Tuesday, July 24, 2012

Paul D. Simmons, MD, FAAFP
Family medicine is a young specialty, a mere forty-three years old (1).  Unfortunately, family medicine will be extinct before it reaches its 70th birthday if current trends continue and—although I write as a family physician who educates family medicine residents and loves the idea and ideals of family medicine, I say—this might not be a bad thing.  Several forces, both from within and external to family medicine, are conspiring to make us irrelevant, unnecessary and obsolete.  We’ve all seen the Match Day trends (2).  Each year until 2010, fewer medical students pursued training and careers in family medicine, and the slight increases over the last few years are largely attributable to more family medicine residency positions available.  We cannot fill our available positions with US graduates.  Many of those who match in family medicine are trained in a shrinking spectrum of skills.  Many new graduates quickly jettison any broader skills they may have had in the name of work-life balance (3).  Across the country, specialists and insurers implicitly or explicitly argue that family physicians cannot and should not be doing surgical (or non-surgical) obstetrics, endoscopy, minor surgery, ICU care or hospital medicine (4).  We are often complicit in this effort to minimize our domain of practice, again in the interest of lifestyle or avoiding liability.  
As our skills and practice scope are diminishing, a wave of mid-level practitioners (i.e., physician assistants and family nurse practitioners) are moving into primary care medicine (5,6,7).  They share many of our same skills, are able to prescribe and order just as we are in a growing number of states, and are paid less.  Most of these so-called “physician extenders” do excellent work and are viewed as equivalent to physicians by many patients.  It is inevitable that health systems, policy-makers and third-party payers will soon realize—with dollar signs in their eyes—that these practitioners are inexpensive physician substitutes rather than physician “extenders.”  All of the skills, more empathy and a similar scope of practice without the egos or paychecks of physicians.
Sadly, family physicians are ill-equipped to resist our own demise because we lack a clear sense of what, exactly, it is we do.  Not only does the public have little sense of how a “family doctor” differs from an old-fashioned “GP” or an internist, many of us have a difficult time explaining the distinction apart from defensively sputtering, “We’re a specialty, too!”  Family medicine, some say, takes care of 90% of medical problems that present in the outpatient setting.  Of course, so do internists (for adults), pediatricians (for children), and emergency physicians (for everyone).  Family medicine, some say, provide continuity of care over the lifespan.  Perhaps thirty years ago this was true.  Now, however, vanishingly few family physicians will spend a career in the same location, taking care of the same population.  
Even more troubling, however, is a deeper sense of inadequacy within the family physician’s psyche.  Yes, I take care of adults, but can I really do so as well as an internist?  Yes, I take care of children, but can I really do so as well as a pediatrician?  I may deliver babies, but can I really provide the same quality of care as an obstetrician?  If the reader balks at these questions, consider:  if your wife were to experience a pregnancy complication, and you had the option, would you ask for an obstetrician or a family physician?  If your child was suddenly struck with serious illness, would you bring her to a pediatrician or a family physician?  We claim we are “equal” to our specialty colleagues—yet when serious or complex illness strikes those we love, we may find we have been playing doctor and we want a Real Doctor to step in to save us.  Do patients sense this as well?
The larger medical world certainly seems to have detected our impotence.  Family physicians exert minimal or no influence in determining our own payment structure, nor are our protests taken seriously.  The Accreditation Council of Graduate Medical Education (ACGME) frequently ignores or delays our specialty’s recommendations or intentions (8).  The AMA/Specialty Society Relative Value Scale Update Committee (RUC) continues to perpetuate an unjust payment model despite our protests (9).  Family physicians are not the doctors that come to mind when patients think of disease-detecting, mystery-solving “experts” at the Mayo Clinic or Cleveland Clinic, nor do many tertiary- and quaternary-care institutions see a significant role for us in their delivery of medical care.  Our medical journals are of comedically dubious quality, and we seem to be best at publishing, if anything, within the review article genre (10).
