Monday, August 5, 2013

Is prevention or treatment the heart of family medicine?

- Kenny Lin, MD, MPH

The comprehensive scope of family medicine has always made it a challenge to describe, in a nutshell, what family physicians do. Unlike subspecialists or general internists, surgeons, or pediatricians, family physicians do not define their patient populations by age, gender, or organ system. A series of editorials published a few years ago in the Annals of Family Medicine argued that family physicians practice a "science of connectedness" that includes a distinct approach to clinical problem-solving. A more recent study in Family Medicine asserted that the training and attitudes of family physicians make them uniquely qualified to provide cost-effective health care. The emergence of the Patient-Centered Medical Home model has emphasized the role of the family physician as a facilitator and leader of care teams for patients with multiple preventive and chronic care needs.

Dr. John Hickner, editor of The Journal of Family Practice, worries that well-intentioned initiatives to improve family physicians' skills at providing screening tests and facilitating behavioral change may come at the cost of neglecting patients' acute concerns. He wrote in a recent editorial:

At times I fear that all the focus on prevention and chronic disease management, necessary as these are, distracts us from our most important work: meeting the immediate needs and concerns of our patients. The agenda of the office visit used to be exclusively the patients’. Now a visit—and our attention—is often split between their agenda and ours, which includes screening for this and that and exhorting patients to a healthier lifestyle whether they want it or not. I had one irate patient tell me, “Don’t put me on that scale again! I know I’m fat and if I want your help, I’ll ask for it.”

Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.

As a family physician who teaches public health and preventive medicine, I appreciate the tension between prevention and treatment in my own practice. Previous studies concluded that paying exclusive attention to providing guideline-recommended preventive and chronic disease services would leave literally no time to address the many other reasons that patients come into the office. As Dr. Hickner noted, "The 'number needed to treat' to listen carefully and provide reassurance and proper treatment to a patient with an acute complaint is one!" So is prevention or treatment the heart of family medicine? Is the answer to this question different today than it would have been a generation ago, and is it likely to be different a generation from now?

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