Family physicians told to evolve so specialty can survive

Recommendations from a two-year study include a more patient-centered, evidence-based practice, documented on an electronic medical records system.

By Damon Adams — Posted April 12, 2004

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In the nearly four decades since it was created as a specialty, family medicine has become a core component of primary care for Americans.

But the specialty now finds itself threatened by declining reimbursements and the treatment of health care as a commodity. Medical school graduates are increasingly turning to other specialties that offer more money and better hours.

Unless family medicine reverses this trend, it could become extinct.

That's the message spelled out in a new comprehensive report by the Future of Family Medicine project.

To transform the specialty, family physicians should embrace a new model of care that is patient-centered and evidence-based and features an electronic health records system, the report says. They should offer open scheduling to patients and welcome e-mail communication between the office and patient. Changes to the U.S. health system, including better reimbursements and funding for research in integrated care, also are needed.

"The research says that if family medicine does not make the changes that we talked about here, and if the system doesn't evolve in some way to allow that to happen, there probably will not be a family medicine 20 to 30 years from now," said James Martin, MD, chair of the FFM project leadership committee and board chair of the American Academy of Family Physicians.

The report does not say how much these changes would cost the average family physician. A task force is developing recommendations on reimbursement and financial models.

"The report has good points in it, but what's going to be the hard part is putting it into action," said Maggie Blackburn, MD, a Stamford, N.Y., family physician who served on one of the project's task forces. "System change is going to take a long time. What do we do in the meantime?"

Others wonder if the report's medical education proposals will reverse the declining number of U.S. medical school graduates choosing family medicine.

"Students are voting with their feet, in essence. I don't see anything in the report that will change that," said Michael Whitcomb, MD, senior vice president for medical education of the Assn. of American Medical Colleges.

Time for change

In 2002, seven national family medicine organizations, including the AAFP, launched the Future of Family Medicine project to develop strategies to renew the specialty.

Research firms conducted a national study, and, along with focus groups, helped identify what patients want from family physicians. Five task forces explored issues such as medical education, practice development and health system changes.

Health leaders say the report, released March 30, is a compass and a call to action for family doctors.

"The fact that this report came out does not mean everything is wonderful now, but it gives us a starting point to fix things from many angles," said Kurt Stange, MD, PhD, who served on the project's leadership committee and is editor of the Annals of Family Medicine, which published the two-year project's report as a supplement to its March/April issue.

The report calls for a new model of care as the core of clinical practice. Patients would have a personal medical home that is patient-centered and evidence-based. They would receive acute, chronic and preventive medical services, and practices would reduce barriers by offering open scheduling and flexible office hours. Care would be provided through a multidisciplinary team approach, which could include nurse practitioners, nutritionists and behavioral scientists.

The model's central nervous system would be electronic health records. Practices would develop a Web portal and use e-mail to communicate with patients. Systems would include evidence-based clinical practice guidelines, order entry and referral tracking. Family physician leaders hope to have EMRs in all family practice residency programs by 2006.

Medical education for students and physicians needs refining, the report said. Future education should be grounded in evidence-based medicine and be technologically up-to-date while providing more in-depth training in practice management. Family physicians would become more active in local schools, helping to identify youths who want to be family doctors.

For practicing physicians, lifelong learning needs to be redesigned, and maintenance of certification, which has been a tough sell to some physicians, needs to be a part of physician assessment. "There is resistance to this, primarily because by some it is seen as an additional burden," said James C. Puffer, MD, executive director of the American Board of Family Practice, one of the seven groups that initiated the project.

Broader systemwide changes are needed to ensure the vibrancy of family medicine, the report says.

Family medicine needs to improve its relationship with academic health centers. The use and reporting of quality measures should be promoted to enhance care. And reimbursement models that sustain family medicine and primary care must be developed.

Project leaders said some practices already use facets of the new model. But more practices need to embrace the model in its entirety.

"This report kind of takes a thread and weaves all this together to say this is the best credible plan," said John Bucholtz, DO, who headed a project task force and is past president of the Assn. of Family Practice Residency Directors. "If we can put together a quality experience for the patient and satisfying work for the doctor, it's nirvana."

For the recommendations to work, Dr. Martin of the AAFP said doctors in other specialties must be willing to accept the impact the changes would have on primary care and work relationships. Some groups who viewed the report said all of primary care would benefit from the changes.

The American College of Physicians said it does not see the renewal of family medicine as a threat to internists. "Many of the features of this [report] are things the college is working on as well. The characteristics of the new model of practice have features that all primary care physicians might be interested in," said John Tooker, MD, ACP's executive vice president and chief executive officer.

AMA Secretary-Treasurer Herman I. Abromowitz, MD, said the project's recommendations preserve the core values of family medicine and create a blueprint for doctors. "It enhances all disciplines. It's patient-centered."

Family medicine leaders are waiting to see how family physicians react to the report. They expect naysayers, but many are ready to pay attention.

"I don't plan on ignoring it," said Henry E. Francis, MD, a Brooklyn, N.Y., family doctor and president of the New York State Academy of Family Physicians. "As the world changes, we have to change."

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Practice types

Family physicians are still a key source of primary care in the United States. Nearly one in four office visits each year is to general and family physicians.

Family physician group practice 43%
Multispecialty practice 22%
Solo practice 18%
Unknown 9%
Two-person practice 8%

Source: American Academy of Family Physicians

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Declining interest in family practice

Despite some gains in the 1990s, the number of graduates seeking family medicine residencies has dropped by about 50% since 1997. Fewer than 10% of all U.S. medical school graduates picked family medicine in 2003.

Offered Filled
1992 2,486 1,398 (56%)
1993 2,589 1,636 (63%)
1994 2,774 1,850 (67%)
1995 2,941 2,081 (71%)
1996 3,137 2,276 (73%)
1997 3,262 2,340 (72%)
1998 3,293 2,179 (66%)
1999 3,265 2,024 (62%)
2000 3,206 1,833 (57%)
2001 3,096 1,516 (49%)
2002 2,983 1,413 (47%)
2003 2,940 1,234 (42%)
2004 2,884 1,198 (42%)

Note: Percentages are rounded. Figures include family practice programs combined with psychiatry and internal medicine programs.

Source: National Resident Matching Program.

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A new vision

A key recommendation of the Future of Family Medicine project presents a model of patient-centered care. Key features:

  • Patient is center stage.
  • Health records are electronic.
  • Care is evidence-based.
  • Care is given through a multidisciplinary team approach.
  • Care is integrated.

Source: American Academy of Family Physicians

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External links

Future of Family Medicine Project (link)

Future of Family Medicine Project final report and task force reports, Annals of Family Medicine, March/April supplement (link)

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