Family, Medicine, NAPCRG, and the Great Mandella

(Excerpts from acceptance of the Maurice Wood Award at the North American Primary Care Research Group Annual Meeting, Seattle, Washington, 2010.)

In the mid 1970s, I remember NAPCRG as a small band of family physicians, none professing to be a researcher, but all believing that the future of medicine should be created out of the best evidence, in an apolitical and non–discipline-specific environment. Those initial years of NAPCRG were marked by a fervent desire to describe and understand our practice and create and use tools for practice and research. Inquisitiveness about practice kept the physician vital, improved practice, and if systematic, was “research.”

Before computers or even electric typewriters had come to medicine, the small group constituting NAPCRG was interested in the generalist physician’s role in all settings and developed new practice research tools and measurement systems that would allow us to understand our world. In 1976, our world shook. Maurice Wood’s group published what became known as the “Virginia Study” using data from half a million visits.

Through those years a small group of us in the new breed of residency-trained faculty interested in research formed bonds that have lasted a lifetime. NAPCRG became the mentored environment wherein our ideas could blossom. With the support of our mentors, the Ambulatory Sentinel Practice Network became a vehicle for our discipline’s research. And the International Primary Care Network helped convey to other countries the excitement of research in North America.

In 1985, I surveyed all departments and residencies of family medicine in the United States and found that no family physician faculty had received NIH support for research fellowship training or other federal career research support. We’ve come a long way since then. However, many of the challenges are the same. Mau-rice Wood’s generation viewed themselves and family medicine as outside of mainstream medicine with no voice in most medical schools or in the enterprise of medicine. In contrast, my generation grew up in the halls of medicine, and saw the possibility of becoming a part of the house of medicine.

We are now at a point where we will become the core of the house of medicine as demanded by health care reform, Accountable Care Organizations (ACOs), and Patient Centered Medical Homes (PCMHs). However, we desperately need the guidance of research inspired from the world view of the generalist and driven by the core principles of primary care—access, comprehensiveness, and continuity, and the ability to provide coordination and accept accountability for quality and cost.

I want to share observations regarding 3 threats and opportunities.

First, for our patients, the nodal points in their medical lifespans are when they need access to us and our guidance. If we abandon our roles in the hospital, including in maternity service, we forfeit major value for our patients, and give up a major opportunity to guide the development of medicine for decades to come.

Second, while much of our focus as generalist physicians has been on our relationship with our specialist colleagues, we need as much emphasis on engaging over the long-term with the communities where our patients live. How we leverage our roles as physicians in communities has been a theme explored at NAPCRG. Unfortunately, we have not had powerful research tools to describe and disseminate these community outreach initiatives and bring them into the mainstream of practice. Yet PCMHs will need to mobilize the power of their communities in like manner.

The third opportunity we have is the “4th dimension.” Time is fundamentally different in primary care than for our specialist colleagues. This is due in part to the tyranny of the office visit and the 1-year medical insurance contract. Diagnosis, the prized focus of specialty care, is cross-sectional; prognosis, central to primary care requires the dimension of time. How do we as healers interact with our families around time? Time will be a critical dimension to optimize and measure the performance of the primary care team nested in the PCMH and the ACO.

At my stage of life, while I still enjoy the mentor-ship of Maurice Wood, I find my greatest joy in mentoring others. For those who are successful mid-career investigators, I extend a job offer. Your discipline needs you. Over the next few years, there will be many openings for chairs of departments. Right now few departments have chairs with research backgrounds. If you are a successful seasoned investigator, you likely have refined the skills that will make you a magnificent departmental and institutional leader. The rewards of mentoring a department have been the highlights of my life and have allowed me opportunities to have far greater impact through research being conducted by mentored faculty than I would have as an investigator. When the time and opportunity come in your life, take up the challenge.

• © 2011 Annals of Family Medicine, Inc.