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william-haefeli-if-you-bring-joy-and-enthusiasm-to-everything-you-do-people-will-think-y-new-yorker-cartoonI received the following comment to my previous post (which I have paraphrased some) and feel compelled to respond in depth:

I am a new 4th year medical student who entered medical school to become a Family Physician. However, the challenges facing family medicine give me great concern and I was wondering if I could get feedback on a few of these concerns.

(1) The Turf War between Nurse Practitioners and Family Physicians.

It seems to me that Family Physicians are treating only a fraction of disease entities that comprise the requirement for licensure and graduation from medical school. From what I have seen Family Physicians are not even reading EKGs and require a cardiologist.

To me, this creates a opportunity for the nurse practitioner to boldly say they can function as family physicians – by addressing that small fraction of entities which makes up the current repertoire of FPs. 

Family physicians need to be vocal about what their training and expertise bring to the table. Most of the noise regarding nurse practitioners and physicians assistants becoming the primary care provider of choice is just that, noise (go to this link for more details). First, as Bob Bowman I’m sure will elaborate, the workforce and work product from these types of providers has not been shown to provide for the needs of our country.  Every other country uses generalist physicians to lead the primary care team. The move to exclusive use of these providers for primary care would be yet another natural experiment in health policy for our country should we chose to go in that direction. The ones to date have not been shown to lead to better quality, less cost, or better health for Americans. We are now in the process of transitioning to the Patient Centered Medical Home team based approach to care in this country. The team will almost certainly include other providers and I would argue we need to be more expansive and include pharmacists and care managers as part of the team. Yes, Family Physicians need to maintain core skills but in our 11 years of training (as compared to 5-7 for PAs and NPs) and 21,700 hours of clinical training (as compared to 5350) we learn how to provide the first contact care that Americans need. As we transition it will be important for physicians to reacquire skills that may have atrophied as they focused on acute, self-limited illness care (which is likely more suited to care in a collaborative fashion by a PA or NP).

(2) The huge number of referrals from a family physician also results in disrespect from the medical and patient community.

– Examples include dermatology, minor procedures, ophthalmology referral for a retina screening 

Family physicians have been trapped in a world where they were seeing patients every 7 minutes, which is untenable. This was an artifact of our payment structure which valued volume over value and encouraged physicians in some settings to refer rather than perform many services they were trained to do. As payment methods change, chronic illness care is valued, and patient satisfaction is measured to reflect the skill and care of the physician, this will change. You need to learn how to perform procedures skillfully while being cognizant of your limits. Realize also that in academic settings referrals are made often for political reasons and do not reflect the scope of practice that physicians can enjoy away from the academic health center. The following is from an open letter to new graduates after the question was raised in one of our journals several years back

Avoid the temptation to limit voluntarily the things you do simply because the subspecialist does it better or more frequently. Your patients want and need you to do all that you can for them, not for you to be a speed bump on their road to care. If your consultants do not respect you enough to return your patients after answering the question you asked, find other consultants. Their role is to answer a question or perform a procedure you choose not to perform, not to expound on their superiority in some field or another. Your job is to take care of your patients, not to make the limited practitioners feel better about themselves.

(3) The future of Family Medicine :
I believe, that if Family Physicians continue to practice in this manner of treating only a fraction of what they know how to treat, within the next 10 years no one will go into family medicine…. Right now the numbers going into family medicine ranges below 10% at the “top schools”.

I believe that medicine is changing. Our specialty went through a thought exercise about 10 years ago now and put out a series of articles regarding where the specialty needed to go called, ironically, “The Future of Family Medicine.” Our Academy has taken up the mantle and provides information for students such as yourself here. The future of all health care in this country is a team approach to care with a focus on improving the health of the population at a high quality and lower cost. Family physicians have been shown to do just that. We have taken the principals developed in the Future of Family Medicine project and, working with the American Academy of Pediatrics, American College of Physicians, and the American Osteopathic Association among others, embraced the Joint Principals which led to the Patient Centered Medical Home (more information found here)

(4) Also can Family Medicine training agree to evolve the services of a Family Physician? Or is the plan to stay the same?

