Reinventing Family Practice Again

In this issue of JFP, 2 well-known family physician leaders, Carol Herbert and Stephen Spann,^1,2 describe a variety of threats to the specialty of family practice, warn of its potential demise, and call for its reinvention. The threats include new knowledge in genomics, new technologies, increasing patient desire for direct access to other physician specialists, increased access to information by patients through the Internet and media, evidence-based medicine (EBM), alternative and complementary medicine, nurse practitioners and physicians assistants, nurse triage systems, the abandonment of traditional roles such as hospital care, the push for higher quality of care, and the demand that costs be contained. For tangible evidence of a threat, the authors cite the decreased numbers of medical students entering family practice, decreased satisfaction among physicians, and the replacement of traditional family physician roles by other care providers.

Is our demise impending? To paraphrase Mark Twain, another Missourian: Rumors of our impending death are greatly exaggerated.

Changes offer opportunities

I agree we live in a time of dramatic reorganization of health care and tremendous growth in biologic knowledge and the capacities of information technology. One result of this is that patient expectations are increasing. At the same time, the rising cost of medical care is forcing uncomfortable choices in how we practice medicine. These changes can be seen as opportunities rather than threats. Our opportunity in family practice is threefold: to continue to respond to the need for patient-centered medical care, to translate emerging knowledge into improved patient outcomes, and to manage that knowledge through information technology to put it to the best use for our patients and communities. Pursuing these opportunities seriously will certainly require changes in strategies and roles for family physicians; in doing so, we must maintain the core function of the family physician as a personal physician and enhance the physician-patient relationship, not detract from it.

Solutions through creativity

Spann² identifies such a strategy for the discipline in his vision of information technology harnessed to help rather than threaten us. In his model, technology would be used to give health care providers and patients easier access to reliable information and more assistance with decision making and informed consent. We would thus commit fewer errors, improve access, and provide a higher quality of care. Such a system could assist us in managing genomic information, selecting diagnostic and therapeutic technologies, and managing the information overload and hype that appropriately concern Herbert.¹ Hopefully this will allow us to spend more time with patients and less time with paperwork and tracking down information, and will enable us to continue our strong focus on the physician-patient relationship. Spann’s model is an example of the creative solutions that I am confident will be generated. These solutions could enable family physicians to maintain their essential and satisfying historical roles as personal physicians in North America.

My belief that family medicine will succeed is based on my confidence in the creativity of my colleagues and of those in other disciplines, and on the fact that I find the evidence of potential demise unconvincing. Student interest fluctuates in all disciplines. Physicians in many specialties have experienced a greater relative loss of income and decreased personal satisfaction in the past decade than family physicians. Most family physicians I know welcome the opportunity to lead a more balanced life by having emergency coverage and appreciate nurse triage lines for minor problems. Many work in multidisciplinary team settings in which the burdens of care are shared. These physicians still have strong physician-patient relationships and play an important role as personal physicians. Do not misunderstand; I grumble about loss of autonomy, unfairness in the system, and the paperwork, too. I was disappointed as well when our residency program did not fill this year. But when I think about my experiences practicing medicine in Columbia, Missouri, in Sierra Leone, and in Guatemala I recognize how blessed we really are. As Ringdahl described so eloquently in her recent essay,³ we only have to step back and consider the devastating life experiences of our patients to gain proper perspective on “tragedies” like not filling our residency programs.

Family Medicine Research

I agree with Herbert’s recommendations,¹ particularly her points about the need for research career paths, the need for family medicine researchers to understand the changing landscape of health care and health care research, and the integrative and multidisciplinary nature of much of the best family medicine research. In fact, those multidisciplinary teams could, and do in many cases, productively include basic scientists, ethicists, and health promotion experts. However, I do not agree that family medicine as a discipline is particularly well trained or has a distinctive capacity to address such broad social issues as poverty, violence, pollution, and climate change beyond our roles as responsible citizens and as those issues affect our patients.

