1. Family Medicine: Now and Future Practice - Robert B. Taylor
In the beginning, the specialty of family practice had originated within the lifetimes of all its practitioners. Today family practice is in its fourth decade. Many of today's family physicians (FPs) were born following the pioneering efforts in the 1960s to begin the new specialty: family practice. Others were in grade school and high school while family physicians worked to attain credibility, hospital privileges, and curriculum time in medical schools. Some others have been on the sidelines, yet have benefitted from the specialty's success over the past 3-plus decades. Not all know the story of the family practice movement. For these reasons, I begin this book with an overview of the specialty's origin, evolution and current status.
One important function of reference books is to serve as historical records of milestones for a specialty and the thinking in a discipline during the time of each edition's life. Sometimes this record shows how much things have changed: In Osler's Modern Medicine, published in 1907, Dr. Osler (1849-1919) tells how to treat diabetes mellitus with opium and arsenic, although adding "the writer rarely resorts to them."1 And sometimes a review of past writings reveals much that has not changed. Near the end of his career, Sir William Osler also wrote: "It is more important to know what patient has a disease, than what disease the patient has."2 Osler added personal comments to many of his discussions, and since family medicine is arguably the most personal of all medical disciplines, this will be a "personal" chapter with some first-hand opinions, beliefs and anecdotes. What follows is a short history of the specialty, a discussion of current concepts important to the discipline, and some thoughts about future practice—based upon the author's 41 years of practice (three years in the US Public Health Service; 14 in rural general practice, then family practice; and 24 years in academic family medicine).
Family practice in the United States of America evolved from general practice, which was the dominant force in health care until the early 20th century. Here is how it happened.
Medical care in the United States has been described as characterized by aggressive action, a mechanistic approach, problem orientation, and an emphasis on victory over disease.3 This connotes that the good physician will record a comprehensive history, perform exhaustive testing, fix the defective organ, and cure the disease. Into this setting came family practice. In contrast to an aggressive assault on disease, family physicians championed longitudinal health care, which allowed both patient and physician to understand the nature of illness and to share decisions over time. A relationship-based, biopsychosocial approach integrated with the evolving new technology was advocated. The emphasis of family practice was on the broad-based care of the person and family, rather than a narrow focus on the disease problem. Finally, family physicians advocated improving the quality of life, particularly important when patients suffer chronic or terminal illness and victory over disease is not really possible. These principles, more often intuitively shared than explicitly articulated during the early years, guided subsequent historical events.
Family practice arose during the 1960s—the time of the Vietnam War, the civil rights movement, and social unrest in many areas of the world. These events coincided with a decline in access to broad-based health care in the United States, which occurred for a number of reasons: too few medical graduates to serve America's growing population, a trend toward specialization that began with World War II, and generalist training that was inadequate for an increasingly complex health care system. In response, the American public and far-sighted health care planners decried the fragmentation of American medicine and called for the creation of a physician who specialized in personal health care—the family physician.4,5
With the support of the American Academy of General Practice and U.S. general practitioners, in 1969 family practice became the 20th American medical specialty.
Four early decisions helped shape the future of the new specialty. A specialty certifying board—the American Board of Family Practice—was established in 1969; until 1979 a physician could qualify to sit for the certifying examination based on practice eligibility, but since then all candidates for specialty certification must be graduates of approved 3-year family practice residency programs. Three-year residency training programs were established, in contrast to the prior norm for general practitioners of a single year of internship perhaps supplemented by a 2-year general practice residency. Mandatory recertification was pioneered by the American Board of Family Practice, and all U.S. board-certified family physicians must take a recertification examination every 7 years; most other specialties have since followed this lead in various iterations. Finally, mandatory continuing medical education was required by the American Academy of Family Physicians and the American Board of Family Practice. The latter organization requires 300 hours of approved continuing medical education every 6 years as one component of the recertification process.
