Wednesday, January 26, 2011

Family Medicine: One Windmill Too Many?

Family Medicine started as a "counter culture" specialty in the late 1960's with an opportunity to facilitate a course correction for the medical profession.  Redirect medical care toward patients.  Redirect academic medical centers toward patients.  But no, we came up short.  To quote from G. Gayle Stephens, MD in his presentation "Family Medicine as Counter Culture" in 1979, "We have expended our energy on professional legitimation and enfranchisement rather than reform."

As we recently got employed by corporate interests such as hospitals and gave up hospital care of patients, we left the culture we sought to reform.  We responded to quota mandates, giving up the opportunity to effect the best outcomes for our patients in exchange for a comfortable lifestyle.  We can crank out the patients if we listen less and get efficient, to better support health system needs.  We can game the satisfaction surveys and get a high level of approval.  The more superficial we become, the more our patients feel disconnected and the more emergency room visits they experience with higher and higher expense at less and less overall quality.  Now we're aligned more with shareholder value for the system than with our patients.

We're broke financially if not comfortably established in a corporate system, sometimes groveling for dollars with procedural schemes to attempt to have a cash flow increase.  We've lost our direction and forgotten our purpose.  What happened?  How do we get realigned with the people?  Is it too late?

The Patient Centered Medical Home (PCMH) is supposed to be the model that buys our freedom and our realignment as family physicians.  In many ways, though, it looks more like the "Payment" Centered Medical Home.  It's supposed to save primary care and optimize care coordination with a team approach to primary care.  But how is the patient engaged in the new model?  Who is training patients and employers to connect to the model?  Who is  protecting the family physician from a massive work addition and burnout during and after the transformation of our practices into Medical Homes?

We attacked the windmills and had some victories, but now it looks like the last windmill defeated us.  Family Medicine and  our patients are losing fast.  I've written before that five family physicians left practice in my county in the last 19 months, leaving around 10,000 patients without a physician.  There are now two major hospital  health systems in this area and both flagship hospitals closed their family medicine training centers in the last two years and built heart hospitals that opened in 2010.  Who will protect the employers from the expense that is headed their way?  Do they even see it coming?

Who will answer?, I keep thinking as I hear the old Ed Ames song by the same title playing in my head.   There is no way this community can afford the medical care system that is being built for them.  Three heart hospitals and a diminishing primary base.  It looks like our specialty, family Medicine, has failed to lead in a way that would best serve the medical needs of the people. I am very worried.  Who will answer?


  1. Of course a paradigm shift in essential. I envision primary care leveraging technology to better communicate with patients. Have an office but stop churning. Videovisits, email, IM, and housecalls. Have small, low overhead office for necessary face-to-face visits only. Perhaps contracting directly with patients with cash, but not necessarily. Unless we lead, traditional office-based primary care is on its way to FAIL.

    Bruce Hopper Jr MD

  2. With all respect to those who founded our speciality, perhaps some of that "counter culture" is now beginning to work against us. I suspect that the majority of family physicians in the U.S. are not engaged with politics, payer systems, etc at all. They valiantly work their long days for inadequate pay, and quietly battle disease and share compassion day in and day out.

    But we, as a speciality, have failed to adequately advertise and advocate for ourselves. The majority of Americans don't even know the difference between a family doc and an internist! We are a largely invisible speciality and can no longer afford to be.

    We must showcase the amazing-ness of our speciality. We must show more medical students about the joys of a primary care career. We must get the lay public to help us create a groundswell of support for reforms - payment and otherwise - that would allow the "churning" Dr. Hopper describes to stop.

  3. How many of those 10,000 patients are actually willing to pay for medical care? If 95% of them suffer from terminal entitlmentiasis, demanding 24/7 refills of their narcotics and same day appointments for a stuffy nose that just started, and how dare you ask them to actually cough up their $2.00 co-pay, well then yes, that's a tough population to service.

    I agree with everything you say about Family Practice, though. From where I sit (solo), it looks like the PCMH is designed to make a large group practice look more like me to the patient. Everything they're talking about: I've been doing it for years!

  4. Thanks for your comments. They represent good insights about our situation from three different perspectives. If patients filter their use of medical services will we have a lot more family doctor time to serve those with needs? #1 Dinosaur knows some ungrateful patients, and we all do, who could plan their use of services better.
    Did the founders set us up for misalignment of family doctors with systems and media? It looks that way, Dr Jen.
    Can we get more comfort and efficiency with better use of evolving technological solutions? Right on, Bruce. There are many independents who worry about finding the front money, though, to get more tech so the gov can reward us later for our efforts, IF we please them that our use of tech is "meaningful."
    Thanks again for your insights. Dr S (independent 2 doc, 1 FNP part time, practice)