Shaping the Future of Academic Health Centers: The Potential Contributions of Departments of Family Medicine

I very much appreciate being asked to comment on the Annal's supplement dealing with Academic Health Centers. I found the issue fascinating and insightful, both in framing the opportunities we face in such an environment and in finding "best practice" solutions.

Using Dr. Newton's lead article as a frame work, there are several thoughts I want to submit.

Our current model for training students is based on a report in the second decade of the last century which called for increasing specialization of medicine. Fifty years later the public reeled against this approach and demanded a return to the idea of a generalist physician, thus the specialty of Family Medicine was born.

The public and lawmakers general embraced this development while AHC's had a more uneven response. Regardless, our specialty enjoyed a heyday of rapid expansion which lasted for the better part of two decades.

We now are in the position of renewing and revitalizing Family Medicine in the light of declining numbers of students choosing the specialty and the aging workforce of practicing family docs.

AHCs play a determining role in what type of workforce is trained and therefore our engagement with these institutions is critical to Family Medicine's success.

It is perfectly clear at this point that Family Medicine provides a significant benefit to populations, societies and individuals by delivering health care that is of higher quality and more cost effective.

Opinions to the contrary, no one who can read a scientific study in an unbiased manor can argue against the volumes of data that show how valuable primary care in general, and family medicine in particular, is to any health care system that hopes to achieve high quality at an affordable cost.

Our current system of medical education has fundamentally misaligned the incentives to train the type of physicians the country wants and needs verses those that bring in large dollars to the AHC from research and procedures.

This must change. The opportunity for FM departments to take the lead in, and get big money from, translational research is real, is better than ever before, and must be acted on now before leadership at NIH changes and this part of medical inquiry is deemphasized.

Through the AAFP's National Research Network, the many Practice Based Research Networks, and NAPCRG, our specialty is uniquely positioned to conduct real landmark studies that will make a difference in people's lives.

We must persuade our deans that the "planning" approach to workforce is just as flawed as the "supply-demand" model of Cooper and both should be replaced by a needs-based approach like the AAFP took in its recent workforce study. That is, determine what the country needs as a workforce to provide a cost effective, high quality health care system, and train that type of physicians.

We must dissuade the deans from the bizzare opinion that many of them now hold that any expansion of medical school class size needs to come with the purpose of increasing the number of sub-specialists. There could not be an idea which is more certain to produce high cost and less quality than this one!

The primary care based model works well for care of populations which are underserved, on Medicaid, are disadvantaged, or who suffer from disparirites in health care. Studies show that increasing the amount of primary care in a population wipes out disparities caused by socoieconomic status. This is a powerful fact.

We need look no further than North Carolina's Mediciad system to see the positive effect on chronic disease and cost that the medical home has. Disease management is best done by physicians who are trained in both primary and secondary prevention and who are masters of complexity science -family docs.

The initiative with Academic Health Centers is a major cornerstone in shaping the future of health care in America. This effort by the Annals to get a handle on what needs to be done and how it may be done is exceptional work and the editors, contributing authors and staff are to be highly commended.

To achieve high quality health care for everyone in the United States, we must have our training institutions putting out the kind of physicians Americans both want and need-Family Docs!

Larry S. Fields MD, FAAFP Board Chair, American Academy of Family Physicians

Competing interests:   None declared