The new specialty began with 15 residency training programs, most converted from previous 2-year general practice training programs. Federal grant programs supported new departments of family medicine in medical school. And clinical departments of family practice were formed in community hospitals across America.
In 1986 the American Board of Family Practice adopted the current definition:
Family practice is the medical specialty which is concerned with the total health of the individual and the family. It is the specialty in breadth which integrates the biological, clinical, and behavioral sciences. The scope of family practice is not limited by age, sex, organ system, or disease entity. (Source: American Board of Family Practice, Lexington KY. Used with permission.)
From 1969 until today, the family practice movement continued to gain momentum, with solid gains in student interest, more residents in training, increased numbers of board-certified FPs in practice, and family physicians in leadership positions in clinical medicine and academia.
There are 797,000 physicians in the United States. Of this number, 69,000 are family physicians and 17,000 are general practitioners. Each year U.S. family physicians provide more office visits than the combined totals of physicians practicing general internal medicine and pediatrics.6 Today there are 471 U.S. family practice residency training programs in community hospitals and academic medical centers. In the early years a few medical schools created departments of family medicine, often prompted by state legislative mandate or the prospect of federal grants; today almost all U.S. medical schools have departments of family medicine or other academic family medicine units.
In the beginning family practice entered the academic setting as both a new specialty and a social movement, aiming to refocus health care on the patient and family; this approach was not always well received. Today medical education and health care delivery are profoundly influenced by family medicine values, both through the impact of our presence throughout the health care system and through the power of our core mission of caring for the patient.
There are family medicine courses in almost all U.S. medical schools, teaching students family practice values and the family practice approach to health care. These courses—and the presence of family physicians in the academic medical centers—are demonstrating the importance of medical education in the office setting. Students who a generation ago would have never seen a multigenerational family of patients or cared for a patient with problems in multiple body systems are now learning to provide truly comprehensive health care, and are doing so in the offices of family physicians in the community.
In 1987 Pellegrino7 commented: "The birth of Family Practice two decades ago, and its development as a genuine specialty within the bodies of both medical practice and academia is surely one of the most remarkable stories in contemporary medical history. The present success of family practice is a tribute to the intellectual foresight, astute social perceptions, and political acumen of a small group of dedicated general practitioners." Family conferences, shared decision making, home care, and community-based research are now respected components of 21st century health care. Family physicians are the only physicians who are distributed across America in the same geographic proportions as the American people. Also, during the 1990s family physicians were the only specialists whose incomes rose (38%) more than the general inflation rate for the decade (33%).8Today we see the continuation of this story as family physicians assume leadership in national medical organizations, hold important roles in determining health policy, and become deans of medical schools in the U.S. For further information about the history of family medicine, see Chapter 131, which provides a chronology of the evolution of family practice as a specialty in the U.S.
Family practice has a long history in Canada. In countries outside North America, family and general practice has evolved in various ways.9 In Spain, for example, the Royal Decree of 1978 officially endorsed the specialty of family practice: "The family physician shall constitute the fundamental figure of the health system."10 In England the general practitioner (GP) is the key provider in the National Health Service, and the countries of the European Economic Community (EEC) have agreed that postgraduate training in general practice should be a minimum of 2 full years, of which 6 months should be in an approved practice. There is a European Academy of Teachers of General Practice and a European Center for Research and Development in Primary Health Care.
Family practice residency programs exist in a number of Latin American countries, and an International Center for Family Medicine is located in Buenos Aires, Argentina. In Cuba the family physician is the chief provider in a comprehensive health plan for Cuban citizens. Family practice has played a role in the health care of Mexico since the 1970s.
In 14 Asian Pacific countries there is a core curriculum in family practice. Family practice is well established in South Korea, Malaysia, Singapore, Hong Kong, Taiwan, and the Philippines, as well as in Australia and New Zealand. Japan, Russia, India, and China now have family practice training programs. In the Ukraine, by government decree, pediatricians and internists are being retrained as family doctors to serve as the chief physicians in their new health care system. In 2001, the government of Vietnam declared a commitment to deploy trained family physicians in the 10,000 health centers serving the country's population of 67 million people.
