You may be surprised at what family physicians do

There are surprising misconceptions about what family physicians actually do in practice.

Americans maintain a fond respect for the classic image of the family physician, making house calls with black handbag in tow. They admire the Marcus Welbys of the world. While this classic image is endearing, it should not be confused with the 21st century family doctor.  The modern family physician is trained to engage in the adaptable world of health care and systems innovation. The face of family medicine is certainly changing as it responds to the needs of both patient and community. However, the tradition of compassion and personal relationship remains intact. So, while some may suggest that family physicians are a dying breed, we contend that family physicians are a flexible and essential component of the next generation of medicine.

To be upfront, we are all faced with a seriously challenged health care system – one that is outrageously expensive, poorly coordinated, and generally not accountable for outcomes. The problems are manifest in lack of transparency, inefficiency of communication and continuity, and absence of personalized care.
So, what then, does our health care system need more than anything else?  Our answer is the ingredient that brings sanity, cost effectiveness, quality of care, and patient centeredness: the family physician.

An important agent of necessary practice evolution is the family medicine training program.  These programs are purposefully and actively working to provide better tools for the new generation. For the Marcus Welbys 2.0. The new “tools” in the next generation black handbag for family doctors include population health management, flexible usage of technology, advocacy, teamwork and communication.  Family medicine residency  programs from around the country have already begun to develop teaching opportunities  to address areas such as (1) population data management and community engagement; (2) adaptable integration of technology; (3) awareness and involvement in active patient advocacy; and (4) clinical team dynamics. This will allow future generations of family doctors to address patient, community, and system needs in a new and unique manner that can provide a better chance for success in our rapidly changing health care environment.

We are the Marcus Welbys of the new generation, uniquely trained and with versatile experience.    Family medicine residents spend nearly 10,000 hours with patients before our first day of practice beyond residency.  This training allows us, collectively, to fill essential niches in health care, such as sports medicine, geriatrics, women’s health, obstetrics, complementary and alternative medicine, occupational medicine, and global health.  It is this versatility that comes from being the only field that is not limited by patient age, sex, or organ system. While our scope of practice and expertise may certainly change in the near future, none can argue that the paradigm of family medicine is unique and essential to patients and the communities in which they live.

One of the most important services we provide is the ability to assess a patient with a high level of integrative analysis – those 10,000 hours after medical school give us the experience and intuition to work through complex cases.  Meanwhile, our focus remains on the whole patient, with the complete nature of all of their illness and wellness, as well as associated family, social, and community circumstances. This ability compensates, in many cases, for the siloed and uncoordinated management patients often receive in our current system, a system in which one in four Medicare beneficiaries sees 13 physicians each year, and fills 50 prescriptions in that time. A family doctor can juggle multiple chronic diseases in a single visit, can refer based on procedural need and therapy recommendation with the workup already in progress, can handle multiple intersecting decisions, and can recognize those rare case zebras.   Family physicians are trained to handle complexity well, and to integrate assessment and planning.   

Our diverse and comprehensive training means that we can practice in environments with a limited physician supply, and provide services that otherwise patients might need to travel hundreds of miles to receive.  Because family physicians can serve many of the functions provided by multiple specialists, we are particularly well suited for underserved settings.  Additionally, we are the only medical specialists that are distributed geographically in the same proportion as the general population. We are there for just about anybody and everybody.

We are also particularly dedicated to seeing the patient in the context of his or her family and community.   Our broad knowledge base and big picture approach to care also means that a single family physician in an under-served setting can apply skills to most of the needs of that community and its members.  What results are opportunities, even on a world stage, such as a family physician traveling to a remote province of Haiti to construct a health delivery system from scratch.  And it is one reason why family physicians make good Surgeons General to serve the needs of the national community, at home in the U.S.

Looking to the future, today’s family physician trainees enter a world of teamwork and collaboration in health care delivery and continue to engage in systems development and quality improvement. Family medicine residencies continue to find ways to balance service with education and to streamline the training of successful and productive family physicians in modern health care. The kind of family doctor that is best for patients, community, and the profession.

So, what does an outrageously expensive, poorly coordinated, and largely unaccountable health care system need more than anything else?  Family physicians who can provide versatile care in multiple areas of need, who often make the difference between quality care and no care, who can add higher level multifactorial assessment to undifferentiated and complex cases, who are cost-effective, and who are dedicated to service to their communities, often underserved.  We of course cannot exist in a vacuum without colleagues in our collective national health care team, but training and experience allow us to do all of these things well in a system that needs more of exactly this kind of integrated and wide-ranging care.

One more thing.  If you have the opportunity, please tell a family physician you appreciate this effort!

Aaron George is a family practice resident who blogs at Future of Family Medicine. Dennis Gingrich is a family physician.

