Monday, August 25, 2014

Who is defining Family Medicine?

- Jennifer Middleton, MD, MPH

Perhaps you've already heard - a cardiologist raised the profile of family physicians last week.

National Public Radio's Fresh Air program interviewed Dr. Sandeep Jauhar, a cardiologist working in New York City, August 19 and he had this to say about family physicians:

When you have a symptom like shortness of breath that has multiple inputs from different organ systems, probably the best doctor to diagnose that and treat that is a good general family physician. But when you call in these various specialists, they are apt to view the problem through their own organ expertise. And they make recommendations based on their own expertise and these recommendations are frequently not one is really talking and trying to coordinate this care, so it makes it very difficult for the physician who is trying to manage the whole patient...
This particular piece of the interview reminded me of a powerful editorial written a few years ago in the Annals of Family Medicine by Dr. Kurt Stange. Published in 2009, Dr. Stange tells the story of a patient with unresolved low back pain in whom he diagnosed with a large abdominal aortic aneurysm, esophageal cancer, and incidental renal cancer. 
A narrowly focused approach is fine when an obvious problem is linked to a clear solution. When multiple problems are woven into the fabric of life, however, the generalist approach is critical.
In a recent guest post for the Community Blog, Dr. Loftus takes this idea of the generalist's role a step further:
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. 
The struggles of our health care system are bringing our specialty to a critical juncture. Who will we be as family physicians 5, 10, 15 years from now? Will we continue to passively accept employment and reimbursement models that push us to see as many patients in as little time as possible? Will we continue to spend time counseling patients on topics that a well-trained medical assistant, nurse, or pharmacist could probably do more effectively? 

Dr. Stange ends the editorial mentioned above with a call for action to rebuild our health care system with primary care at its core. He provides a long list of concrete steps we can each take; here is just an excerpt:
We can cultivate the courage to take on the narrow self-interest that fuels our system dysfunctions. We can be willing to sacrifice in the short term for a larger good in the long term. We can develop relationships with individuals and groups and societies that are different from us, and thus develop a broader sense of community.As individuals, groups, systems, and society, we can strive to be humble, connected, and open....Think and act in ways that bring meaning to apparently low-level tasks that develop relationships, and iterate between the parts and the whole to foster a larger good.

Maybe just keeping abreast of how others are championing Family Medicine is another worthy first step. Trying to keep up with everything that is happening in the larger world of healthcare policy and legislation might feel burdensome to already overworked family docs, but AAFP News Now provides concise updates in your AFP journals. Supporting and being involved with AAFP, our specialty's advocacy organization, is an easy way to support those efforts.

Sometimes changing the world can feel too big for one person. But maybe if each of us worked within our sphere of influence on just one of Dr. Stange's action steps, our health care system could get back to serving patients instead of payors and companies. Maybe then we wouldn't need cardiologists to raise our specialty's profile.

1 comment:

  1. Sir William Osler Quotes

    Have no higher ambition than to become an all-round family doctor, whose business in life is to know disease and to know how to treat it. "The Student Life: A Farewell Address to Canadian and American Medical Students." Medical News, New York, 87:625, 1905.

    The cultivated general practitioner. May this be the destiny of a large majority of you!…You cannot reach any better position in a community; the family doctor is the man behind the gun, who does our effective work. That his life is hard and exacting; that he is underpaid and overworked; that he has but little time for study and less for recreation–these are the blows that may give finer temper to his steel, and bring out the nobler elements in his character. "The Student Life: A Farewell Address to Canadian and American Medical Students." Medical News, New York, 87:625, 1905.

    The modest country doctor may furnish you the vital link in your chain, and the simple rural practitioner is often a very wise man. Thayer, W. S., "Osler, the Teacher," Johns Hopkins Hospital Bulletin, 30:198, 1919.

    I would speak of [the general practitioner’s] failure to realize first the need of a lifelong progressive personal training, and secondly, the danger lest in the stress of practice he sacrifice that most precious of all possessions, his mental independence. "Chauvinism in Medicine," Montreal Medical Journal, 31:684, 1902.

    In no profession does culture count for so much as in medicine, and no man needs it more than the general practitioner. "Chauvinism in Medicine," Montreal Medical Journal, 31:684, 1902.

    No more dangerous members of our profession exist than those born into it, so to speak, as specialists. Without any broad foundation in physiology or pathology, and ignorant of the great processes of disease, no amount of technical skill can hide from the keen eyes of colleagues defects which too often require the arts of the charlatan to screen from the public. "Remarks on Specialism," Boston Medical and Surgical Journal, 126:457, 1892.

    The incessant concentration of thought upon one subject, however interesting, tethers a man’s mind in a narrow field. "Chauvinism in Medicine," Montreal Medical Journal, 31:684, 1902.

    From Abraham Flexner

    "The small town needs the best and not the worst doctor procurable. For the country doctor has only himself to rely on: he cannot in every pinch hail specialist, expert, and nurse. On his own skill, knowledge, resourcefulness, the welfare of his patient altogether depends. The rural district is therefore entitled to the best-trained physician that can be induced to go there."

    From a collection at