There is family practice training in South Africa, Egypt, and Nigeria. An Arab Board of Family Practice oversees training in Saudi Arabia, Oman, Kuwait, and Jordan.
The nature of practice varies from country to country, and in some areas, such as the United States and Canada, family physicians often have an active role in hospital care. In other settings, such as in the United Kingdom and Latin America, family practice is chiefly office-based, often supplemented by home care.
The international group uniting family practice is the World Organization of National Colleges, Academies, and Academic Associations of General Practitioners/Family Physicians (WONCA), representing 53 member countries. WONCA held its 16th World Conference of Family Doctors in 2001 in Durban, South Africa, with the 17th World Conference scheduled for 2004 in Orlando, Florida, USA.
The following values, concepts, and approach to health care are important to family physicians in the early 21st century and have influenced the global practice of medicine.
Family physicians are bonded by shared beliefs. They value continuing care of the individual and family as beneficial to the patient-physician relationship and as an effective process of providing care. This continuity allows FPs to increase their knowledge of the patient at each office visit. Comprehensive care is an important tenet of family practice and involves full-service health care of both sexes and all ages "from conception to resurrection." Because FPs emphasize that the patient should receive appropriate care at the right place and at the right time, they place a high premium on coordinated care. This emphasis on coordinated care has made family physicians the ideal primary care clinicians in capitated care settings. Finally, a family-centered approach has been a cornerstone of family practice, with increasing recognition that our concept of family includes such diverse units as singleparent families, collective living groups, and same-sex couples. In my practice, a four-generation family of patients is not uncommon.
Relationship-based health care is the philosophical foundation of the specialty, and understanding personal accountability is the key to understanding family medicine. McWhinney11 writes: "In general (family) practice, we form relationships with patients often before we know what illnesses the patient will have. The commitment, therefore, is to a person whatever may befall them." In my family practice I routinely ask about the patient's children, parents, job, dog, or cat; I tell my patients about my grandchildren. I become, in a sense, "a member of the family" (also see Chapter 4).
Family physicians have a community-based health care orientation. As individual practitioners, family physicians can profoundly influence the health of a community, and can also share their knowledge by serving on the boards of community agencies, such as a volunteer health clinic or adult day-care center. In addition, many FPs are leading efforts in population-based health care (see Chapter 6), extending from care of the illness of the individual to addressing community health problems such as smoking use or teen pregnancy.
Over the past three decades, family medicine has advanced medical thought in important ways, answering early skeptics who held that FPs had nothing to bring to the table of medical knowledge.12One of these is the use of comprehensive clinical reasoning, to include consideration of life events, the family's contribution to disease, and the impact of illness on the family (see Chapter 4). For example, as FPs we have all seen how juvenile diabetes can affect a family's dynamics in regard to relationships, family decision making, and the allocation of family resources. When the child with diabetes is sick, everything else in the household is of secondary importance and eventually relationships can be severely strained; early intervention by the family physician may avert family disruption (see Chapter 30).
Also, FPs have recognized how problems of living can influence health. Patients with stressful lives seldom present stress as a chief complaint. Instead they tell of fatigue, abdominal pain, and weight change—chief complaints that often represent a "ticket of admission" to health care. Recognition of the underlying cause of symptoms is important because, for example, a patient who has surgery that relieves chronic back pain may develop severe headaches if underlying life problems have not been identified and addressed.
A third area in which family medicine has advanced medical thinking is by teaching residents the systems approach to health care. In general systems theory there is a hierarchy of natural systems that includes molecules, cells, organs, body systems, person, family, community, nation, world, and so forth. To apply systems theory to medicine, if a person's pancreatic islet cells begin to make insufficient insulin, or if a farmer in Africa contracts AIDS, or if a community suffers an earthquake, all systems in the hierarchy are affected. Although family physicians have special expertise in "person" and "family," they need to consider the impact of disease on all systems, from small particles of matter to the biosphere.13
Family medicine is developing a rich literature heritage. The papers describing our clinical research, practice methods, and advances in medical thought are being published in a growing number of publications. Although I will not attempt to list them all (in fear of offending by omission), there are currently at least six family practice journals worldwide, two major clinical reference books, four student textbooks, one textbook defining and examining the discipline, and at least four review books for board examinations.
