Green, Larry A. MD; Fryer, George E. Jr. PhD
In response to a public outcry for primary physicians and concern about the decline of general practice,1,2 family practice was established in 1969 as the 20th medical specialty in the United States. The development of new technology and a rapidly expanding knowledge base account for most of the proliferation of medical specialties in the last 30 years,* but a powerful reform movement gave rise to family practice. Idealism, feminism, consumerism, egalitarianism, a willingness to fight, and renewed sense of service were at the heart of this movement, and have sustained its momentum since its inception.3
In 1970, 57,948 general practitioners constituted 18.6% of the 310,929 active MDs in the U.S. physician workforce.4,p. 293 At that time 40,487 students were enrolled in the 103 allopathic schools of medicine, none of which had a department of family medicine.5 The first family practice residencies were launched as the specialty was established, and by developing innovations in community-based teaching, such as model family practices and decentralized clerkships, family practice educators had a dramatic impact. In 2000, there were 472 family practice residency programs with 10,503 family practice residents in training.6 Departments of family medicine were operating in 113 of 124 U.S. allopathic medical schools7 that had a combined enrollment of 66,500 students.8 In 2000, the number of general practitioners had continued in decline to 15,215, but there were 71,106 family physicians.4,p. 296 Interestingly, this enhanced family practice workforce accounted for only 9.6% of 737,504 MDs involved in patient care, administration, teaching, or research.4,p. 296 In 2000, direct patient care was the major professional activity of almost all of these family physicians (96%) and remaining general practitioners (97%); compared with 86% of other MDs. Ninety-three percent of the family physicians in direct patient care were office-based.4,p. 294
During the same period, family practice was also developing in other countries. In most other countries medical responsibility for primary care has become the province of family practice alone, not shared among several medical specialties as it is in the United States by family physicians, general internists, and general pediatricians. Internationally, family practice has matured in various forms to achieve a broad, integrating role.9 The health problems of patients attended by family physicians are remarkably similar from one country to another. Derived from the concerns of the populations served, it has been found that just 35 groups of symptoms are needed to account for 45-60% of reasons for visits to family physicians.10 Approximately 50 diagnoses are needed to characterize a majority of all new episodes of care managed by family physicians in Japan, Poland, The Netherlands, and the United States.10 Of course, a very large number of problems and diagnoses make up the balance, precluding boredom in family practice.
The position of family practice in the United States must be viewed in the broader context of the development and growth of other health care provider groups, particularly those involved in primary care, in the last 30 years. While family physicians grew in number and replaced general practitioners, it was 1995 before the number of MD family physicians surpassed the number of general practitioners in 1970.4,p. 293 In aggregate, the proportion of the U.S. physician workforce comprising family physicians and general practitioners has actually decreased since 1970. Meanwhile, new health care providers capable of contributing to primary care were invented during this period, and, for example, in 2000, the numbers of physician assistants and nurse practitioners had reached 45,31111 and 102,829,12 respectively. In the year 2000, the numbers of non-federal MDs in direct patient care with primary specialties of general internal medicine and general pediatrics were 70,362 and 39,176, respectively.13 Also, in 2000, there were 28,407 non-federal, direct patient care osteopathic physicians, of whom 12,194 (43%) were family physicians or general practitioners.13
Although there are a variety of primary care providers in the United States, the degree of reliance of the entire country on family practice is well documented. For example, among the civilian, non-institutionalized U.S. population who identified an individual provider as their usual source of care (121 million people) in the 1996 Medical Expenditure Panel Survey (MEPS), 62% identified a family physician/general practitioner, 16%, a general internist, 15%, a general pediatrician, and 8%, another provider (e.g., specialist physician, chiropractor, nurse practitioner).14 Family physicians are often the usual source of care for all sorts of people, including those suffering from life-threatening and chronic, but manageable, conditions, designated “priority” conditions by the Agency for Healthcare Research and Quality. Table 1 uses three physician specialty groups to quantify the distribution of people who, as of 1996, had a physician as a usual source of care and also had one of these high-priority conditions; the table's data are the most recent of this type available. This table also shows the distribution of visits made to office-based physicians for these high-priority conditions in 1996. Thus, family physicians and general internists were the usual source of care and provided much of the service received by people with these conditions. It is notable that only 11% of these people had changed their usual sources of care during the previous year (1995), usually because of relocation or administrative reasons. Like findings for many other specialties, in 1996, about 97% of people visiting a family physician when sick or in need of advice about their health were satisfied.14
Even though family physicians are a small fraction of the physician workforce, the population of the United States visits the offices of family physicians and general practitioners more than those of any other medical specialty. Results from the 2000 National Ambulatory Medical Care Survey indicated there were 822 million visits to physicians' offices, and of these, 199 million were to family physicians or general practitioners. By comparison, there were 126 million visits to general internists, 104 million to general pediatricians, 65 million to obstetricians—gynecologists, and 17 million to general surgeons.15
Undoubtedly, some of the public's reliance on family practice stems from the specialty's geographic distribution, which is—more than for any other specialty—congruent with the distribution of the U.S. population.16 In 2000, 19.7% of the population lived outside metropolitan statistical areas,17 and 25.7% of the offices of family physicians or general practitioners were located in non-metropolitan statistical areas, in contrast to 11.9% of other office-based physicians.4,p. 342Figure 1 illustrates the dependence of the United States in 1999 on family physicians and general practitioners by mapping the counties that either were already or would become whole-county primary care health professions shortage areas without family physicians and general practitioners.18
Given family practice's original mandate in 1969, the brief characterization above confirms a policy success: a medical specialty that delivered on its promise to reverse the decline of general practice and provide front-line clinical services to all areas of the country. The contribution family physicians are making now to meet the needs of the population is large, especially when it is recognized that they make up a relatively small part of the physician workforce.
