Dinosaurs, Hospital Ecosystems, and the Future of Family Medicine

Hold on there, Dr Paulsen. The train may be boarding, but it is far from leaving the station. While I share many of your concerns, and being of the same generation have experienced many of the same events that you describe, I am not anywhere near ready to say goodbye to the noble experiment called 'family medicine'. The next iteration of family medicine may be evolving in the 'family medical home' project being carried out thoughout the country. Those of us old enough, will recognize the values of this project as the same values you talk about in your response to Dr Glazner's article. The family medical home project seems to me, to be a repackaging of the very aspects of family medicine that inspired us to join this specialty 30 years ago. It is being packaged to accomodate changes in technology, such as an EHR, and to appeal to the public and hopefully the next generation of medical students. But at its core are the basic values of what it has always meant to be a 'full service' family physician.

So I encourage you and others of our generation of family physicians to hang in there. Continue to be a role model for younger students, residents and family physicians. Push your colleagues to be engaged in the most recent projects coming out of the AAFP and other like organizations. Encourage your near-by training programs to push students and residents to embrace the same values that we did when we entered our residency program when dinosaurs still roamed the earth.

Marc Tumerman MD

Competing interests:   None declared

Dr. Glazner has eloquently described what happens to patients when they do not have a personal physician willing to take overall responsibility for their care. We all agree that patients will get the best care and have the best outcomes when each patient has a primary physician that is involved in all aspects of his care. Unfortunately, the vast majority of family physicians have turned their back on this philosophy. Those of us still talking about it are in a small and ever shrinking minority.

I practiced in the same hospital as Dr. Glazner for nearly twenty years. I was welcomed into a collegial medical staff where nearly every specialty was present. I was allowed to do everything I wanted to in the hospital. I participated in medical staff governance and eventually served as Chief of Staff and on the Board of Directors of the hospital. Turf battles were rare. I enjoyed daily interaction with both primary care doctors and specialists and I had a highly competent group of partners to share call with. My job was ideal and I loved it.

Things started to unravel about 3 years ago, and by last year most of my partners had left the hospital. I was faced with the prospect of having no one to share call with if I wanted to continue hospital practice. My group was recruiting new physicians by offering the opposite of what I was offered twenty years ago. When I was recruited, I was told of all the things I could do. Hospital practice was assumed to be an integral part of the job. Now we recruit new graduates with a list of all the things they don't have to do: hospital, OB, ER, procedures, and so on.

I too felt like a dinosaur as I watched all my colleagues walk away form all the things I thought were so great about our medical community. I was left with two choices: embrace the change and go along with it, or leave. I left and now I practice in a tiny hospital in a small town. I fear that my days here are numbered, but I hope I will be able to finish my career without giving up hospital practice. It is hard for me to believe that family practice is dying, but it is. Family medicine was a noble experiment which failed. How can family practice survive if no one is willing to do it?

Competing interests:   None declared

I am a family physician, not a primary care clinician and certainly not a provider. Many Americans – including many in our profession and even some in or specialty – cannot articulate the difference between a family physician and a nurse practitioner, physician assistant or naturopath. I believe the difference must be clear: Physicians have real experience taking real responsibility for people who are real sick. An important part of that experience is obtained and maintained in the hospital setting. Of course, family doctors provide many other important services, most outside of the hospital.(1) Important questions remain.(2) What specific skills and knowledge form the essential core for family medicine? How do we acquire and maintain them most efficiently? Which require ongoing practice? But there should be no question that family physicians have the capability to diagnose and treat – not just recognize and refer – serious illness when it occurs in their patients.

1. Phillips WR and Haynes DG. The domain of family practice: scope, role, and function. Family Medicine 2001;33(4):273–277.