Another point in Herbert’s article with which I disagree is her criticism of EBM. Those who have articulated the concepts that fall under the rubric of EBM have acknowledged the role of patient preferences and values, pathophysiologic reasoning, and the history and physical examination as essential ingredients of clinical judgement. The clinical epidemiologic research adds the most valid and relevant findings to this mix.^4-6 Each source of “evidence” plays an important role in the management of individual patients. Unfortunately, Herbert criticizes EBM because of how it is abused and for the paucity of research available. These are certainly problems, but they are indictments of the users and of insufficient research, not of EBM. The practical application of EBM in a patient-centered fashion (referred to as information mastery⁷) is the single most important competence we need to add to our training of medical students, residents, and faculty.

Herbert’s approach of asking a basic scientist, an ethicist, and a health promotion expert to describe the role of family medicine research revealed her colleagues were uninformed. I believe her intent was to illustrate that we lack a widespread recognition for our research. That may be useful information, but given our developmental stage I do not find it surprising. For the past 5 years I have chaired the North American Primary Care Research Group’s Committee on Building Research Capacity and the Association of Family Medicine Organizations Research Subcommittee and directed 4 research capacity building workshops involving the chairs and research directors of 29 family medicine departments. I see a vision of the scope, role, and nature of family medicine research coming into sharper focus. Practice-based research is clearly a central contribution of family medicine research. Family medicine research is primarily integrative in nature, using multiple methods. The paper Stange⁸ presented on this topic at the Keystone III Conference articulates much of this vision.

The delivery of personal preventive health services is an example of an important body of knowledge to which family medicine researchers have contributed significantly. The American Academy of Family Physicians’ groundbreaking initiatives have led to the development of 3 family practice research centers, a national research network, a national policy research office, and a large number of family physicians receiving advanced research training. We are developing research in our discipline as we should; the recognition will come in due time. More important, we are producing original research and translations of that research that will provide family physicians with the knowledge that they are obligated to bring to their relationships with patients.

Conclusions

General practice was reinvented as family practice in the United States in 1969 as a response to society’s need for a personal physician to provide medical care. The need for a trusted physician-patient relationship has not changed, but that relationship will be expressed in different ways. How patients need us to serve in that relationship has changed, and we must adapt. We must embrace and contribute to emerging knowledge and translate that knowledge into beneficial care as partners with our patients, collaborate more with our colleagues in other disciplines, and add information mastery to our armamentarium. By doing so we will reinvent family practice again—and probably not for the last time.

Acknowledgments

My thanks to Robert Blake, Mary Barile, Jack Colwill, and Steven Zweig for their thoughtful review of this manuscript.

In this issue of JFP, 2 well-known family physician leaders, Carol Herbert and Stephen Spann,^1,2 describe a variety of threats to the specialty of family practice, warn of its potential demise, and call for its reinvention. The threats include new knowledge in genomics, new technologies, increasing patient desire for direct access to other physician specialists, increased access to information by patients through the Internet and media, evidence-based medicine (EBM), alternative and complementary medicine, nurse practitioners and physicians assistants, nurse triage systems, the abandonment of traditional roles such as hospital care, the push for higher quality of care, and the demand that costs be contained. For tangible evidence of a threat, the authors cite the decreased numbers of medical students entering family practice, decreased satisfaction among physicians, and the replacement of traditional family physician roles by other care providers.

Is our demise impending? To paraphrase Mark Twain, another Missourian: Rumors of our impending death are greatly exaggerated.

Changes offer opportunities

I agree we live in a time of dramatic reorganization of health care and tremendous growth in biologic knowledge and the capacities of information technology. One result of this is that patient expectations are increasing. At the same time, the rising cost of medical care is forcing uncomfortable choices in how we practice medicine. These changes can be seen as opportunities rather than threats. Our opportunity in family practice is threefold: to continue to respond to the need for patient-centered medical care, to translate emerging knowledge into improved patient outcomes, and to manage that knowledge through information technology to put it to the best use for our patients and communities. Pursuing these opportunities seriously will certainly require changes in strategies and roles for family physicians; in doing so, we must maintain the core function of the family physician as a personal physician and enhance the physician-patient relationship, not detract from it.