These successes of family practice have been insufficient by themselves, however, to reform the health care system. Some of the challenges family practice was expected to address and still aspires to help resolve remain unsolved, such as disparities in health and health care among various population groups,19 reliable delivery of health promotion and disease prevention services,20 and coordinated care for people with chronic diseases.21 It is widely believed that the role of family practice in the United States is at risk in our confused, disorganized, ailing health care system.22 Concerns about the future of family practice have been voiced23,24 and fueled by the match rate for family practice, which, after a period of increasing student interest, has dropped to 1992 levels. Only 1,413 of U.S. senior medical students (10.5%) chose to match into family practice in 2002.25
In this context, in the rest of this article we identify some of the major issues affecting family practice, examine some contradictions embedded in family practice's current position, and suggest some mistakes that family practice has made. Then we offer some conjecture about the immediate challenges facing family practice and what factors may influence its further evolution. We conclude that the significance of its contribution to improved health and health care depends, again, both on how it chooses to adapt to meet the challenges it is facing and also on how the rest of the health care system responds to the 21st-century version of family practice.
Rosemary Stevens has provided a cogent formulation of three major issues that affect family practice now.23,26
Role. The first is the lack of a clearly established role through a formal, nationwide administrative structure for U.S. primary care. This role is less clear now than when family practice was launched. Managed care fleetingly looked like an opportunity to establish the role. However, managed care became managed cost; and the role of the primary care physician was further confused by intrusions into the relationships between patients and their doctors, forced disruptions of care, and “double agency.”27
Differentiation. The second issue is insufficient differentiation of family practice from the rest of medicine while becoming entrenched in the medical establishment as a specialty and one of several overlapping and competing primary care fields.23,26 The public is confused by all the names: generalist, general practitioner, “GP,” family practitioner, family physician, family doctor, family practice doctor, “PCP,” primary physician, primary care physician, general internist, and general pediatrician. Furthermore, many other providers have developed primary care aspirations, with nurses, alternative health care providers, and various physician and non-physician specialists wanting some piece of primary care.
Environment. Third, there have been simultaneously too many and too few changes in the cultural and political environment of the United States to establish family practice as a foundation of health care as originally envisioned.23,26 The tide turned from reform to fiscal and cultural conservatism, and Dr. Gayle Stephens observed that family practice “expended [its] energy on professional legitimation and enfranchisement rather than reform.”28 Public opinion has vacillated, with strong preferences expressed for specialism rather than generalism. Consequently, specialists have been supported through major money streams for services and research without symmetrical investment in the enterprise of generalists. Dr. Rosemary Stevens also suggested that a persistent belief in the family physician as a mythical hero who could overcome insurmountable odds if only faithful to the idealized calling may not have served the field or public well and may have limited strategic thinking. And, of course, the expectation of universal inclusion of everyone in the health care system along with systems to rationalize this commitment was not realized and still proves elusive. Consequently, a field such as family practice, which is dedicated to taking in whoever decides to present whatever problem they wish and coordinating their care, is seriously compromised by substantial chunks of the population's remaining disenfranchised.
SOME CONTRADICTIONS AND TENSIONS WITHIN FAMILY PRACTICE
There are significant contradictions and tensions in family practice's current position, some of which apply, at least in part, to other health care disciplines. Taken together, they help explain family practice's failure of differentiation and the underachievement of the specialty and the entire health care system.
