Joseph Scherger, MD, MPH
Many educators are lamenting today that the scope of family medicine is shrinking.
They refer to fewer family physicians working in hospitals and doing procedures. Warren Newton, MD, MPH, chair of the American Board of Family Medicine, recently sent out a letter expressing this concern. Such a grave outlook is dangerous to our specialty at a time when we are struggling to motivate medical students to go in to family medicine.
I think just the opposite. Family medicine today is more complex and expansive in some ways than ever before. Sure, fewer of us are delivering babies and doing hospital medicine, but family medicine is first and foremost a primary care specialty. Primary care is expanding and becoming far more complex in this new age of medical homes and the advanced use of information systems.
The Willard Report that set the stage for the transition from general practice to family medicine called for the creation of a new primary physician. That doctor would be the personal physician to individuals and their families. It is that personal physician role that is the essence of our specialty. New models of primary care, from concierge medicine to team-oriented medical homes to populations of patients, are deeply complex and expansive.
What do I mean? Prevention became part of primary care in the 1970s and continues to expand. Primary prevention includes all efforts to prevent disease, and since lifestyle causes 50% or more of disease, motivational counseling toward lifestyle change is a new and vital part of being a personal physician. Secondary prevention is the early detection of disease and knowing and applying all aspects of the US Preventive Services Task Force recommendations requires good information systems and skills. Tertiary prevention is the prevention of complications of chronic disease and is far more complex than when I finished residency 30 years ago.
Chronic illness drives about 75% of all health care costs so effective management of these problems is vital to our health care system. The routine visit of a type 2 diabetic patient is far more complex than before and requires much more time. Acute problems are still a major part of family medicine and if we are available to our patients online, we can manage or coordinate care much more efficiently. Relationship-centered care calls on us to know our patients well and provide the counseling services our patients need to deal with what life brings to them, attending to the biopsychosocial and spiritual dimensions of illness.
So, let’s stop this talk about the scope of practice of family medicine shrinking. I am grateful to have more time to take a deep dive with my patients and be their personal physician with much greater complexity and effectiveness than ever before. Let’s train our residents to do the same and show off this rewarding specialty to our students. What can be better than being a family physician?
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I couldn’t agree more. Years ago patients were admitted to the hospital to pass a kidney stone, to manage a miscarriage, or to treat diabetic foot ulcers. Now I manage these issues and much more in my office, on home visits, and with visiting nurses and care managers. Especially in communities like mine where a substantial portion of patients are uninsured – the pressure is quite great to have a broad scope. And our residents like these challenges, too!
Oh, Spin, Spin, Spin :). Ambulatory care, PCMH, Chronic Illness management is much more complex than it used to be. However, in many ways the scope is shrinking. For those faculty who continue to do OB and at least adult, (and even Peds) inpatient work plus PCMN/Complex Chronic illness and Nursing Home/facility care it certainly seems like the scope of practice for many of our young colleagues is diminished. Most of the graduates, at least here in the NW, can actually practice competently a much broader range than they choose. These often are personal and lifestyle choices. Scope of practice is a real phenomena with important training implications, not a ‘heads in the sand’ through language evolution issue.
Bill Gillanders
Providence, Portland, Oregon
Comprehensivist. That is what I want to be, that is whom I want to train. I believe the comprehensivist primary care doc is the answer to the future delivery of health care. It is more fun, more challenging, and offers much more flexibility for scope of practice. Thank goodness there are still RD like Bill Gillanders trying to maintain the integrity of the comprehensivist.
I would point everyone back to Family Medicine as Counterculture that Gayle Stephens wrote in 1989 http://www.aafpfoundation.org/online/etc/medialib/found/documents/programs/chfm/stephensfmascounterculture.Par.0001.File.tmp/Stephens_FM_as_Counterculture.pdf
where he pointed out that our problem going forward would be more with ourselves than with others and used the metaphor of church vs. sect to frame inclusivity vs. exclusivity as the problem. With a society that is more diverse about whow we are, finding ways to decide who is “in the tent” and who is not is commiting us, in my opinion, to being continually marginalized and left talking among ourselves rather than with the society and political system that we live in. While Joe Scherger has always been someone pushing envelopes, the increasing diversity of jobs, roles for family doctors, and opportunities to do everything from a rural practice to leading primary care policy centers makes it imperative that we bring and include everyone since the future is not well known, to say the least. The discipline – and society – needs to have a diversified portfolio.