Our support for the Patient-Centered Medical Home (PCMH) model, for example, while predicated on admirable ideals, could easily be speeding our demise.  The PCMH model rests on the idea of team-based care, where many of the functions previously carried out by physicians are delegated to nurses, medical assistants and case managers.  This is intended to free up the physician to deal with the “hard” cases for which we are best suited.  The problem is: we are not best-suited.  The endocrinologist is best-suited to deal with the complicated, uncontrolled diabetic patient that cannot be brought under control by the nurse practitioner’s efforts.  Similarly, the cardiologist is best-suited to deal with the refractory hypertensive; the gastroenterologist with the complicated hepatitis C patient.  The family physician, in the PCMH model, is an unnecessary (and expensive) middle-man who has very little to add to the best management efforts of a high-functioning team operating with evidence-based protocols and guidelines.  Inevitably, someone in authority will realize this cost-saving, simplifying fact.
While our specialty shrinks and delegates itself out of existence, some of us take refuge in the ridiculous romanticism of “biopsychosocial” or “patient-centered” or “holistic” flag-waving—as if patient’s would rather have sympathetic hand-holding than competent, efficient, expert medical care.  That’s all fine, of course.  We’re generally nice people.  But while we’re spending our collective efforts on patient focus groups, learning acupuncture, satisfaction surveys, lifestyle balancing acts and “restoring the mystery” to medicine, our colleagues in internal medicine, pediatrics, obstetrics, critical care, surgery and emergency medicine are taking care of actual seriously sick people and showing that they can do a better job of it than we can.  Perhaps we should step aside and let them get back to work.
1.  Piscano, NJ. (n.d.) History of the Specialty. From American Board of Family Medicine website.  Retrieved from https://www.theabfm.org/about/history.aspx.
2.  Porter, S. (2012) Family Medicine Match Rates Increase Slightly.  AAFP News Now, American Academy of Family Physicians.  Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/education-professional-development/20120316matchresults.html.
3.  Kotmire S. (2012) Shrinking Scope of Practice Raises Questions About Future of Family Medicine Training.  Leader Voices Blog, American Academy of Family Physicians.  Retrieved from http://blogs.aafp.org/cfr/leadervoices/entry/shrinking_scope_of_practice_raises.
4.  Should Colorectal Surgeons and Family Doctors Perform Colonoscopy? (2012).  Gastroenterology.com, retrieved from http://www.gastroenterology.com/featured/should-colorectal-surgeons-and-family-doctors-perform-colonoscopy.
5.  Rough G.  (2009).  For many, a nurse practitioner is the doctor.  Arizona Republic.  Retrieved from http://www.azcentral.com/news/articles/2009/02/21/20090221nursepractitioners0220.html.
6.  Horrocks S, Anderson E, Salisbury C.  (2002).  Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. British Medical Journal 324: 819-23.  Summary retrieved at http://apps.who.int/rhl/effective_practice_and_organizing_care/SUPPORT_Task_shifiting.pdf.
7.  Flanagan L.  (1998).  Nurse practitioners:  growing competition for family physicians?  Family Practice Management 5(9): 34-43.  Retrieved from http://www.aafp.org/fpm/1998/1000/p34.html.
8.  Wood J. (2012).  Changing training standards for maternity care. Leader Voices Blog, American Academy of Family Physicians.  Retrieved from http://blogs.aafp.org/cfr/leadervoices/entry/changing_training_standards_for_maternity.
9.  AAFP Opts to Remain in the RUC (2012).  AAFP News Now, American Academy of Family Physicians.  Retrieved from http://www.aafp.org/online/en/home/publications/news/news-now/inside-aafp/20120313rucdecision.html.
10.  Van Driel L, Maier M, De Maeseneer.  (2007).  Measuring the impact of family medicine research:  scientific citations or societal impact?  Family Practice (2007) 24 (5): 401-402.  Retrieved from http://fampra.oxfordjournals.org/content/24/5/401.full.