Family medicine 2.0

Twelve years ago, the seven national family medicine organizations launched The Future of Family Medicine Project (http://www NULL.aafp NULL.org/about/initiatives/future-family-medicine/ffm NULL.html).  The goal of this project, was to define the core values of family medicine and establish our specialty’s role in a modern medical world.  Some good ideas came out of this including the development of a new practice model known as the Patient Centered Medical Home.  In fact, the clinic where I practice is currently involved in what seems like a Sisyphean task of becoming PCMH certified.  Now, twelve years later, the same organizations are again working to a) define the role of the 21st century family physician and b) ensure that the specialty can deliver the workforce to perform this role.  As I happen to be board certified only in family medicine, my future income depends upon family doctors continuing to play a robust role in delivering primary care medicine and, as such, I am grateful to the Future of Family Medicine Working Party for their endeavor.  And, if I were smarter than I am, this blog post would stop right here.  But it won’t.

My argument, one which I try not to state too loudly as it goes against my own self interest, is that anyone who takes an objective and critical look at how we deliver healthcare in the 21st century will realize that the specialty of family medicine does not need to exist.  No single person or entity invented the medical specialties.   They grew up organically.  And, as such, there is substantial overlap between them.  I spent 3 the standard 3 years completing my family medicine residency.  During those 3 years I learned how to care for adults (internal medicine resident take care of only adults for 3 years), I learned to take care of children (pediatric residents take care of only children for 3 years), and I learned to do prenatal care and deliveries (obgyn residents spend 4 years doing this).  I continue to do all these things as part of my practice.  How is it possible that I became competent in these areas in 3 years when it would take me a total of 10 years to complete an internal medicine residency + a pediatrics residency + and obgyn residency?

I think the main answer to this question is that we simply can’t/don’t do as much for the patients we see as doctors of other specialties.  We’re more likely to referer an adult patient to a specialist than our internal medicine colleagues; we are much more likely to refer our pediatric patients to a specialist than our pediatric colleagues and the vast majority of family medicine trained physicians never deliver another baby upon completion of their residency training.  While I’m glad that the Future of Family Medicine Working Group is fighting the good fight on my behalf, I’m not sure I see a bright future for family medicine.  As medical knowledge continues to exponentially increase, it will be impossible for a single person to become competent in all the areas which our training covers.  Sure, we can continue to cover all areas of medicine in minimal depth, becoming ever more reliant on specialists and subspecialists to provide the sharp end of medicine while we coach our patients on quitting smoking, losing weight and getting a flu shot.  But a PA or a nurse practitioner can do this just as well as we can.  In fact, in many places, they already do.  We have reached the point where the service that family physicians perform can be effectively taken over by mid level providers. 

With the continuing shortage of primary care providers in the country, there’s no doubt that family medicine physicians practicing today will have useful work to do until they retire.  But, I seriously question the wisdom of continuing to train new ones.

 

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