Monday, September 12, 2011

Clinical problem-solving is a strength of family medicine

Working with family physicians since 1978, I have noticed two things in particular.

First, they take great pride in their interest in relationship-based care. They talk about the value of continuity. They tell stories that describe how much they treasure relationships with patients. They tell these stories in their teaching. They write books about it. It's a powerful force that energizes their work and their career satisfaction.

They rarely, if ever, mention the power of their clinical problem-solving abilities. Why is that? The absence of mention and the seeming lack of pride (my assumption) in this area makes me wonder if FPs really believe they are effective in the area of clinical problem-solving.

From my earliest days in family medicine, I came to believe that FPs' impact as physicians was a result of their patient/relationship-centered approach that included effective communication skills, their fund of knowledge, and their clinical problem-solving skills. All three are essential; any two working alone, except in special circumstances, will not lead to the best results.

Family physicians embraced the work of Barbara Starfield, MD, MPH, who told the world that FPs, in particular, and primary care clinicians, in general, had a positive effect on population health while reducing the cost of care. When I hear FPs take pride in their relationship centered approach to care but never mention their approach to clinical problem-solving, it leads me to believe they think that continuity alone produces the impact documented by Dr. Starfield.

I put this issue to a number of colleagues and heard the following.

"Because of the variety of patients and undefined illnesses that family physicians see, they become better at development of realistic differential diagnosis than any other medical specialty." - Doug Smith, MD, Orono Family Medicine, Orono, Minnesota

Shantie Harkisoon, MD, director of the Phelps Family Medicine Residency Program in Sleepy Hollow, New York, told me that she thinks the strength of FPs is strong skill with differential diagnosis of the patient as person while sub-specialists are generally more effective at differential diagnosis of a disease.

I have been talking to a documentary film maker who wants to tell a story about family medicine and primary care innovation. In his interviews with FPs, all he hears about is the value of relationship centered care. He can't understand how the care provided by FPs costs less money. When I told him that FPs are effective clinical problem-solvers and their approach to decision making is a key piece of this story, he almost did not believe me. When he interviewed FPs, he was not hearing about this. Why do we not hear more about family physicians' clinical problem-solving prowess?

Laurence Bauer, MSW, MEd
Chief Executive Officer

1 comment:

  1. It takes more than hand-holding to be a good doctor. Yes, I think family physicians differentiate themselves from other specialties by their sense of “relationship centered care,” as mentioned here. I suspect that because they see subspecialists as having expertise in a narrow disease or procedure focus, they don’t see themselves as having similar expertise in a “big picture” focus. Yet every day family physicians and other primary care physicians apply their skills to the challenging tasks of 1) differentiating serious from non-serious symptoms; 2) effectively managing the vast majority of medical problems they encounter; 3) triaging patients when needed to subspecialty care; and 4) caring for patients in context. In other words, putting into practice the principles of primary care, which has been shown to improve the health of populations (with the added side benefit of saving costs). Our specialty has a history of undervaluing itself, and it’s important for us to be our own advocates. Leave it to Larry Bauer, an exceptional non-physician leader in family medicine, to recognize and value what we do!

    Jay Siwek, MD
    Professor and Vice Chair
    Department of Family Medicine
    Editor, American Family Physician
    Georgetown University Medical Center
    Washington, DC 20007