These publications not only are important in presenting the family medicine approach to health care, but also allow the intergenerational transfer of values, methods, and thought—the "storytelling" of a specialty.
When future medical historians ask what was the major contribution of family medicine during its first half century, the answer might be the advances made in the traditional clinical encounter, adapting it to 21st century practice. The family physician's clinical encounter is analogous to the surgeon's surgical procedure, the gastroenterologist's endoscopy, or the radiologist's roentgenogram in that it is what we do. Its scope includes the FP's approach to undifferentiated problems, communication techniques, physician behavior, presentation of information to the patient and family, involvement of the patient and family in decisions, and ongoing care in the context of family and community. The office-based clinical encounter typically includes multiple problems, an average of 2.7 problems in one study.14 By law it may be categorized as ranging from "minimal" to "high complexity." However long or short, the encounter is distinguished by a broad-based and longitudinal approach that is often not present in other specialties.
Over the past four decades, the family practice clinical encounter has become more streamlined, cost-effective, and (we hope) clinically relevant. The improvements have been achieved by the use of enhanced communication techniques, the use of "high-payoff questions," modern diagnostic and therapeutic instruments such as the fiberoptic nasopharyngoscope and the flexible sigmoidoscope, innovations in the style of documentation such as SOAP (subjective data, objective data, assessment, and plan) notes, advances in decision analysis, and the introduction of computer-based records.
In the new millennium, the clinical encounter is rapidly evolving to reflect the current advances in technology, with contact via the World Wide Web and telecommunications expanding our patient care capabilities, as described below.
At this time the specialty faces several challenges. These include the increasing scope of primary care practice today, the growing tendency to consider health care a commodity rather than a professional service, and the current popularity of subspecialization among medical students.
Over the past few years, the scope of care provided by all primary care physicians has increased, chiefly because of capitation and the gatekeeper role.15 In my solo family practice 20-some years ago, I saw 40 patients a day and yet I was usually on the way home by 5 P.M. Most of my patients had bronchitis, sprained ankles, earaches, lacerations, vaginitis, back pain, skin rashes, and so forth. Of course, like all FPs, I had some complex cases, such as my two female patients with systemic lupus erythematosus and the middle-aged man with amyotrophic lateral sclerosis, but those were the exceptions. This is no longer the case.
Today's office patient may have a half-dozen problems, and is more likely to be sick and to require more time than would be needed to treat an ear infection. Why the change? Today, most of my patients are capitated, chiefly with the Oregon Health Plan, and my care is most cost-effective when I see only those patients who really need office care. This means that many instances of back strain, flu, cystitis, vaginitis, and so forth receive advice through the nurse triage line, and only those who cannot be managed by telephone are given appointments. This also means that there are very few "easy" visits that allow me to catch up with my schedule. And even though a recent paper showed that the average duration of office visits increased by between 1 and 2 minutes from 1989 to 1998,16this small increase in my opinion is insufficient to account for the greater complexity of problems encountered in office practice.
Family physicians can take the lead in preventing medicine from being converted to a commodity.17Health care is not a hamburger or a toaster oven, although health maintenance organizations (HMOs) and the government often seem to act as though it were.
In 1969 one of family practice's initial roles was to combat the fragmentation of medicine.4 At that time there was excessive specialization, and the patient with hypertension, joint pain, and a skin rash often needed to see three physicians. With the current presence of family practice, this is happily no longer the case. Today, the family physician's new role is to be the patient's advocate in a system that appears to treat health care as a commodity, often one to be rationed—using tight schedules, relative value units, incentive payments if the physician orders few tests and lower cost drugs, and severe financial penalties for minor coding errors. Even the term provider reinforces the "commodity" mentality.
