In this issue of JFP, 2 well-known family physician leaders, Carol Herbert and Stephen Spann,1,2 describe a variety of threats to the specialty of family practice, warn of its potential demise, and call for its reinvention. The threats include new knowledge in genomics, new technologies, increasing patient desire for direct access to other physician specialists, increased access to information by patients through the Internet and media, evidence-based medicine (EBM), alternative and complementary medicine, nurse practitioners and physicians assistants, nurse triage systems, the abandonment of traditional roles such as hospital care, the push for higher quality of care, and the demand that costs be contained. For tangible evidence of a threat, the authors cite the decreased numbers of medical students entering family practice, decreased satisfaction among physicians, and the replacement of traditional family physician roles by other care providers.
Is our demise impending? To paraphrase Mark Twain, another Missourian: Rumors of our impending death are greatly exaggerated.
Changes offer opportunities
I agree we live in a time of dramatic reorganization of health care and tremendous growth in biologic knowledge and the capacities of information technology. One result of this is that patient expectations are increasing. At the same time, the rising cost of medical care is forcing uncomfortable choices in how we practice medicine. These changes can be seen as opportunities rather than threats. Our opportunity in family practice is threefold: to continue to respond to the need for patient-centered medical care, to translate emerging knowledge into improved patient outcomes, and to manage that knowledge through information technology to put it to the best use for our patients and communities. Pursuing these opportunities seriously will certainly require changes in strategies and roles for family physicians; in doing so, we must maintain the core function of the family physician as a personal physician and enhance the physician-patient relationship, not detract from it.
Solutions through creativity
Spann2 identifies such a strategy for the discipline in his vision of information technology harnessed to help rather than threaten us. In his model, technology would be used to give health care providers and patients easier access to reliable information and more assistance with decision making and informed consent. We would thus commit fewer errors, improve access, and provide a higher quality of care. Such a system could assist us in managing genomic information, selecting diagnostic and therapeutic technologies, and managing the information overload and hype that appropriately concern Herbert.1 Hopefully this will allow us to spend more time with patients and less time with paperwork and tracking down information, and will enable us to continue our strong focus on the physician-patient relationship. Spann’s model is an example of the creative solutions that I am confident will be generated. These solutions could enable family physicians to maintain their essential and satisfying historical roles as personal physicians in North America.
My belief that family medicine will succeed is based on my confidence in the creativity of my colleagues and of those in other disciplines, and on the fact that I find the evidence of potential demise unconvincing. Student interest fluctuates in all disciplines. Physicians in many specialties have experienced a greater relative loss of income and decreased personal satisfaction in the past decade than family physicians. Most family physicians I know welcome the opportunity to lead a more balanced life by having emergency coverage and appreciate nurse triage lines for minor problems. Many work in multidisciplinary team settings in which the burdens of care are shared. These physicians still have strong physician-patient relationships and play an important role as personal physicians. Do not misunderstand; I grumble about loss of autonomy, unfairness in the system, and the paperwork, too. I was disappointed as well when our residency program did not fill this year. But when I think about my experiences practicing medicine in Columbia, Missouri, in Sierra Leone, and in Guatemala I recognize how blessed we really are. As Ringdahl described so eloquently in her recent essay,3 we only have to step back and consider the devastating life experiences of our patients to gain proper perspective on “tragedies” like not filling our residency programs.
Family Medicine Research
I agree with Herbert’s recommendations,1 particularly her points about the need for research career paths, the need for family medicine researchers to understand the changing landscape of health care and health care research, and the integrative and multidisciplinary nature of much of the best family medicine research. In fact, those multidisciplinary teams could, and do in many cases, productively include basic scientists, ethicists, and health promotion experts. However, I do not agree that family medicine as a discipline is particularly well trained or has a distinctive capacity to address such broad social issues as poverty, violence, pollution, and climate change beyond our roles as responsible citizens and as those issues affect our patients.