Is family practice a reform movement or an incumbent medical specialty?
Family practice simultaneously lays claim to both. The role, tasks, and the tools of the reformer are not typically those of the incumbent. When our current system is acknowledged to be so flawed it cannot be fixed,29 family practice can be viewed simultaneously as a promising route toward innovation and reform or alternatively as a legitimized component of an insufficient enterprise, partially accountable for its failings, ripe for replacement by genuine reform.
Is family practice a gatekeeper, a gateway, or a delightful place to stay?
Each of these image-provoking terms represents a function that family physicians are trained and expected to do. Which one it is for a given patient on a given day, depends on a host of personal, clinical, and economic variables. Is a family physician a triage artist with little to offer in direct service, a miserly curmudgeon standing between patients and the rest of health care, or the doctor you can count on to provide best care for most of your problems most of the time? Different segments of the economy and health care system and patients do not agree about their expectations of family physicians. In the resulting confusion, there has been an erosion of trust among patients and their family physicians and among family physicians and their consultant colleagues. The confusion creates contradictory messages and impedes optimizing systems because of conflicting expectations.
Is a family physician a specialist or a generalist?
The claim of specialist was, in the 1960s as well as now, in some ways a practical necessity in a medical establishment and a society that, despite evidence that quality is a systems property,30 tends to equate a specialist with quality and a generalist with mediocrity. Buried in this obvious contradiction of terms is also a plea from family physicians, like other clinical generalists, to be recognized as providing important services well. Nonetheless, this unresolved situation creates role confusion for patients, payers, and providers. It allows what has been labeled the “persistent contradiction” to flourish within academic institutions, where faculty advise students that family practice and primary care are so hard no one can do them well—and then say, perhaps later the same day, that they are so easy anyone can do them.31 The first message predicts mediocrity and the second suggests wasting one's medical career. These messages reflect poorly on ill-informed faculty and are not attractive messages from a student's perspective. They persist despite evidence that family practice manifests a coherent set of principles and skills that are intellectually challenging, personally rewarding, as learnable as any others, and necessary to successful, sustainable health care.32,33
Is family practice vital for everyone or an option for just a few?
The name itself, family practice, results in a lack of clarity about who is eligible for family practice. Large portions of the population do not live in a traditional family structure; and most of the current population of the United States have lived their lives, not in a time of dominance by general practitioners, but in a time of scarcity of family physicians. Absent personal experience, many may wonder what a family physician is and whether family practice is just for families with parents and children. Family practice's strong association with meeting the needs of underserved populations also makes some wonder if family practice is only for those who are disadvantaged by their location or station in life. This sets up misunderstandings about the scope and domain of family practice and leaves many wondering whether or not family practice is a place for everyone regardless of age, sex, or presenting complaint, or just another boutique option within medicine.
Can family practice conduct business relying solely on knowledge from other fields or is it another discoverable part of medicine?
This has been labeled “the unfortunate misunderstanding,”31 and persists because of a widespread belief that all the knowledge necessary for family practice either already exists elsewhere or could best be developed by someone other than family physicians. Fortunately, a cadre of family practice and primary care researchers is emerging, along with relevant tools and laboratories, producing critical new knowledge.33,34 Congress has created in statute within the Agency for Healthcare Research and Quality a center devoted to primary care research, and this center is succeeding in galvanizing the growing community of family practice and primary care researchers.
Translation of knowledge from one field to any other, when useful for solving the problems of that field, is desirable; and family practice is the beneficiary of contributions of knowledge and technologies from diverse fields of endeavor. Increasingly, the translational process is becoming bidirectional, translating research into practice as well as translating practice into research.35,36 It is obvious to those in family practice that there are problems and opportunities that are not amenable to existing solutions and possibly not even approachable absent further development of methods and theory.23,37 Sometimes, this recognition promotes negativism toward the mature biomedical enterprise to the point of neglecting promising opportunities to adopt technologies and clinical breakthroughs into family practice. As long as this contradictory view of the knowledge requirements for family practice persists, it inhibits a wholehearted commitment to discovery available in, possibly only in, family practice. It inhibits family practice from being the best it can be based on all the sciences. Meanwhile, people await innovations that could benefit not a few, but millions on a daily basis.
Is family practice a service to be valued and financed explicitly for its intrinsic value, or is it a loss leader to be tolerated as a means to “downstream revenue”?