Solutions through creativity

Spann² identifies such a strategy for the discipline in his vision of information technology harnessed to help rather than threaten us. In his model, technology would be used to give health care providers and patients easier access to reliable information and more assistance with decision making and informed consent. We would thus commit fewer errors, improve access, and provide a higher quality of care. Such a system could assist us in managing genomic information, selecting diagnostic and therapeutic technologies, and managing the information overload and hype that appropriately concern Herbert.¹ Hopefully this will allow us to spend more time with patients and less time with paperwork and tracking down information, and will enable us to continue our strong focus on the physician-patient relationship. Spann’s model is an example of the creative solutions that I am confident will be generated. These solutions could enable family physicians to maintain their essential and satisfying historical roles as personal physicians in North America.

My belief that family medicine will succeed is based on my confidence in the creativity of my colleagues and of those in other disciplines, and on the fact that I find the evidence of potential demise unconvincing. Student interest fluctuates in all disciplines. Physicians in many specialties have experienced a greater relative loss of income and decreased personal satisfaction in the past decade than family physicians. Most family physicians I know welcome the opportunity to lead a more balanced life by having emergency coverage and appreciate nurse triage lines for minor problems. Many work in multidisciplinary team settings in which the burdens of care are shared. These physicians still have strong physician-patient relationships and play an important role as personal physicians. Do not misunderstand; I grumble about loss of autonomy, unfairness in the system, and the paperwork, too. I was disappointed as well when our residency program did not fill this year. But when I think about my experiences practicing medicine in Columbia, Missouri, in Sierra Leone, and in Guatemala I recognize how blessed we really are. As Ringdahl described so eloquently in her recent essay,³ we only have to step back and consider the devastating life experiences of our patients to gain proper perspective on “tragedies” like not filling our residency programs.

Family Medicine Research

I agree with Herbert’s recommendations,¹ particularly her points about the need for research career paths, the need for family medicine researchers to understand the changing landscape of health care and health care research, and the integrative and multidisciplinary nature of much of the best family medicine research. In fact, those multidisciplinary teams could, and do in many cases, productively include basic scientists, ethicists, and health promotion experts. However, I do not agree that family medicine as a discipline is particularly well trained or has a distinctive capacity to address such broad social issues as poverty, violence, pollution, and climate change beyond our roles as responsible citizens and as those issues affect our patients.

Another point in Herbert’s article with which I disagree is her criticism of EBM. Those who have articulated the concepts that fall under the rubric of EBM have acknowledged the role of patient preferences and values, pathophysiologic reasoning, and the history and physical examination as essential ingredients of clinical judgement. The clinical epidemiologic research adds the most valid and relevant findings to this mix.^4-6 Each source of “evidence” plays an important role in the management of individual patients. Unfortunately, Herbert criticizes EBM because of how it is abused and for the paucity of research available. These are certainly problems, but they are indictments of the users and of insufficient research, not of EBM. The practical application of EBM in a patient-centered fashion (referred to as information mastery⁷) is the single most important competence we need to add to our training of medical students, residents, and faculty.

Herbert’s approach of asking a basic scientist, an ethicist, and a health promotion expert to describe the role of family medicine research revealed her colleagues were uninformed. I believe her intent was to illustrate that we lack a widespread recognition for our research. That may be useful information, but given our developmental stage I do not find it surprising. For the past 5 years I have chaired the North American Primary Care Research Group’s Committee on Building Research Capacity and the Association of Family Medicine Organizations Research Subcommittee and directed 4 research capacity building workshops involving the chairs and research directors of 29 family medicine departments. I see a vision of the scope, role, and nature of family medicine research coming into sharper focus. Practice-based research is clearly a central contribution of family medicine research. Family medicine research is primarily integrative in nature, using multiple methods. The paper Stange⁸ presented on this topic at the Keystone III Conference articulates much of this vision.

