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- Page navigation anchor for Dawn After Nightfall: A Perspective from ChinaDawn After Nightfall: A Perspective from China
I studied family medicine in Cuba for seven years, public health in Spain for four years, edited a primary care journal in China for four years, and am currently continuing research in this field.
I'd like to present a perspective shaped by living under different national systems and experiencing various healthcare systems: The fundamental strength of primary care is not a creation of medical technicians, nor a gift from the government. It is inherently intertwined with the needs of the people, bound closely to a state and system that serves the people. The desire to do something for those less fortunate, driven by people's needs and empathy, incites some doctors to take action. These individuals can be supported and organized by a government dedicated to serving its people, fostering the development and growth of primary care.
China's healthcare system, like others, has been entwined with and distorted by capital in the past four decades, making the development of primary care in China incredibly difficult and securing research funding challenging. In recent years, I have been deeply saddened: I may be limited in what I can accomplish in this era, but what I can do is leave knowledge and experience for those possibly born in a better age.
Despite these hurdles, I believe in the power of moral authority that can inspire future generations to act, transcending capital and personal interests. Five years ago, I read seven editorials by Pro...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Restoring humanity to health and health to humanityRE: Restoring humanity to health and health to humanity
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...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Time for Family Medicine to Stop Enabling a Dysfunctional Health Care SystemRE: Time for Family Medicine to Stop Enabling a Dysfunctional Health Care System
I greatly appreciate this article by Dr. Stange. I toiled in the system for many years as an educator and clinician convinced that in my practice lifetime family medicine would become consequential to more than just our patients. I nearly left medicine in despair but found a second wind and my moral compass again by opening up a DPC office in a small Michigan town 7 months ago. With small patient panel sizes DPC is not the immediate solution to health system access issues. However, by removing ourselves from insurance, demanding better in our conversations with patients, employers, and health systems and refusing to participate in the systems that eat us alive we can at least pursue a path that can better serve patients and give us opportunities to really develop the patient-centered relationships and care we hold dear as a discipline. What we have now is not only dysfunctional, but absurd.
Competing Interests: None declared. - Page navigation anchor for Payment Reform and New Family Medicine ResidenciesPayment Reform and New Family Medicine Residencies
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 achi...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Dr. Strange's editorialRE: Dr. Strange's editorial
Dr. Strange’s editorial offers his prescription to cure family medicine in particular and the US health system in general. Like so many others I have read in the nearly 46 years since I entered medical school, it will not work. He offers 2 specific “glimmers of possibility”: direct primary care (DPC) and accountable care organizations (ACOs). Neither is the answer. Per the Robert Graham Center (2019) there are 228,000 primary care physicians in the US. Per the US Census Bureau (2022) there are 333,287,557 persons in the US. If all primary care physicians moved to DPC with “panels of around 500 patients”, where would the roughly 220,000,000 persons not in one of those practices get care? ACOs like all businesses are designed to maximize revenues and profit not improve quality, reduce spending or redesign practices. See, for example, Am J Manage Care. 2021;569-572. https://doi.org/10.37765/ajmc.2021.88795.
I do not know the right prescription, but alas neither does Dr. Strange nor, seemingly, anyone elseCompeting Interests: None declared. - Page navigation anchor for RE: Time for Family Medicine to Stop Enabling a Dysfunctional Health Care SystemRE: Time for Family Medicine to Stop Enabling a Dysfunctional Health Care System
Dr. Stange you voice the thoughts that drove me to explore ways to get back to relationship-based care in 2001. I chose at that time to leverage the concepts ‘lean’ from Jim Womak @MIT, and used technologies to help reduce overhead so that I could remain within the typical insurance reimbursement system while stepping off of the hamster wheel to focus on the needs of patients.
This worked well enough in Rochester NY for the time, though the ever-increasing administrative demands and commoditization of primary care makes this untenable today without exploring alternative approaches to funding.
I’m waiting for the established health care finance system to pay more than lip service for the benefits family medicine brings to society and grow weary of the lack of substantive response to the well-meaning output of committees and commissions. Like Napoleon’s retreat from Russia we are losing too many colleagues and coworkers to the empty coldness of RVUs and metrics focused on body parts.
I join you in recognizing that it is time to stop enabling a dysfunctional system: when we focus on relationship with the whole person we transcend the morass and can deliver on the full scope of family medicine.Competing Interests: None declared. - Page navigation anchor for RE: Dr. Kurt Stange's editorial on enabling a dysfunctional health care systemRE: Dr. Kurt Stange's editorial on enabling a dysfunctional health care system
Dr. Stange's piece was brilliant and articulate, and his proposed solution had a compelling ring to it. I am concerned however that if lots of primary care providers were to move to the (admittedly appealing) direct care model, the eventual result might be a more functional system, but the near term result would be a great many patients unable to access primary care. I wonder if a more practical approach might be for those of us who believe in a system more equitable, accessible, and responsive to patient's needs, to lend strong support to the movement for "Improved Medicare for All." A single payer, publicly funded, publicly accountable health care system that covers everyone, could choose to make the much needed greater investment in primary care (among other improvements) that we are unlikely to see in our current hopelessly fragmented and profit-driven system.
