Payment 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 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.