The delivery of personal preventive health services is an example of an important body of knowledge to which family medicine researchers have contributed significantly. The American Academy of Family Physicians’ groundbreaking initiatives have led to the development of 3 family practice research centers, a national research network, a national policy research office, and a large number of family physicians receiving advanced research training. We are developing research in our discipline as we should; the recognition will come in due time. More important, we are producing original research and translations of that research that will provide family physicians with the knowledge that they are obligated to bring to their relationships with patients.

Conclusions

General practice was reinvented as family practice in the United States in 1969 as a response to society’s need for a personal physician to provide medical care. The need for a trusted physician-patient relationship has not changed, but that relationship will be expressed in different ways. How patients need us to serve in that relationship has changed, and we must adapt. We must embrace and contribute to emerging knowledge and translate that knowledge into beneficial care as partners with our patients, collaborate more with our colleagues in other disciplines, and add information mastery to our armamentarium. By doing so we will reinvent family practice again—and probably not for the last time.

Acknowledgments

My thanks to Robert Blake, Mary Barile, Jack Colwill, and Steven Zweig for their thoughtful review of this manuscript.

In this issue of JFP, 2 well-known family physician leaders, Carol Herbert and Stephen Spann,^1,2 describe a variety of threats to the specialty of family practice, warn of its potential demise, and call for its reinvention. The threats include new knowledge in genomics, new technologies, increasing patient desire for direct access to other physician specialists, increased access to information by patients through the Internet and media, evidence-based medicine (EBM), alternative and complementary medicine, nurse practitioners and physicians assistants, nurse triage systems, the abandonment of traditional roles such as hospital care, the push for higher quality of care, and the demand that costs be contained. For tangible evidence of a threat, the authors cite the decreased numbers of medical students entering family practice, decreased satisfaction among physicians, and the replacement of traditional family physician roles by other care providers.

Is our demise impending? To paraphrase Mark Twain, another Missourian: Rumors of our impending death are greatly exaggerated.

Changes offer opportunities

I agree we live in a time of dramatic reorganization of health care and tremendous growth in biologic knowledge and the capacities of information technology. One result of this is that patient expectations are increasing. At the same time, the rising cost of medical care is forcing uncomfortable choices in how we practice medicine. These changes can be seen as opportunities rather than threats. Our opportunity in family practice is threefold: to continue to respond to the need for patient-centered medical care, to translate emerging knowledge into improved patient outcomes, and to manage that knowledge through information technology to put it to the best use for our patients and communities. Pursuing these opportunities seriously will certainly require changes in strategies and roles for family physicians; in doing so, we must maintain the core function of the family physician as a personal physician and enhance the physician-patient relationship, not detract from it.

Solutions through creativity

Spann² identifies such a strategy for the discipline in his vision of information technology harnessed to help rather than threaten us. In his model, technology would be used to give health care providers and patients easier access to reliable information and more assistance with decision making and informed consent. We would thus commit fewer errors, improve access, and provide a higher quality of care. Such a system could assist us in managing genomic information, selecting diagnostic and therapeutic technologies, and managing the information overload and hype that appropriately concern Herbert.¹ Hopefully this will allow us to spend more time with patients and less time with paperwork and tracking down information, and will enable us to continue our strong focus on the physician-patient relationship. Spann’s model is an example of the creative solutions that I am confident will be generated. These solutions could enable family physicians to maintain their essential and satisfying historical roles as personal physicians in North America.