2. Phillips WR. Questioning the Future of Family Medicine. Fam Med. 2004 Oct;36(9):664-5.

Competing interests:   None declared

Dr. Glazner's article illustrates three important roles for the family physician in the hospital: 1) the manager of multiple medical problems for a complex patient with a straightforward problem; 2) the patient advocate/ethics consultant for a patient who's values don't correlate with the consultants' values, or are just not understood and explored by the consultant; and 3) the coordinator of inpatient care with outpatient care. When a family physician is lacking these roles still need to be filled, so the patient gets a hospitalist, an ethicist, an ethics committee, and a discharge planner; all strangers to the patient, none seeing the whole picture, and none responsible to the patient for the whole picture. What patient would not prefer a family physician if the choice were available to all?

I believe family physicians also have other hospital roles, such as the management of many common clinical problems requiring hospitalization (chest pain, dehydration, syncope, common infectious diseases, etc.) As a specialty it is our responsibility to better define these roles, and more explicitly teach them to our residents, our colleagues, and our hospitals. Our residency curricula need detailed definitions of what competencies in inpatient care our graduates posess, and what qualifies them to be board certified. We need to arm ourselves appropriately to fight the privileging battles that are evolving, so that we can continue to provide what we all agree is a very valuable service to our patients.

Competing interests:   None declared

I appreciate Dr. Gillanders thoughtful comments to my article. As he suggests, I am less concerned about family physicians continuing to practice obstetrics than about them pulling out of inpatient care. I do agree with him that it is imperative that we continue to train our residents to practice across the full spectrum of health care, and that means continuing to provide training in adult and pediatric hospital care, as well as obstetrics. What graduates choose to do once leaving is their onus; ours is to present family medicine in its entirety.

I cannot reconcile family physicians arguing that the specialty provides continiuty of care across the health care spectrum, while at the same time consciously and purposefully pulling out of hospital care. Hospitalization is a time when our patients are in greatest need of their primary care physician. How can our specialty argue that we are central to a healthy, functional health care system of the future when we are present for our patients at our convenience, and not their need? We cannot.

This is a critical time for family medicine; the current non-system of health care is crumbling and the future is a mystery. Family physicians must continue to be present and necessary in order to influence that change and be at the core of a future health care system. We have tremendous power as family physicians, but I see a tremendous reluctance to exercise that power.

Giving up is not the answer. Working harder in the old paradigm is not the answer. Training residents to do less is definitely not the answer. The Gen X and Y graduates will be able to adapt systems in ways that we cannot, so it seems even more important they be trained with all the belief and skills that we were by our predecessors.

Dare I say that it is a matter of keeping the faith? If we lose our belief that what we do is meaningful, important and of unmeasurable value, then we have lost already and will become extinct, a footnote in a medical history book. If we maintain our belief that what we do as family physicians is the heart and soul of medicine, we survive and thrive during difficult times of change. Patients benefit; residents benefit; physicians benefit.

It is our choice. May we choose wisely.

Competing interests:   None declared

There is a great deal of discussion in Family Medicine academic circles about to OB or not to OB--witness the lively discussion at the recent PDW meeting. However, I sense that Dr. Glazner feels walking away from the hospital is actually a much bigger threat to the soul of our specialty.

I could not agree more. This is something we have done to ourselves in the name of more efficient use of fixed office overhead, better ambulatory access in the face of 'primary care shortage', and, of course, 'lifestyle'.

However, there is a price to be paid in both the quality of care we provide to our patients and their satisfaction with the quality of the relationship they we have with them.

I can only hope that we are at least expected to continue to train to the level of 'hospital competency', and feel fortunate to be able to retain my hospital skills. It is with considerable regret that I witness the majority of Family Medicine graduates 'bail' on the hospital.