If only a minority of Family Physicians take the lead in providing full-spectrum services while the vast majority treat a fraction of what they were taught to treat – there will be nothing to distinguish their service from the one provided by the nurse practitioner.

Family medicine (and all residency training) programs are dynamic processes. About 70% of the curriculum is proscribed by the governing body, the Residency Review Committee. This curriculum is reviewed about every 5 years and another review is due out any day now. It is anticipated that there will be major changes in training requirements to reflect the changing needs of our health care system. We are already training our physicians to be leaders of the care team, knowledgeable about chronic illness care, and able to care for all patients as a physician of first contact. I anticipate that this is the direction training will take. In addition, 30% of the curriculum can be set by the program to reflect local strengths and all of the curriculum acquires a local flavor. Our program, for example, has a strong underserved component. Our patients cannot get in to see a dermatologist closer than 4 hours away (an insurmountable barrier to those with poor transportation). As a consequence we are very good at managing diseases of the skin without a dermatologist. Programs in the west offer a lot of OB. I would encourage you to look at the 400 family medicine programs in the country and find one that offers training you find appealing. My experience in training residents who have taken positions everywhere from rural Alabama to Alaska tells me you will find a practice that will value your skill set.

Good luck with your decision. I hope that others will pitch in their two cents about “Why Family Medicine” as well because people like you are our future.

I wrote recently that I did not feel my specialty was threatened by Advanced Practice Nurses and stated why the threat (present since the mid-1990s) had not been made good. There is more evidence in a recent American Medical News that while people may like to shop at WalMart, they are not necessarily looking for health care. The article points out that the Minute Clinic concept is not consistently a break-even proposition and the number of new sites has leveled off. On top of that, many are likely loosing money if you run the math. Why is that? Turns out that the business model of putting a provider among the Kleenexes might work in the winter but isn’t a good idea in the summer. Additionally, these providers are so limited in their scope that even folks that like to consume lots of health care are left wanting. For those that still want to believe that Family Physicians can be replaced, fear not.  “Other clinics are betting that expanding their scope will have some impact. Many are expanding to include wellness services as well as chronic disease management to help spread the business year-round.” I only hope they are up to providing quality care amongst the bowel care products.

While at the Alabama Academy of Family Physicians meeting this weekend, the discussion turned (as it is in a lot of places) to health care reform, the climate in Alabama, and whether primary care can survive the next 10 years in Alabama. As I have chronicled the environment for Family Physicians in private practice is not very favorable and Medicaid in Alabama is inherently unstable. To give ourselves yet something else to worry about that we can’t control, the conversation around the table moved the suspicion that the major payors (Blur Cross and Medicaid) are attempting to transform the care delivery system by dropping the reimbursement so low that non-physician providers will be the only ones who can afford to provide primary care services.

This concern has been around at least since the HMO “revolution”. The New York Times ran an article detailing the demise of the primary care physician and the rise of non-physician primary care in 1997. On the service, it is an appealing concept. Advanced practice nurses take less time to train (5 years with undergrad counting) than physicians (7 years post-baccalaureate). To the untrained eye as well as to the partialist physician, what I do seems “so easy a caveman could do it” so why should we waste physician resources on primary care? Lastly, patient satisfaction is always higher for visits to advanced practice nurses when reported than it is to physicians.

 So why am I not unemployed? As my friend Bob Bowman has posted, Family Medicine Advanced Practice Nurses spend only 3.5 years in primary care before moving onto something else. They will constitute at best only 12% of the primary care workforce. Expansion of training to take advantage of the more rapid training cycle without fundamental change in the delivery system will result in more Advanced Practice Nurses but no more in primary care practices. It is true that Advanced Practice Nurses are likely to practice in rural areas when they go into primary care and this must be captured and expanded upon.

It is true that if 30,000,000 folks who do not currently have access are given access, there will be a signficant unmet need for primary care. As Lori Heim, the president of the American Academy of Family Physicians stated, our  common goal of improving access should dictate the relationship between physicians and Advanced Practice Nurses. I suspect there is enough business in the new model of healthcare for both groups.