Wednesday, September 7, 2011

Family Medicine: Why Don't FP's Talk About Their Clinical Problem Solving Prowess?

Larry Bauer, CEO of FMEC sent this email to several Family Medicine leaders and educators recently.  It's a good question.  What do you think?

Subject: Why don't FP's talk about their clinical problem solving prowess?

I have been working with Family Physicians since 1978. I have noticed two things in particular.

First they take great pride in their interest in relationship-based care. They talk about the value of continuity. They tell stories that describe how much they treasure relationships with patients. They tell these stories in their teaching. They write books about it .Its a powerful force that energizes their work and their career satisfaction.

They rarely, if ever, mention the power of their clinical problem solving abilities. Why is that? The absence of mention and the seeming lack of pride (my assumption) in this area makes me wonder if FPs really believe they are effective in the area of clinical problem solving.

From my earliest days in Family Medicine I came to believe that FPs impact as physicians was a result of their patient/relationship-centered approach that included effective communication skills, their fund of knowledge and their clinical problem solving skills. All three are essential; any two working alone, except in special circumstances, will not lead to the best results.

Family Physicians embraced the work of Barbara Starfield, MD, PhD. She told the world that FPs, in particular, and primary care, in general, had a positive effect on population health while reducing the cost of care.

When I hear FPs take pride in their relationship centered approach to care but never mention their approach to clinical problem solving, it leads me to believe they think that continuity alone produces the impact documented by Dr. Starfield.

I put this issue to a number of colleagues and I heard the following

          Because of the variety of patients and undefined illness that Family Physicians see, they become better at development of realistic differential diagnosis than any other medical specialty. Doug Smith, MD, Orono Family Medicine, Orono, Minnesota
          Another FP Shantie Harkisoon, MD director of Phelps Family Medicine Residency Program (a new program in Sleepy Hollow, NY) told me that she thinks the strength of FPs is strong skill with differential diagnosis of the patient as person while sub-specialists are generally more effective at differential diagnosis of a disease.

I have been talking to a documentary film maker who wants to tell a story about family medicine and primary care innovation and in his interviews with FPs all he finds is the value of relationship centered care. He cant understand how the care provided by FPs cost less money. When I told him that FPs are effective clinical problem solvers and their approach to decision making as a key piece of this story, he almost did not believe me. When he interviewed the FPs he was not hearing about this.

Why do I not hear more about Family Physicians clinical problem solving prowess?

What do others think?



Laurence Bauer, MSW, MEd

Chief Executive Officer
Family Medicine Education Consortium

Here's my short response.
Subject: RE: Why don't FP's talk about their clinical problem solving prowess?

Many may consider pride in one's skills to be "sinful", but our specialty, possibly because of our humility- misguided or not, is indeed "complicit" in medicalizing American life, as Allen Perkins, MD, MPH notes, and, as I believe, helping to bankrupt America by co-dependence with a mis-aligned Medical Industrial Complex. 

We have moved beyond McWhinney,  who wrote and spoke of the clinical methods and skills of Family Physicians, but forgot to integrate his message in many of our teachings. We now understand in a different way that "all our patients will die". That fact dampens clinical pride a bit and enhances our relational connections with patients for the long haul. 
Intense celebration of diagnostic wizardry and "high fives" for clinical acumen give way to quests for better understanding of the human condition. Patients teach us that allowing them to be human and protecting them from medical misadventures is part of our job. Another part is validating their humanity and their sufferings. The heartfelt quietness of the slow dance with the human condition is instructive.  Family Physicians Dance well, but we may dance slow.  
We love the dance. BUT, it doesn't do much for the quarterly return on the investment of Wall Street or help the budget of the local hospital that may own our practice and expect us to feed it. Many questions face Family Medicine.


Comments are invited.  What do you think?


  1. I love this post. I get so tired of people thinking FPs are "just GPs". We are EXPERTS in what we do and that is DIAGNOSTICS. We are in charge of directing the care for patients. If we don't make the diagnosis or at least come close, the patient will not get the right tests, the right specialists or the right treatment. We save health care dollars because we are SO good at diagnosis that we don't have to just randomly order every test in the book. I'm proud to be an FP and I'm proud of the fact that I can often get a diagnosis when others can't.

  2. I think my FP is stronger in diagnostics than some of the specialists I see. The key traits I observe are looking at the bigger picture and good listening skills.

    At the risk of jinxing myself, I don't see them resting on the laurels of disease/patient/medical stereotypes or getting stuck in one groove of thinking.

    Specialists are like a stubborn one way road with no exit. FPs read off a bigger map.


  3. Thanks for the comments Dr F to F. Your FP pride is refreshing and helpful to the cause of good health care.

    Thanks for your input about the family medicine approach to relating and diagnosing differently than narrower specialists.

    Pat Jonas, MD

  4. I agree with POP. My family physician is a great diagnostician. I love how he can listen to an odd assortment of symptoms and pull everything together to know how to treat the problem and explain it clearly.

    Specialists just get a vague idea about things outside their specialty and refer patients to a different specialty to get things figured out.

    Family Physicians are selling themselves short if they don't realize what good diagnosticians they are.