The first option positions family practice to determine its costs and be organized for comprehensive care and sustainability. As a loss leader, however, family practice is positioned to beg for subsidization and be subjected to minimization. Profitable piecework and services reimbursed at higher rates if done elsewhere may be relocated out of family practice. There may or may not be a mechanism or the will to “subsidize” the less lucrative work still necessary for patients in family practice and other primary care settings. There is a limit to wringing out further efficiencies, and a point at which reimbursement revisions are necessary. Overall, this financial situation tends to impede designing a solid business plan in which revenues exceed costs, the enterprise becomes attractive for investment, and those working in family practice can expect fair and equitable compensation.
MISTAKES MADE BY FAMILY PRACTICE
Family practice has spent too much effort on justifying its existence and declaring its values and too little on securing the practical means to accomplish its goals of comprehensive, continuous, coordinated care. This has been captured in the phrase, “constructing the mind of family practice instead of its place.”23,38 For decades, family physicians have argued about the role of technology in family practice and rightly proclaimed the centrality of relationships in their work and the importance of “being there.”23,39 Unfortunately, relatively little effort has gone into designing optimal settings in which the best tools can be marshaled to sustain relationships and to execute reliably the services that are needed, based on their importance, frequency, or urgency, and thus make sense in family practice. Implementing systems that capitalize on new technologies, particularly information technology, has been slow, and capital needs for the family practice setting have not been addressed adequately. The result is too often a specialty that is justified, but not positioned to execute its important contribution to better health care and better health.
The strong alliance with public need and expectations present at the beginning of family practice has been eroded, in part because family practice, at least initially, welcomed an association with managed care. The role embraced by family practice and other medical generalists was imagined, perhaps naively, to be a valuable, national, coordinating role in organized systems of care. In some instances this has been achieved; but in many others, this role failed and received a healthy portion of the backlash against managed care. In too many instances, managed care altered or dismissed a sustained partnership between people and their family physicians. Fueled by advertising, fantasy, and an occasional breakthrough, public expectations have risen to believe that just about anything can be fixed if you can get past your PCP to the right specialist. Consequently, segments of the public probably are no longer sure that their interests are aligned with family practice.27
Family practice has allowed its breadth and versatility to be too often a source of conflict instead of a spectrum of strong alliances within medicine. Because many of its boundaries remain indefinite and contested,23,26 family practice and other medical specialties and professional groups are often positioned to invade and dispute each other's “territory,” compete rather than integrate, and defend rather than engage. These conflicts among various types of providers are often argued in terms of quality, with evidence cutting both ways about the performances of generalists and specialists and physicians and nurses.40–50 In reality, these interface issues are too often grounded in concerns of status and economics. Meanwhile, the balanced cooperation critical for the superior performance people deserve from the health care system may not occur. While there are very successful examples of alliances with family practice, such as in sports medicine and geriatrics, other interfaces are acknowledged to be inadequate, including those involving emergency services, maternity care, screening procedures, and intensive hospital-based services. Family practice is not unilaterally responsible for these conflicted interfaces. Unfortunately, the energy and effort expended at these interfaces dilute family practice's and other specialties' responsiveness to important opportunities associated with, for example, mental health, public health, and rural health.
Family practice initially chose to make research an elective. Consequently, it remains intellectually immature and is not yet positioned as a major source of new knowledge about the origins of health and disease and means of relieving suffering and promoting health. Family practice has not yet figured out how to measure its effects, and it is not the place people automatically look for breakthroughs. This most importantly deprives people of improvements of care through insights available through research into the problems and processes that comprise family practice,31,36 but it also results in family practice's not being valued by academic health science centers with core missions of research. Consequently, students and physicians keen to learn through investigation tend to look elsewhere to apply their intellects; and academic health centers may wonder why, if at all, they need a department of family practice.
PROMISING OPPORTUNITIES: DESIGN, DEFINE, DISCOVER, AND DIFFERENTIATE
The “mistakes” described above align with immediate opportunities that family practice may want to seize. Now that a substantial workforce of relatively young family physicians coexists for the first time with robust information technology, it is feasible to launch a full-scale effort to re-design the work and place of family practice, intentionally matching best strategies and tools to what people need and want from their primary physicians. This invites precisely defining interfaces between family practice and other medical specialties and other critical components of health care such as mental health and public health. The desired result is a maturation—beyond traditional silos of expertise and the specialist—generalist arguments—to integration, with explicit, accountable divisions of labor. The target is optimization of results for people at the front door of modern medicine, safely, right the first time. An explicit commitment to the discovery of family practice, all of it, is essential.23,37,51 This includes installing the infrastructures necessary for original and translational research that establishes and differentiates family practice as a scientific approach to achieving the primary care function for men, women, and children of all ages. These efforts could be expected to redress family practice's need to differentiate its role and place in health care in the United States.