Competing Interests: None declared. - Page navigation anchor for RE: bravoRE: bravo
This should be in every corporate medical office in America. Drs are no longer physicians. They are form fillers, puppets of gov ill informed oversight and the skanky greedy demands of big pharma
Competing Interests: None declared. - Page navigation anchor for RE: Time for Family Medicine to Stop Enabling a Dysfunctional Health SystemRE: Time for Family Medicine to Stop Enabling a Dysfunctional Health System
Amen.
Competing Interests: None declared. - Page navigation anchor for RE: Perhaps time for another eulogy, and another movement.RE: Perhaps time for another eulogy, and another movement.
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 ex...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Stating the obviousRE: Stating the obvious
Well said, Dr. Strange. I doubt anyone would say the system is fine as it is. But as many have pointed out, one physician, one group of physicians, one large physician organization or health system can't change it. Having lived through the 50's and 60's and trained in the 70's I don't think anything short of radical change will fix it. But that won't happen - too much inertia. But maybe if the AAFP stops tip toeing on the subject and begins to put real pressure on Congress and tell the public they are not getting the best medical care they could get. Constant and repeated messages of the system's shortcomings and how it could be improved might get voters to support radical change. Or not. But I know that continuing to do the same thing will definitely not improve things.
Competing Interests: None declared. - Page navigation anchor for RE: Time for Family Medicine to Stop Enabling etcRE: Time for Family Medicine to Stop Enabling etc
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 n...
Show MoreCompeting Interests: None declared. - Page navigation anchor for RE: Time for Family Medicine to Stop Enabling a Dysfunctional Health Care SystemRE: Time for Family Medicine to Stop Enabling a Dysfunctional Health Care System
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 man...
Show MoreCompeting Interests: None declared. - Page navigation anchor for Starting the MovementStarting the Movement
Thank you Dr. Stange for this thoughtful and provocative commentary. As someone who grew up in the discipline reading Gayle Stephens' Family Medicine as Counterculture, and as someone who in my academic practice wrestles with trying to provide the best care, this commentary resonates strongly.
Along with Kevin Grumbach's commentary from the March issue of the Annals, which suggested the need for a movement, I'm wondering how we can kick this movement off? Is this something that our Family Medicine organizations can tackle, or do we need something more grass roots?
As has been said in the past, if we're not part of the solution, we're part of the problem. For myself, I want to be part of the solution. It's time.
Competing Interests: None declared. - Page navigation anchor for RE: Agree with Dr. StangeRE: Agree with Dr. Stange
I totally agree with Dr. Stange.
We started doing much of what he proposes at Michigan in 2019 with moving to capitation, looking at social determinants of health, etc. and even starting to study our interventions. Then the pandemic hit, and changed how Michigan Medicine sees this. It's been harder, with more pressure for us (we've been resisting) to expand our panels, etc. And since we're moving to most docs being employed by institutions, we now have to deal with those as we make this happen.I do think that this is something that will likely require either an institution that is going to experiment and let us try doing this (possible, unlikely) vs. all of us somehow organizing and making change (hard to do, but could really have an impact). Either way, we can't keep going as we have.
Competing Interests: None declared. - Page navigation anchor for RE: Time for Family Medicine to Stop Enabling a Dysfunctional Health Care SystemRE: Time for Family Medicine to Stop Enabling a Dysfunctional Health Care System
It is not surprising to see my colleague and former co-resident of forty years so cogently unearth the soft underbelly of the modern American Health Care conundrum. While so much in the science of medicine has changed over the course of the forty years of our careers, so little has occurred to recognize the failings outlined by Dr. Stange. The obsession with technologies, high-cost cures and therapies, and scientifically unproven treatments has created a top-down system which diminishes caring, compassionate and preventive care. The same challenges wrought the recognition of the specialty of Family Medicine and the establishment of the ABFM in 1969.
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A recent letter published in JAMA (1) which states “The “old style family physician,” formerly the ideal example of medical practitioner who was family councilor and comforter as well as omnimedical adviser, is passing. Several most interesting articles have appeared which have emphasized his worth to the community, regretted his gradual disappearance, and suggested means of bringing him back; but he is the victim of human limitations, and in the “time honored” sense cannot “come back,” because medical science has made it impossible.…” highlights the uphill battle faced by those of us who would join Dr. Stange in his proposed mission.
Although I do echo the sentiment of his proposal to “focus family medicine on delivering the highest quality personal doctoring for the number of people for whom that is feasible, a...Competing Interests: None declared.