Time for Family Medicine to Stop Enabling a Dysfunctional Health Care System

Thank you, Dr. Stange, for your insightful essay. Your piece serves as a poignant reminder that the core problem runs deep. Family medicine, as a discipline, was initially established on the foundations of a holistic understanding of health, aligning with the 1948 World Health Organization definition. https://www.who.int/data/gho/data/major-themes/health-and-well-being

Family medicine conceptualized health as the comprehensive integration of physical, social, and overall well-being. Health, in this sense, encompasses the capacity to adapt to changing circumstances within the framework of nurturing relationships with oneself, others, the community, and the wider world.

Unfortunately, family medicine's perception of health directly clashed with the depersonalizing, reductionist, disease-centered biomedical definition. Consequently, family medicine has often been viewed as a counter-culture discipline, marginalized from its inception. This conflict surrounding differing health paradigms has led to the absence of an explicit national definition of health in the United States. https://pubmed.ncbi.nlm.nih.gov/37343061/

Instead, the US healthcare system has appropriated certain aspects of family medicine's language, such as "person-centered care" and even "social determinants of health." These concepts have been commodified within a biomedical model of health. Regrettably, the implicit definition of health within the US healthcare and research realms is biomedical. The healthcare system reimburses based on billing for procedures (CPT codes) related to specific diseases (ICD-10 codes), delivered through isolated clinician-driven visits. Disturbingly, as family medicine has become integrated into larger healthcare systems, it too has been assimilated within the biomedical model, resulting in family medicine's commodification and deconstruction. The biomedical model is fatally flawed. It is incapable of enhancing population health at reasonable cost, much less doing so equitably.

To establish a functional healthcare system, the first step is to define and operationalize what health truly means to us. The National Academies of Sciences, Engineering, and Medicine have provided guidance through their reports on Implementing High-Quality Primary Care and Achieving Whole Health. However, the biomedical model remains deeply entrenched within what Henrich (WEIRDist People in the World, 2020) describes as a WEIRD culture: Western Educated Industrialized Rich Democratic, founded on reductionism. While reductionism can be a powerful tool in medicine and the world at large, it should not be deployed to diminish our humanity or depersonalize care. Creating a functional healthcare system necessitates a restoration of humanity to the concept of health and more broadly, health to humanity.

So many responses here and across the country applaud what Dr. Stange has written, and then proceed to statements of impediments followed by a yearning for an equation that answers--HOW? Maybe "it is time" to file the complaints safely in our backpacks, and pour every ounce of energy into creating the new world of family medicine, together with the many patients and healthcare professionals that share family medicine's dismay, including subspecialty physicians and inspired community leaders. I too wonder about how to proceed.

The first era of Family Medicine commenced with inventing mostly community-based family medicine residencies that radically placed at their center outpatient, rather than hospital based education and training, often birthed out of existing, outstanding local general practices. The second era this article envisions could repeat this history not to replace general practitioners, but to create the best personal physicians ever, positioned to traverse and connect hospital, practice, community, and home. Continuity can finally be achieved, escaping the constraints of geography. Comprehensiveness can be enabled by rapidly accessible knowledge and intentional adoption of technologies not previously available, e.g. genetics, AI, wearables. Coordination and integration of care will require time to think and know patients well, strong doctor/patient relationships, strong inter-professional teams, information systems designed to achieve patient goals and continuously improve care. None of this is fantastical; there is capacity and experience to be marshalled.

This can't flourish in current business arrangements. For FM residencies to redesign to graduate the personal physicians necessary for this new model of care, there must be simultaneous, fierce pursuit and insistence for a revised investment strategy for primary care--both graduate medical education and local practices where people liive, work and play., and where the new graduates will hold forth as community leaders. The outcome of revised investment must yield more revenue than these new residencies and practices cost. There is plenty of money that could be redirected. To do so requires assembling power. Road maps to guide this journey are available in the 2014 IOM GME report and the new NAM primary care report.

Can the current family medicine, pediatric, and internal medicine organizations jettison what in the current milieu are minor differences and unite and launch an offense to advance a proper foundation of highly personalized and prioritized care for all? If not, then a key next step is to create a new one. "It is time" to act, knowing these ideas are powerful enough to prevail, eventually. People in need are waiting.

Everything that Kurt Stange writes is accurate; a great summary of how we got to the place we are and the factors that impede practicing the kind of personal care that family doctors want to provide for patients and their families. But if we are enabling the current system through our passivity in the face of forces committed to control rather than education, about stockholders, marketing and convenience rather than care and relationships, then we have to examine our own role in that process.