What are family physicians to do? We must put the patient first, insist on affording the patient enough time so that we can do a good job, work to eliminate incentive payments that create ethical dilemmas for physicians, fight government efforts to criminalize administrative disagreements, and refuse to accept the insulting epithet provider.
Beginning in 1997, we saw a relative rise in the number of medical students entering subspecialty fields and a reciprocal decline in those selecting family practice and other primary care specialties as careers. Is this merely a sine wave that will correct in time? Perhaps. Progress is rarely a straight line, but occurs with peaks and valleys.
Family practice leaders are well aware of the trend, and are working to effect change through increased attention to student activities, efforts to close the income gap between primary care specialists and consulting specialists, and reduce the bureaucratic hassles inherent in managed care. In the meantime the current—and probably temporary—reduction in interest in FP careers may have a salutary effect; it will weed out the weak training programs in the system, and it will ensure that those joining our specialty at this time are the most firmly committed to the tenets of the specialty. In the end, the drop in FP trainee numbers may result in a stronger specialty in the future.
Tomorrow's health care will be shaped by current influences. In selecting what I believe to be the most significant influences on future practice, I chose from a long list that included the current focus on evidence-based health care (see Chapter 5), the medical and societal impact of HIV and AIDS (see Chapter 42), and the burgeoning interest in complementary and alternative medicine (see Chapter 128). The following are the four factors I believe most likely to influence family practice in the decade to come.
Here we return to the evolving clinical encounter. The technologic influences on future practice include medical technology such as lasers, fiberoptics, and diagnostic ultrasound. It also includes information technology such as patient contact via e-mail or voicemail, information retrieval, computer-assisted charting, decision support systems, and the virtual house call.18 Just as the automobile spelled the end of "horse and buggy" medicine, and the telephone allowed direct communication with the physician and the development of scheduled office practice, the Internet is profoundly changing the practice of medicine (also see Chapter 127).19 Today, using asynchronous communication, I correspond with patients by e-mail about their health problems. Sometimes the patient sends an e-mail at 2 A.M., knowing it will not be answered until the next day; this has saved a number of early morning telephone calls that were not emergencies. Sometimes the e-mail message is a prelude to an office visit. Occasionally I talk with patients by telephone as we simultaneously search the World Wide Web for clinical answers. The Internet is making the "digital house call" a reality. Face-to-face office visits are needed less often, and when they occur are longer in duration16 and offer more value for time spent than in years past. With the Internet as part of comprehensive health care, FPs move one step further in actualizing their role as health advisor and consultant.
All the technology mentioned here is being used by FPs somewhere, and within a decade these functions will be the state of the art everywhere.
The growing number of older people in the population is the reward for our success in battling infant diarrhea, accidental injuries, treatable infectious diseases, uncontrolled hypertension, and other causes of early death. According to the U.S. Bureau of the Census, there are currently 35 million people age 65 and older, and the number is projected to increase to more than 53 million by the year 2020. The fastest growing segment of our population is the group age 85 and older. Of course these are the people with multiple problems involving various organs and whose health care costs are the highest of any adult age group.
What is the likely impact on family practice? Family physicians need to prepare to serve an increasingly older patient panel, and must be positioned to compete with others who would claim greater expertise. We must insist upon a family practice approach, emphasizing continuity of care (there is no reason to change doctors when one turns 65), comprehensive care (the FP can care for a wider range of problems than any other physician), and family-oriented care (why fragment the care of the elderly and make it separate from the rest of the family?) (also see Chapters 23 to 26).
We see the effect of globalization in the economic marketplace: Price and wage differences between countries become a little narrower each year. Goods and jobs are increasingly moving freely across borders, as is information about lifestyle and economic opportunities.