My belief that family medicine will succeed is based on my confidence in the creativity of my colleagues and of those in other disciplines, and on the fact that I find the evidence of potential demise unconvincing. Student interest fluctuates in all disciplines. Physicians in many specialties have experienced a greater relative loss of income and decreased personal satisfaction in the past decade than family physicians. Most family physicians I know welcome the opportunity to lead a more balanced life by having emergency coverage and appreciate nurse triage lines for minor problems. Many work in multidisciplinary team settings in which the burdens of care are shared. These physicians still have strong physician-patient relationships and play an important role as personal physicians. Do not misunderstand; I grumble about loss of autonomy, unfairness in the system, and the paperwork, too. I was disappointed as well when our residency program did not fill this year. But when I think about my experiences practicing medicine in Columbia, Missouri, in Sierra Leone, and in Guatemala I recognize how blessed we really are. As Ringdahl described so eloquently in her recent essay,³ we only have to step back and consider the devastating life experiences of our patients to gain proper perspective on “tragedies” like not filling our residency programs.

Family Medicine Research

I agree with Herbert’s recommendations,¹ particularly her points about the need for research career paths, the need for family medicine researchers to understand the changing landscape of health care and health care research, and the integrative and multidisciplinary nature of much of the best family medicine research. In fact, those multidisciplinary teams could, and do in many cases, productively include basic scientists, ethicists, and health promotion experts. However, I do not agree that family medicine as a discipline is particularly well trained or has a distinctive capacity to address such broad social issues as poverty, violence, pollution, and climate change beyond our roles as responsible citizens and as those issues affect our patients.

Another point in Herbert’s article with which I disagree is her criticism of EBM. Those who have articulated the concepts that fall under the rubric of EBM have acknowledged the role of patient preferences and values, pathophysiologic reasoning, and the history and physical examination as essential ingredients of clinical judgement. The clinical epidemiologic research adds the most valid and relevant findings to this mix.^4-6 Each source of “evidence” plays an important role in the management of individual patients. Unfortunately, Herbert criticizes EBM because of how it is abused and for the paucity of research available. These are certainly problems, but they are indictments of the users and of insufficient research, not of EBM. The practical application of EBM in a patient-centered fashion (referred to as information mastery⁷) is the single most important competence we need to add to our training of medical students, residents, and faculty.

Herbert’s approach of asking a basic scientist, an ethicist, and a health promotion expert to describe the role of family medicine research revealed her colleagues were uninformed. I believe her intent was to illustrate that we lack a widespread recognition for our research. That may be useful information, but given our developmental stage I do not find it surprising. For the past 5 years I have chaired the North American Primary Care Research Group’s Committee on Building Research Capacity and the Association of Family Medicine Organizations Research Subcommittee and directed 4 research capacity building workshops involving the chairs and research directors of 29 family medicine departments. I see a vision of the scope, role, and nature of family medicine research coming into sharper focus. Practice-based research is clearly a central contribution of family medicine research. Family medicine research is primarily integrative in nature, using multiple methods. The paper Stange⁸ presented on this topic at the Keystone III Conference articulates much of this vision.

The delivery of personal preventive health services is an example of an important body of knowledge to which family medicine researchers have contributed significantly. The American Academy of Family Physicians’ groundbreaking initiatives have led to the development of 3 family practice research centers, a national research network, a national policy research office, and a large number of family physicians receiving advanced research training. We are developing research in our discipline as we should; the recognition will come in due time. More important, we are producing original research and translations of that research that will provide family physicians with the knowledge that they are obligated to bring to their relationships with patients.

Conclusions

General practice was reinvented as family practice in the United States in 1969 as a response to society’s need for a personal physician to provide medical care. The need for a trusted physician-patient relationship has not changed, but that relationship will be expressed in different ways. How patients need us to serve in that relationship has changed, and we must adapt. We must embrace and contribute to emerging knowledge and translate that knowledge into beneficial care as partners with our patients, collaborate more with our colleagues in other disciplines, and add information mastery to our armamentarium. By doing so we will reinvent family practice again—and probably not for the last time.

Acknowledgments

My thanks to Robert Blake, Mary Barile, Jack Colwill, and Steven Zweig for their thoughtful review of this manuscript.