Bob Bowman has sent me the rest of his thoughts about my post regarding the Family Medicine’s role in the health care delivery system and I will share these with you (with a little commentary from me):

We started with “all he saw was a family practice doctor” – this was a comment that could have been made any time in the past 80 years. For the first twenty of those years medical educators such as Osler, Flexner, and various deans would defend the general practitioner as essential and of great value. The medical education leadership began with a perspective that was predominantly generalist and steadily transitioned to physicians more focused on subspecialty, hospital, and research areas.

 One of the consequences of separations between types of physicians was the somewhat derogatory term LMD or Local MD. Town versus gown is another descriptive phrase for the competitive situation although in more recent decades, both town and gown physicians have been losing out. Control of accreditation, training, exclusive markets, health policy influences, associations, and journals has moved steadily toward physicians born, raised, educated, trained, and practicing in top concentrations. Over 70% of US physicians or more arise from about 25% of the population.

Josh Freeman has done a lot of work on this. He points out that not only are physicians-in-training overwhelmingly from caucasian families but also 15.7% of students had one or more parents who was a physician and 24.1% more had a non-physician professional parent. This is important because “…a student’s having a physician parent had a pervasive negative effect on graduates’ choice of any generalist-primary care specialty…”  Bob goes on to point out:

This is the component least likely to become basic health access workforce and this elite group has had the least exposure to more normal people. The leadership design has also come with serious side effects regarding primary care, basic health access, and the ability to understand the health care needs of most Americans.

It became clear in the 1960s that the status quo would lead to a shortage of medical professionals provided what is now known as primary care. In the 1970s Family Medicine was established as the natural extension of the GP tradition. The Physician Assistant and the Advanced Practice Nurse were also established at this time in part to participate in the primary care workforce.

These models emphasized decentralized training and emphasis on broad scope family practice in preceptors and in training focus. The family physician was returned to prominence by early FM leaders raising awareness state to state and year to year. Even with state funding supplied for family medicine training by states, family physician leaders had to fight to ensure that the funding made it to family medicine programs. The same problems have been found with hospitals that receive the funding for training, but the hospitals determine how much to send to primary care programs. During the 1970s there was federal funding directed to medical schools to improve primary care training

 FM leaped from zero to 3000 [annual] graduates in less than a decade – but has had zero growth in annual graduates since this time. Initial NP and PA growth was slow but NP annual graduates doubled in the 1985 to 1996 period and PA annual graduates doubled from 1998 to 2008. NP and PA growth has averaged 6 percentage points in annual growth since 1980. The new PA graduates are twice the level of a decade ago.  Graduates entering primary care are unchanged.

Turns out that the “midlevel” workforce has been subverted into facilitating efficient speciality care delivery, allowing specialists to perform more procedures.

 The case can be made that the factors have frozen family medicine growth have also frozen the primary care workforce size, shape, distribution, support, and delivery. When policies supportive of primary care  in the 1970s and briefly in the 1990s were put into place, there were increases in generalist interest in US MD grads, choice of family medicine by the US MD grads, in internal medicine graduates choosing and remaining in primary care, and PAs entering and remaining in primary care with trends in the other direction whit less favorable policies.

Primary care workforce is explained in part by career selection and in part by primary care retention. Family medicine has about 80% of graduates remaining in office based primary care throughout a career. This falls to nearly 45% for pediatrics, 33% for Advanced Practice Nurses, below the initial 28% for new physician assistants, and below 20% for physicians trained in internal medicine.

Based on trends observed over the past 15 years, it is likely these numbers will certainly be lower.

Primary care retention started at 50 – 60% but was cut in half to the current levels in the past 12 – 15 years. The forces leading other potential members of the primary care workforce to leave primary care have also resulted in declines in primary care retention in all sources, have resulted in lower choice of family medicine in the US MD graduates, have resulted in loss of generalist interest as recorded by AAMC, and have resulted in family practice workforce cut in half (50% to 25%) in non-physician clinicians.

Bob concludes:

 We still have a 1970s design that really is not a design for primary care workforce. We have a 2010 population that will [exhibit] increased primary care demand. We have a 2030 health care coverage design that required increasingly more complex care from existing primary care workforce that is shrinking. We have patients who want advanced technology as well as the quality patient care relationships of past decades. And we have [payors] that are still looking to shave dollars when the major problem is $125 billion in primary care spending when the nation needs $200 billion.

 The perspectives used to examine primary care access as well as access for basic health has been extremely limited. Research, foundations, government reports, and major journals capture at best two variables. Dimensions of primary care delivery, equitable distribution of services and clinicians, policy, training, accreditation, and numerous relationships must be coordinated and compiled into a comprehensive plan for recovery of basic health access over the next 50 years.

 Understanding how exclusive in origins our current physician workforce is as well as how exclusive training and policies have become, it is easy to understand why health care in the United States is in trouble. It is also easier to understand why family physicians get a bad rap. Family physicians arise from all types of populations in the United States and are found serving all types of populations. Non-family physicians are more likely to arise from more exclusive origins and training. More humble origins and more non-elite training results in local physicians. These town physicians can be gown physicians.  These are physicians that serve where most needed at 2 to 4 times greater levels to all the populations in most need of care. In fact, if the nation had any reasonable understanding of the value of family physicians and any real emphasis on health access, the nation would be rushing to expand the family physicians workforce as a priority.