The United States has yet to experience the full effect of globalization in health care. We in the United States spend billions of dollars annually for antianxiety medication while in other countries children die of infectious diseases for want of a vaccine or an inexpensive antibiotic. A woman in a developing country is 38 times more likely to die of pregnancy-related causes than a woman in the developed world. There are currently 35 million persons with AIDS worldwide, with an estimated 12 million AIDS orphans in Africa. These are, increasingly, problems shared by the global community and they represent both challenges and opportunities for all physicians.
U.S. Surgeon General David Satcher, M.D., Ph.D., a family physician, points out that 89% of the world's population lives in developing countries that bear 93% of the world's disease burden, but that account for only 11% of the world's health spending.20 To phrase this another way, 89% of the world's health care resources are spent on 11% of the world's population. Dr. Satcher lists three "prescriptions" to improve health worldwide: supporting public health initiatives; enlisting allies such as computer specialists, economists, and patients; and challenging public health leaders to advocate for all health care consumers.
What about family practice and family physicians? Our roles may include controlling unnecessary health care expenditures in America and other developed countries, serving as physicians in developing countries, and advocating for sick persons whatever their nationality. We should also prepare to live and practice in a world where the differences in incomes, standard of living, and health care are much less than they are now.
Health policy is the "wild card." How national and state governments dictate eligibility for programs and the methods of making health care payments has a strong influence on how health care is provided. Witness what happens in those countries, such as Japan, in which the government controls health care payments, allows unrestricted access to any physician, and mandates relatively low fees. The result is many office visits for minor problems, long waits, very short visits, and frequent (and often medically unnecessary, at least by U.S. standards) follow-up visits for routine problems. The local saying is, "Three-hour wait, three-minute visit." It is, curiously, the opposite of the model that has resulted from capitated care in the U.S.—with increasingly complex problems seen in (slightly) longer office visits by primary care physicians.
In my home state of Oregon, we have seen how government can abruptly change health care. When it began, the Oregon Health Plan suddenly converted a large number of previously uninsured patients to being insured under the new state plan. This caused a major shift in where patients received care, as the newly insured patients sought to abandon the clinics that had struggled for years to provide their care and were courted by physicians in more "prestigious" settings. On the other hand, a state-mandated reduction in reimbursement can cause some physicians to withdraw from the plan, increasing the burden on those who remain.
On a national basis, a federal plan for universal access to health care will correct the disparity of 45 million Americans who lack insurance or other funding for health care. It will also profoundly affect how health care is delivered in America, depending on method of funding, how access is controlled, and how clinicians are paid. Let us hope that common sense and fairness prevail.
Family medicine has been such a positive influence on health care worldwide that we would have had to invent it for the new millennium, if it did not already exist. Despite past predictions to the contrary, family medicine has survived into the 21st century. A study reported in 2001 showed that each month a large portion of the U.S. population has health problems and almost 25% visit a physician's office.21 Of those visits, more are to family physicians than to any other specialists (see Chapter 130). Approximately 11% of U.S. physicians are family physicians or general practitioners, and the number of FPs is growing.6 Outside the U.S., there have been major successes in a number of other countries, as described earlier. Family medicine has done much more than survive; it has prospered and has had a powerful impact on health care delivery and medical education worldwide. It is a rapidly evolving discipline that brings a much-needed social conscience to medicine and, to some degree, is reinventing itself as it uses the new technology to expand its service role. The values of the specialty put people first—first before profit, first when there are ethical conflicts, and first before a single-minded emphasis on disease. In the 21st century, family physicians continue to care for the world. And all physicians should honor family practice's remarkable history of achievements and recognize its unlimited potential for future contributions to humankind.
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American Academy of Family Physicians
American Academy of Family Physicians
www.abfp.org American Board of Family Practice
American Board of Family Practice
www.stfm.org Society of Teachers of Family Medicine
Society of Teachers of Family Medicine
www.globalfamilydoctor.com World Organization of Family Doctors
World Organization of Family Doctors
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