Monday, June 16, 2014

Guest Post: The Future of Family Medicine - Some Sacrifices Required

- Matthew Loftus, MD

The American Academy of Family Physicians is collecting thoughts now on the future of Family Medicine in America; I shared mine and thought that I would post them here for discussion.

Right now the health care cost curve is being broken across the backs of hospitals & specialists. I think that they'll come for primary care next. If we're not prepared, we'll find our payments decreased and our specialty torn apart as the hospital systems that own us realize that the reimbursable services provided by physicians can often be provided by other types of health professionals. Fighting against nurse practitioner independence wastes time, money, & energy — we need to do more and define all of the roles that work together to create a vigorous primary care system. We're calling on some of our specialist colleagues to sacrifice some of their income and independence for the good of our patients as we try to restrict unnecessary or harmful procedures and tests. However, we have to lead the way by sacrificing a few things of our own — and if we do it now, we’ll get to do it on our terms.

I think that Family Medicine needs to recognize that most primary preventive care doesn't belong in the medical silo at all. While all of us are family physicians because we recognize the value of preventive care, it is important to recognize that our value to our patients and to the population does not come from our ability as physicians to deliver preventive care. Routine preventive care and basic primary care for simple diseases can be done thoughtfully and efficiently by other providers. Rather, our role as physicians is best used doing things that no other provider can do — coordinating care across inpatient and outpatient systems, guiding patients through difficult decisions, managing complex medical problems involving multiple organ systems, and helping to shape policies affecting whole communities. These are challenges uniquely suited for family physicians to address, which give us unique satisfaction even as we give up the often comfortable routine tasks of preventive care. When we are being paid for these services and have the systems in place to support this work, we can expect both our satisfaction with our jobs and our value to our patients to increase.

To this end, we should support the development of community health worker programs made up of residents local to a particular area who are responsible for giving vaccinations, doing basic health education for simple chronic diseases, and following the protocols for screening that clutter our computer screens. While providing preventive care and talking to patients who don't have very many medical problems is an enjoyable part of practice, we must recognize that our medical degrees overqualify us for such tasks and we should be doing them about as often as we are teaching our patients how to give themselves insulin —  it happens and we can do it well because we understand how it works, but it shouldn't be our bread and butter.

Family physicians should then focus on mastering the knowledge and expertise that we have acquired during our medical education and embrace our role as experts at managing multiple complex chronic diseases, especially with psychosocial co-morbidities. We should be supervising and leading teams of community health workers, health coaches, care coordinators, nurses, pharmacists, physician assistants, and nurse practitioners who are managing the simpler medical issues, as is often the case in many other countries around the world. We should also embrace a more active role in coordinating care across the inpatient/outpatient divide; more family doctors should seek inpatient privileges and care for their patients in the hospital. This is one of the ways that we can avoid becoming aloof consultants ourselves. We should learn as much as possible about diseases such as sickle cell anemia & cystic fibrosis so that we can help transition these patients from their pediatric specialists to adult ones.

Another important aspect to our role as family doctors is embracing public health and population health; we should be spending our time not just in seeing very sick patients but also addressing the structural issues pertaining to our local neighborhoods where our patients live. Capitation-based payment may be one way to help tie particular doctors to particular communities, but it is not necessary if we are living in the same places as our patients and getting to know their neighborhoods & leaders. Our residency programs should emphasize leadership training as well as opportunities to engage local communities. I wrote about this in my Family Medicine Educational Consortium "This We Believe" essay titled Proximity, Vulnerability, Faith, & Love.

We are too well-trained to order colonoscopies and flu shots all day. Family doctors should find the sickest patients and care for them in a relational, longitudinal, team-based manner that demonstrates our value to payers, hospitals, and specialists and forces them to recognize our role in health care. This is not just about surviving health care reform — it’s about leading it so that our patients get the best care possible.


Matthew Loftus (@matthew_loftus) is a recent graduate of Medstar Franklin Square Family Medicine Residency. He lives with his wife and daughter in Baltimore, MD, where he will soon begin practicing at Healthcare for the Homeless.