In 1964, Nicolas Pisacano, who became the first president of the ABFM wrote "General Practice: A Eulogy" which was published in GP Magazine with a forward by the editor saying, repeatedly, "he doesn't speak for us, he writes his own point of view". An apology by an editor BEFORE an article appears is unusual, as Dr. Stange and Dr. Richardson would attest. But the opening line likely struck a chord: "Most of us by now recognize that the species known as the general practitioner is all but extinct". Pisacano was advocating, five years before family medicine came into existence, for a rapid move to revise and restructure graduate education, not dwell in the past but move into the future, and take on the American Medical Association and, more importantly take on the doubters in the American Academy of General Practice. He and his colleagues knew the path would not be easy. But many family doctors around the country knew that not changing meant extinction. In fact, a published manuscript about general practice showed that, without radical modification in training that would attract students to family medicine, GP's, would disappear by 2010 (Fahs and Peterson Public Health Reports 1968).

Family Medicine has not disappeared but it is threatened once again. What might enable, in the positive sense, a thriving future for family medicine is another reinvention - one that would retain the principles of care that Dr. Stange outlines while engaging what Grumbach has called "Counterculture professionalism" and marching figuratively (and perhaps literally) with patients, communities, health professionals in a social movement to create primary care for all as a common good. It is time to get going.

As a Family Physician in practice for 44 years, 13 in a group of Family docs, 10 years in "institutional medicine", and the past 18 as a solo doc, I 100% agree with Dr. Strange. My experience in the first 13 years of practice was along the lines of his model. The cracks in the Family Doc providing relational, ongoing, take-enough-time care began in 1985 (in the Seattle-Tacoma area) with the local Blue Shield plan offering us 85% of "usual and customary fee" if we joined their network...which all of us had to do in order to refer to the secondary specialists as we had been doing, and because doctors are not allowed to share reimbursement information (anti-trust...anti - "trust"). That is now ~25% discount on disproportionately lower fees than the secondary specialists command.

My one question to Dr. Strange is this: How?

Convince docs to leave hospital-led practices? with no guaranteed salary, no health benefits, no income until patient base is built up...and possibly a non-compete clause to deal with?
Convince students and residents to take up the cause when they face those first three challenges and have massive debts to pay?

My fear is that the Family Physicians who lead the charge to this new (former and better) model of care will end up like the revolutionaries of Les Miserables , plowed under by the combined forces of institutional medicine, health (sic) insurance companies, politics, et al. I devoutly hope not.

I agree with Dr. Stange's diagnosis - our health care system is seriously ill and in need of radical treatment. I also agree with Dr. Hays that the recommended treatment is unlikely to succeed. Family physicians, or all primary care clinicians, are unlikely to be willing or able to start refusing to care for substantial numbers of patients in need in order to force action on a crisis in access to primary care. Were we somehow to precipitate such a crisis, we should also be cognizant that it takes far less time to produce nurse practitioners and physician assistants than board-certified primary care physicians.

A smaller proportion of physicians are in private practice now than in the past; employed physicians typically have little or no control over their scheduling/workload. The growing role of private equity firms in owning medical practices should not be overlooked, either - their goal is to extract money, not improve health care.

This problem cannot be fixed without addressing a major cause of the dysfunction in our health care system - private health insurance and fee-for-service payment. We cannot continue to ignore the huge direct and indirect costs driven by this dysfunctional system. It is more of a blue whale than a mere elephant in the room. Direct Primary Care may offer a better way for some clinicians to provide high quality, personalized care for patients and make a good living while working sane hours, but it is not an option for many patients, nor something that clinicians like me in America's health care safety net, can contemplate. Tinkering with wRVU values continues to fail to address the overvaluing of procedural vs. cognitive services as conversion factors are adjusted to avoid decreasing specialist payment or increasing overall payment.

I think the only way we could get to a substantially more functional system is to start with moving to a single-payer health care system, giving us substantial, immediate savings and eliminate huge amounts of practice overhead. If the system were capitated and primary care clinicianswere responsible for reasonable, risk-adjusted patient panels, we would then have the flexibility to address patient needs in whatever manner was most appropriate - office visits, video visits, telephone calls, patient portal messages, etc. Not worrying about "billable visits" would allow formation of provider teams that could better provide needed services more efficiently and cost-effectively.

Alas, I never expected when I started my career that, near the end of it, we would have made so little progress toward a more sensible, efficient, and patient-centered system. We probably cannot get there without major action to force change in our dysfunctional system. But I don't think the actions suggested by Dr. Stange will happen or, if they did, be enough to create the change we need. I doubt we could ever get agreement on a system-wide strike of primary care (and hopefully other) clinicians, but I suspect that nothing less than that would lead to meaningful change.