasm: A New Health System for the 21st Century.41
    Care is based primarily on visitsCare is based on continuous healing relationships
    Professional autonomy drives variabilityCare is customized according to patient needs and values
    Professionals control careThe patient is the source of control
    Information is a recordKnowledge is shared and information flows freely
    Decision making is based on training and experienceDecision making is evidence-based
    Do no harm is an individual responsibilitySafety is a system property
    Secrecy is necessaryTransparency is necessary
    The system reacts to needsNeeds are anticipated
    Cost reduction is soughtWaste is continuously decreased
    Preference is given to professional roles rather than the systemCooperation among clinicians is a priority
    • View popup
    Table 2.

    Distribution by Specialty of the Usual Source of Care for People With Selected Conditions and a Physician as That Usual Source

    ConditionFamily Medicine %General Internal Medicine %General Pediatrics %All Others %
    Note: Data are based on 1996 Medical Expenditure Panel Surveys.
    Atherosclerotic cardiovascular disease56310.014
    Stroke56340.99
    Hypertension63280.28
    Diabetes67230.610
    Cancer60262.311
    Chronic obstructive pulmonary disease62225.411
    Asthma581520.86
    Anxiety/depression62207.011
    • View popup
    Table 3.

    Key Attributes of Family Physicians

    AttributeDescription
    A deep understanding of the dynamics of the whole personThis 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’ livesThis 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 experienceThe 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 complexityFamily 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 accessibilityFamily 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
    • View popup
    Table 4.

    Characteristics of the New Model of Family Medicine

    CharacteristicDescription
    Personal medical homeThe practice serves as a personal medical home for each patient, ensuring access to comprehensive, integrated care through an ongoing relationship
    Patient-centered carePatients 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 approachAn 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 accessElimination, 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 systemsThe 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 officesOffices 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 orientationA 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 contextA culturally sensitive, community-oriented, population-perspective focus
    Emphasis on quality and safetySystems are in place for the ongoing assessment of performance and outcomes and for implementation of appropriate changes to enhance quality and safety
    Enhanced practice financeImproved practice margins are achieved through enhanced operating efficiencies and new revenue streams
    Commitment to provide family medicine’s basket of servicesA commitment to provide patients with family medicine’s full basket of services—either directly or indirectly through established relationships with other clinicians
    • View popup
    Table 5.

    Basket of Services in the New Model of Family Medicine

    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
    • View popup
    Table 6.

    Comparison of Traditional vs New Model Practices

    Traditional Model of PracticeNew Model of Practice
    Systems often disrupt the patient-physician relationshipSystems 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 relationshipsCare 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 stagePatient is center stage
    Unnecessary barriers to access by patientsOpen access by patients
    Care is mostly reactiveCare is both responsive and prospective
    Care is often fragmentedCare is integrated
    Paper medical recordElectronic health record
    Unpredictable package of services is offeredCommitment to providing directly and/or coordinating a defined basket of services
    Individual patient orientedIndividual 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 assumedProcesses are in place for ongoing measurement and improvement of quality and safety
    Physician is the main source of careMultidisciplinary team is the source of care
    Individual physician-patient visitsIndividual and group visits involving several patients and members of the health care team
    Consumes knowledgeGenerates new knowledge through practice-based research
    Experience basedEvidence based
    Haphazard chronic disease managementPurposeful, organized chronic disease management
    Struggles financially, undercapitalizedPositive financial margin, adequately capitalized
    • View popup
    Table 7.

    Suggested Program Guidelines to Further the Vision and Mission of Family Medicine Resident Education

    GuidelineDescription
    Flexibility/responsivenessAbility to provide education in areas needed to meet geographical and community needs
    Innovation/active experimentationPrograms 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/reliabilityPrograms 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 servePrograms offer enhanced educational opportunities in areas needed by graduates, such as maternity care, orthopedics, and emergency care
    Supportive of critical thinkingPrograms encourage and/or require research and expect a thorough understanding of evidence-based medical practice
    Competency-based educationPrograms stress a new paradigm for evaluation of resident performance based on competency assessments
    Scholarship- and practice-based learningPrograms 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 knowledgePrograms model knowledge acquisition and processing from both perspectives in the patient care setting
    Medical informaticsPrograms 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 integrationAn 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
    ProfessionalismPrograms 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 learningPrograms 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

Additional Files

  • Figures
  • Tables
  • 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.

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The Annals of Family Medicine: 2 (suppl 1)
The Annals of Family Medicine: 2 (suppl 1)
Vol. 2, Issue suppl 1
1 Mar 2004
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The Future of Family Medicine: A Collaborative Project of the Family Medicine Community
Future of Family Medicine Project Leadership Committee
The Annals of Family Medicine Mar 2004, 2 (suppl 1) S3-S32; DOI: 10.1370/afm.130

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The Future of Family Medicine: A Collaborative Project of the Family Medicine Community
Future of Family Medicine Project Leadership Committee
The Annals of Family Medicine Mar 2004, 2 (suppl 1) S3-S32; DOI: 10.1370/afm.130
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  • 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
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