It is time for family medicine to stop enabling a dysfunctional health care system.
The patient needs that family physicians witness and strive to meet each day are immediate and personal.1 That immediacy, and directly knowing the individuals, families, and communities we serve over time, have impelled us to continue to do whatever it takes to be a force for integration in a disintegrating system.2
But in doing whatever it takes, we have enabled the larger system’s avarice and depersonalization to grow. We have unintentionally become part of the problem by holding together an unsustainable, unfair, and too often ineffective system.3 Every day we witness the needs of people we are no longer able to help, as we crank patients through and tick boxes to meet so-called productivity and quality metrics. This is a perfect recipe for the burnout, moral distress, and depersonalization that are rampant among clinicians, staff members, and patients.4-6
We can’t do it anymore.7-10 We are burned out, not as much by overwork as by under value—stuck in a system that asks us to meet business goals first and patient needs with what time and energy is left over. We are like the hobbled parent, a step too slow to rescue her child from running into the busy street. We are the line worker, dutifully tightening a couple bolts on a jalopy when we are trained and motivated to lead teams building Ferraris. We are the unreplenished main course of a buffet in which the dessert side of the table has been so oversupplied that most diners are left starving while a few grow corpulent.
Our hallowed role as the front door for people seeking health, healing, and connection11 has been relegated to the position of weathered doormats for a system bent on optimizing its ability to deliver and be paid for commodities.12,13 But as was pointed out by a recent National Academies report, primary care is a common good that benefits and is deserved by everyone.14 The health it seeks to foster fundamentally emerges from relationships.15-27 Our system has lost the thread of connected, personalized care because it has not invested in supporting family physicians who provide the majority of the care that people need.28 It has not invested in or prioritized the relationship bank of the personal physician that can be drawn upon with interest when the chips are down.29,30
The many well-intentioned patches designed to improve primary care have added untenable administrative burden,9,10 made care less available and less open to the patient’s agenda,31 and have diminished and demoralized the workforce.32 How ironic is it that we take the most complex task in medicine—integrating, personalizing, and prioritizing care for whole people—try to cram it into 10 minutes, and pay those doing this work less than those providing narrow technical care?
What if we stop asking an insufficiently sized and undersupported primary care workforce33,34 to assume the responsibility of holding together a fragmented and failing health system? What if, rather than just providing the easiest, simplest medical services for all Americans, we focus family medicine on delivering the highest quality personal doctoring for the number of people for whom that is feasible,35 and let the resulting growing demand drive the needed systemic changes?
What if, for the moment, we worry less about the number of people we are training and more about the situations in which they will be practicing? What if we offer care that is so personal and effective in advancing health, healing, and connection that students clamor and compete to enter our training programs—care for which patients create such demand that payments to generalist personal physicians began to exceed those to narrowly focused technical providers? What if we make urgent care unnecessary for our patients, and emergency and hospital services a rarely used but well-integrated part of care? What if we show that a recent call for a new specialty for patients with perplexing conditions36 is unnecessary if people have a personal family physician who knows and cares for them over time in their family and community context?
Now is the time to invest in developing primary care that is able to serve as the foundation of an effective, sustainable, and fair health care system.
Accessible personal doctoring by well-trained, well-supported family physicians with reasonable panel sizes would create demand among patients, health care systems, and medical students for the thing we actually most value—care in the context of ongoing relationships with a person who has earned our trust.37,38 The market, which currently is driving fragmentation and low-value expenditure, would then be disrupted toward supporting and expanding the short supply of family physicians offering personal doctoring.
Re-energizing the internal motivations and professionalism that have been co-opted by external command and control metrics21 would begin to unknot the tangled problems of burnout and low student interest.39 It would enable on-the-ground action to personalize care for the disadvantaged and provide time with patients to address the social and environmental drivers of health that also require complementary systemic solutions.
Some, by necessity or choice, will need to keep working in dysfunctional systems. As a transitional phase, some will need to continue in the current protocol-driven primary care system, even as a growing number of others show the benefits of more sophisticated primary care. But the more family physicians who insist on and create practice situations that support them in using their full skills to meet the needs of their patients and communities, the more people will see that having a personal physician is not a dream from the past but a reality for today and a feasible foundation for a functional health care system of tomorrow. The more of us that can work in practices and systems that allow our “family doctorness” to shine, the sooner we’ll reach a tipping point in which the high-level generalist personal doctor becomes the valued norm for nearly everyone.40
We already see glimmers of possibility for re-energizing the role of the personal family physician in the actions of direct primary care physicians who care for mixed panels of working poor and more-advantaged patients, charging an accessible monthly subscription fee to assure all primary care for panels of around 500 patients.41-44 We see the systemic possibilities in physician-led accountable care organizations that have improved quality and controlled costs by investing in on-the-ground knowing and relationships and use that capital to selectively contract for targeted use of more specialized services.45,46 We see hope in the eyes of a new generation that wants to model in their own lives the fairness, balance, and health they seek for their patients.
When Annals of Family Medicine was launched two decades ago47,48 as an unprecedented collaborative forum,49 the discipline believed that we should strive to prepare one-half the health care workforce that would provide a “basket of services” for a “New Model of practice.”50-52 Embedding that experiment in a system that knows how to take, but not to give, doomed it to failure. We now have the opportunity to move from a broken system, that supports us only in providing commodified services, toward a system that values and invests in healing and health-promoting relationships with our patients and communities. By refusing to enable our dying system, we can plant the seeds for the rebirth of health care that starts with the whole person and then focuses on the parts only in the context of knowing and connectedness.30,53,54 We can show that the personal doctoring that fosters health and healing is possible. This is not a pipe dream. We can be the change we wish to see.
Acknowledgments
I am grateful to Olivia Dhaliwal, Rebecca Etz, Robin Gotler, Larry Green, and Will Miller who provided very helpful comments on an earlier version of this editorial. I appreciate the many valiant family physicians and other primary care clinicians who swim upstream every day against a system that makes it so challenging to use their skills to make a difference in peoples’ lives. I am grateful for the support of the University Suburban Health Foundation Wisdom of Practice Initiative and a Distinguished Scholar fellowship from the American Board of Family Medicine Foundation.
I appreciate the invitation from the Annals of Family Medicine editorial team to write an editorial as part of their celebration of the Annals of Family Medicine’s 20th anniversary. And I am grateful to the vision of the leaders who birthed Annals, and gave someone who originally had no desire to be an editor (me) a chance to serve in that role for 17 years. I am thankful for the continued support of the sponsoring organizations, editorial and publishing teams, and contributors who have made Annals of Family Medicine a forum for the knowledge we need49 to support the kind of personal doctoring espoused in this editorial.
Footnotes
Conflicts of interest: author reports none.
- Received for publication March 4, 2023.
- Revision received March 4, 2023.
- Accepted for publication March 22, 2023.
- © 2023 Annals of Family Medicine, Inc.