There is reason to believe that these steps may be taken. All seven national family practice organizations have united in a project launched in early 2002 to understand better the expectations of the public and respond to revamp family practice accordingly. This effort has been organized to include a broad spectrum of viewpoints across disciplines and economic sectors and has taken as its starting point that family practice's assumptions must yield to new evidence. It is the first comprehensive effort to adapt family practice to the current mileau, and if successful will provide many opportunities for sincere collaborations intended to strengthen the performance of the health care system in behalf of people.
FACTORS INFLUENCING THE FUTURE OF FAMILY PRACTICE
There are aspects of any discipline or specialty that the field itself largely determines, and there are others that depend on the field's interactions with other specialties and the health care environment. This is certainly true for a generalist domain such as family practice.
Among the factors that family practice can influence least, universal inclusion of the entire population in an organized system of health care stands out. Continued failure to achieve this objective thwarts basic goals of family practice, such as having registered patient populations, stabilized relationships among people and their usual sources of care, and comprehensive care of people with chronic conditions. Also, family physicians constitute only one of many advocacy groups concerned with other broad national priorities. As long as national policies increase the division of wealth, tiering of almost everything seems likely, and family practice's commitment to accepting anyone with any condition will be tested in ways not controlled by the field.52 Alternatively, the establishment of universal inclusion and a national commitment to replacing our ailing system with a better one focused on improving health would provide a framework for important contributions by family practice that could substantially resolve uncertainties about the role family practice adopts in the health care system.
There are many factors that depend on the choices made by both family practice and other elements of the health care system. These include a mutual willingness to define carefully the interfaces between family practice and other medical specialties and to resolve turf issues. Doing so would establish accountability and permit design of practice and training to uphold everyone's commitments. The general agreement about interdependence among mental health, public health, and family practice may be ripe for fuller development. Relationships among family practice and nurses, nurse practitioners, physician assistants, general internists, and general pediatricians remain critical to establishing robust primary care in the United States. How these relationships evolve is likely to influence the ability of all of these groups to reach their potential.
Other issues over which family practice has only partial influence include the development of a financial model that works for family practice and the rest of primary care. This model must have revenues that exceed expenses and must include an adequate information technology infrastructure for modern front-line community practice. Also, family practice must rely on faculty and leaders at academic health centers to resolve misunderstandings and contradictions in order to stabilize the role of family practice within medical schools and teaching hospitals.
There are other factors that are largely under the control of the specialty of family practice.23,53 These include redesign of the workplace of family practice, revisions in predoctoral and residency education needed to enhance the impact of family practice, and capitalizing on a new generation of family physicians that includes many women. Similarly, the rearticulation of the principles of family practice and a renewed commitment to “being there” for patients in a continuing partnership is within the reach of the field itself.39
Whether or not family practice seizes these opportunities may depend on the ability of family physicians to recover from what John McWhorter labeled a “cultural malady.”54 McWhorter's hard-hitting analysis of possible explanations for underachievement of black Americans could find useful application to the case of underachievement of family practice. McWhorter suggests that instead of recognized external factors, internal conditions may play a dominant role. He identifies three: a propensity to be anti-intellectual, a preference for being separate, and a celebration of victimization. This “malady” has its roots in unfair treatment, and there are certainly some analogies between the situation described by McWhorter and the situation of family practice. Family practice's future may depend fundamentally on its ability to commit now to intellectual development, integration into a revised health care system, and an abandonment of the role of victim.
How might all of these issues resolve during the next few years? History, the current ecology of medical care,55 and international experience9,32 converge to support there being a need for a healer having the breadth, depth, and adaptability required to serve as a point of first contact and an ongoing point of integration of personal health care services. This is a rewarding and intellectually challenging role worthy of physicians and likely to become even more important as health care shifts toward chronic care. Family practice is positioned to fulfill this role. If it does not, there will be a major gap created that will present substantial problems for the public and many decision makers.
How substantive a contribution family practice makes to the well-being of the entire country depends critically on redesigned and appropriately financed practice settings. This is possibly the first time in history that the ambitious aspirations of family practice are actually achievable. Embracing and enhancing relevant knowledge and technology, revising training, and forging sufficient alliances with other health care providers represent exciting opportunities for a new generation of family physicians.23,53 Family practice may belong no longer to those who conceived it—rather to those who can make it be that care the Institute of Medicine33 labeled “central and fundamental” and “the logical foundation of an effective health care system.”
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*By the year 2000, the number of specialty classifications for which the American Medical Association was compiling data had grown to 162, often grouped into 39 specialties for statistical analysis and reporting purposes.4,p. xviii Cited Here...