Competing interests:   None declared

I had a housecall only practice, and my patients were often socially compromised with complexities similar or worse than the author's grandmother. They often received terrible care in the hospital due to lack of information. One of the last things I tried could have worked very well. One can see one's patient in the hospital even if they are managed by someone else, even without a request for a consult, though the billing is less. (If requested you use a consult code and then subsequent visit codes, if not just use the latter). All the hours of work trying to get info to or out of that place were suddenly reimbursable, and I didn't have to go every day or make sure I had someone with inpatient privleges to take call when I was unavailable. I didn't even have to have inpatient privleges because I wasn't writing orders. All I had to do was make sure I wasn't duplicating services by using a separate diagnosis code, and since my hospitalists pretty much didn't pay attention to the things I thought were important that was pretty easy. The reason it didn't work for me is it had been too long since anybody in that hospital had done any outpatient primary care, and it was hard to convince my hospitalist's partners how comparably deficient their care had been when they would ignore my faxes about things like history of HCTZ causing hyponatremia. If I had it to try over again I would have found a hospitalist team that "got it" and would have worked with me, even letting me know when my patient was being discharged. Then I could have gotten paid for going over there and reading the chart and discharge orders and preventing the inevitable problems. (It sure beats finding out a few days later when you're expected to fix the problems!)

Competing interests:   None declared

Is maintaining hospital privileges necessary for primary care physicians to feel valued and respected? Maybe. But my experience has been that PCPs who still go to the hospital are just as miserable as those who don't. And nobody is talking about a looming primary care crisis England or Germany, despite the fact that PCPs in those countries don't work (and never have worked) in hospitals.

Primary care is hurting because the American healthcare system has devalued it. That's not going to hinge on whether or not PCPs round in the hospital.

Competing interests:   None declared

"If you only have a hammer, you tend to see every problem as a nail." - Abraham Maslow

As an internist, I have 28 years experience teaching medical students and internal medicine residents. For the past 4 years, I also have taught family medicine residents on their internal medicine rotation.

Family medicine residents and internal medicine residents, as well as their respective faculty, view the entire patient. They bring an entire toolbox to help the patient. They understand the patient’s context.

We cannot overestimate the importance of context. Skilled clinicians consider the complete medical history, including current and previous medications. They understand the social history (and its implications) and the patient’s beliefs and desires. Family physicians have a wonderful perspective on context.

Too often subspecialists have a hammer, and use it regardless. The classic patient situation that Dr. Glazner’s brilliant essay describes is all to recognizable to this reader. Too often I see the problem of too many subspecialists and no single physician in charge.

Too many family physicians and outpatient internists have elected to cede inpatient medicine to hospitalists. As Dr. Glazner describes, they do this for financial and lifestyle reasons. Many hospitalists do a good job at approaching the entire patient. As one who cares for hospitalized patients solely, I know that I have to work harder to understand the patient’s context.

However, too often the family physician is left “out of the loop” during the hospitalization.

Family physicians have the advantage of continuity of context. They have great knowledge of their patients, and understand many issues that are not obvious. They should provide valuable information to the hospitalists or the subspecialists caring for the patient. This responsibility should occur both from the family physicians and from the hospitalists. Hospitalists should involve the family physicians, at least through phone conversations.

Family physicians are losing important experiences when they stop hospital rounding. They less often know their consultants well. They lose some context but not being involved in the hospitalization.

Patients can lose also. Too often patients have multiple soloists treating them, each with their own hammers looking only for their own nails. Patients need conductors for the subspecialty symphony.

While we all understand the short-term benefits of hospitalist programs, I worry about the long term unintended consequences of family physicians staying in their office. We need physicians who care for patients rather than diseases. Family physicians have always filled this role. I hope that they can continue. Our patients do not benefit from fragmentation.

Competing interests:   None declared

I enjoyed the ecosystem article, as I often think of myself and what we are doing in our residency as going the way of the dinosaur.

I'm excited to have started up a hospitalist fellowship at our residency as a response to resident requests for further training and resident desire to stay in the hospital. Isn't this really just adaptation?

Perhaps in our ecosystem, we should leart to ADAPT to changes in our medical "system". My gen x and y learners teach me that having a lifestyle and a profession are not mutually exclusive, and that family physicians can be hospitalists, or "ambulists", or full scope, as they see fit.

What matters most to me is to continue to have choice in deciding what type of Family Physician a graduating resident may choose to be. I am happy to train the undifferentiated stem resident to go to any avenue of Family Medicine. I intend to continue to fight for our right to be at the table, whether it be in a rural office, an urban HMO, a hospital, or the labor and delivery suite.

Competing interests:   None declared