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  • http://womanfoodshinyobjects.wordpress.com/ Brian Stephens MD

    without proper TIME spent to communicate and advocate with patients, the above is meaningless.

    without proper payment for Family doctors to do this work, the above is meaningless.

    without physicians having some respect and authority to be proper medical decision makers for the good of public health (vs lawyers, the masses, and politicians), the above is meaningless.

    without real physician organization and leadership, the above is meaningless.

    we have none of these things.

    • Doug Phelan

      I say this as a student who is looking to go into family medicine – with the utmost respect, seeking to perhaps look at things in a different way.

      With regards to time – I agree, can’t think of anyone who wouldn’t. But more time seems like it will always be something to fight for.

      With regards to payment – the reimbursement rate is being slashed on specialists every year – first the cardiologists for echoes and EKGs, then the GIs for scopes. With few exceptions, it’s looking like that field will level. Yes the way things are going re: payment has plenty of remaining problems, but it would seem primary care is getting more of an emphasis, no? Maybe not to where it should be, but trend it out and then get involved to keep it going.

      With regard to physician respect – what of this “Patient Centered Medical Home” model? To borrow from a talk I heard recently, it would seem plenty has been done on the patient-centered-ness and medical aspects. Plenty has been done about finances, and hours, and forms, and paperwork. But how much has been done about making it a “home?” How are we building relationships with patients so as to become more trustworthy than the politician, than the media? Building a team within the office, so that everyone who has contact with the patient (often for more time than the physician) is welcoming that patient to the home? To be the person who even when bad news needs delivering, can hold that position of trust so that communication is appreciated for its knowledge and sincerity? Interpersonal dynamics would seem to loom large over this conundrum.

      With regard to physician leadership (and your previous comments I perused), how do we intend as a group of physicians to make any national organization count (AMA, AAFP, etc.) if we don’t get our hands in there and our voices counted? Constituant governance only works with active constituancy, 57.5% of the population turned out for the last Presidential Election. Why can’t we as physicians – who surely seem to deal with more urgency and reality than politicians – get at least that? Coach always told us as kids, “You lose 100% of the games you forfeit.”

      We may not have *some* of these things, but we can surely fight to get them. I yield that my youth carries an excess of idealism, but I – and many of my generation – simply cannot lay by and have a healthcare delivery happen to us.

  • http://twitter.com/gcgeraci Gaspere (Gus) Geraci

    Well said, and good comments, Dr. Stephens.

  • http://warmsocks.wordpress.com/ WarmSocks

    One patient here who greatly appreciates family physicians. Thank you!

  • shiriegale

    As one who has been castigated on this site for “dissing” primary care doctors, let me say that your flexibility and willingness to incorporate community and public health concerns as well as electronics and technology will stand you in good stead in the future. Primary care will survive and thrive as it should; your field will need to be a flexible as you are.

  • ninguem

    As long as there’s a form to fill out, as long as there’s a medical service that’s time-consuming and unpaid, there will always be a need for family physicians.

  • http://www.mightycasey.com/ MightyCasey

    Since specialty medicine grew to 70% of MDs in the ’60s (ironically, the same decade that Marcus Welby started making weekly house calls on American TVs), the family practitioner has become the grunt of the US healthcare system. They earn, on average, 50% of what a specialist earns, but are expected to be the experts on population trends.

    FPs are dancing as fast as they can, but this game of musical chairs has run out of chairs and they’re left standing every single time the music stops. Until we move off of a disease-management model of “health” care, and toward a model of prevention and actual health, we’ll be stuck in our current circle of hell.

    • meyati

      They had General Practitioners before specialists. They have always been the grunts. I had a GP-as they were called back then-that made house calls in the 1940s. My GP, George Starr, DO, MD, and doctor of veterinary medicine, applied anesthesia and took out my tonsils, did a hysterectomy on my mother in the 1950s, was a certified cardiologist, took care of my Achilles tendon problems caused by being on the track team. He delivered babies. Chased me around the office to give me shots- along with my father and uncles trying to catch me. This was in Los Angeles. He saved the life of a motorcycle cop on the Philly campus of U of Penn. He and Penn were sued because of cop’s brain damage. The school had to give him free education for the rest of his life. Something new came out- he packed up moved into a dorm with the kids and became a specialist in a new field or updated himself. He said that being a specialist would be too boring and sad— cardiologists at Mt Sinai consulted with him.

      • http://www.mightycasey.com/ MightyCasey

        I’m a huge fan of GPs/FPs. Specialty medicine didn’t really arrive until the ’60s of the last decade: all docs were MDs, if they developed a speciality it was due to community need, not self-selection. The type of doctor you describe has almost vanished from the earth. We desperately need to reverse their extinction.

  • John C. Key MD

    Family/general practice physicians can do a lot but unfortunately many have ceded territory unnecessarily. I really get tired of seeing articles about famly/general physicians being unnecessary and that they are easily replaced by mid-levels….’tain’t necessarily so. All that education isn’t for mothing.