By Shelly Reese
Article from Medscape : November 13, 2014
THE DILEMMA OF FAMILY PHYSICIANS
Many doctors have suggested that family physicians are struggling with an identity crisis. Is it true?
Family physicians are specialists who, paradoxically, specialize in being comprehensivists. They practice in a realm bookended by nurse practitioners (NPs) and physician assistants on one side, and specialists on the other. “The former claim to do what we do, and the latter claim to do it better,” lamented one family physician in a Family Practice Managementeditorial. “Our clinical expertise, both cognitive and procedural, is being assailed.”
The fact that many employed family physicians face restrictions on the scope of care they can deliver exacerbates the identity problem. As Dr Daniel Sprogen, director of medical education at the University of Nevada School of Medicine, wrote, “If family physicians aren’t providing pediatric care or maternity care or doing procedures or inpatient care, how do we differentiate ourselves from NPs or any other health care professionals?”
But the underlying cause of family physicians’ identity struggle may derive from the nature of the specialty itself. Although all physicians must contend with unprecedented regulatory, administrative, and technological changes, most specialists can rest assured that their practice remains anchored in the constancy of their special focus on one system or aspect of the human body.
For family physicians, whose practice is based on a philosophy of comprehensive care, rather than treatment of a distinct biological system or disease, even that constant is off the table.
How Has the Specialty Developed?
Almost since its inception in 1969, the specialty of family practice has been evolving. The description of what constitutes a family physician hasn’t changed: The primary care specialty defines itself by broad-based training and a philosophy of medicine that emphasizes relationships and meeting the needs of patients within the broader context of their families and communities. Because families and communities are in constant flux, family physicians’ role is likewise elastic, constantly evolving in light of shifting societal needs.
“The question of family medicine’s identity has really been a perpetual question since the founding of the specialty,” explains Dr Russell Kohl, chief medical officer of TransforMed, a nonprofit subsidiary of the American Academy of Family Physicians (AAFP) that is working to advance the patient-centered medical home model. “Family medicine is often defined by the needs of the community where it is practiced.”
For years, Dr Kohl practiced in rural Oklahoma, where community needs dictated that he deliver babies and perform colonoscopies. In contrast, he notes, friends with whom he trained went on to practice in inner-city communities where HIV/AIDS posed a major healthcare need. Because family physicians must respond to the needs of the communities they serve, defining their shared identity can result in “a bit of a philosophical argument when you get a group of us into a room,” he says.
Because patients themselves shape the doctor’s role by virtue of their needs, family physicians enjoy a rich and varied practice, says AAFP President Dr Robert Wergin. “A patient may come in with a sore throat and then start crying because she’s having trouble with her marriage or her kids are in trouble,” he says.
“Patients turn to you for help. You’re the one they want to count on because you’re the one with whom they have the relationship,” he says, noting with a chuckle that he’s had elderly patients inquire whether he will be the physician who will put in their new aortic valve.
Perhaps because family physicians are already practicing in such diverse settings and meeting such a broad array of shifting needs, the specialty is taking the reins and working to assert itself as a leader in charting the future of healthcare. In October at the AAFP Assembly in Washington, DC, the specialty kicked off its $20-million, 5-year Family Medicine for America’s Health: Future of Family Medicine 2.0 initiative.
The initiative picks up where a 2004 program, which introduced the concept of the patient-centered medical home, left off and seeks “to transform the family medicine specialty to ensure that we can meet the nation’s healthcare needs and ultimately, improve the health of every American.”
WILL FAMILY PHYSICIANS GAIN MORE PRESTIGE AND CLOUT?
Funded by eight family medicine organizations, the initiative emphasizes the central role of family physicians in helping the nation achieve the triple aim of better health, quality, and value in healthcare. “Where we are trying to go as a nation is at the core of what family medicine has been all along,” Dr Wergin told physicians gathered for the AAFP Assembly. “Family medicine’s time is now.”
That attitude, the movement toward patient-centered medical homes, and the new emphasis on coordination of care is causing a fundamental shift in healthcare, says Kurt Mosely, vice president of strategic alliances for Merritt Hawkins, an Irving, Texas-based physician recruiting firm. For years, family physicians complained that they felt like second-class citizens relative to their specialist peers, he says. “Specialists have always kind of ruled the roost, but the leadership of medicine in America is moving back down to the grassroots level. The best leaders are the ones who know how to get things done, and family physicians are in that role.”
Mosely likens the family physician to the point guard on a basketball team. “They’re the player that brings the ball down the court. They’ve got the complete picture of the field and can see where handoffs should happen.”
That broad perspective is one of the reasons why accountable care organizations, hospital systems, retail clinics, corporations, insurers, and myriad other organizations have made family physicians the most highly recruited specialists for the past 8 years, according to Merritt Hawkins. What’s more, they’re often being sought for high-level positions, such as chief medical officer and chief executive officer, Mosely says.
According to Mosely, the demand stems from several factors, including a shortage of family physicians and recognition that their broad training makes them well suited to emerging team-based care models. But family physicians are also sought because they are revenue generators. In a 2013 survey, Merritt Hawkins tracked the amount of net inpatient and outpatient revenue physicians from 18 different specialties generated for their affiliated hospitals. Physicians across the specialties generated an average of $1.47 million per year. Family physicians generated $2.07 million.
Gradually Gaining Ground
Growing recognition of the importance of family physicians and their unique role in the health system is likewise corresponding to several other subtle but positive developments.
In 2014, medical school graduates matching to family medicine residencies grew for the fifth consecutive year. This year, 1416 US medical school graduates matched to family medicine residency training, according to the AAFP. That represents a 31% increase since 2009.
Compensation is likewise increasing. Family physicians responding to Medscape’s 2014 Physician Compensation Survey reported earnings of just $176,000, a 1% increase over the previous year. Merritt Hawkins reports that in the past 5 years, family physicians have seen their base income—excluding production bonuses and other incentives—increase by 13.7%; in contrast, many specialists have experienced an overall decline in compensation during this same period.
IS SATISFACTION GROWING AMONG FAMILY PHYSICIANS?
Whether or not the gradual increase in pay and the growing sense of centrality to the system is translating to greater satisfaction among family physicians, however, depends on whom you ask.
In a 2014 Merritt Hawkins survey of more than 20,000 physicians conducted on behalf of the Physicians Foundation, 50.3% of family physicians described their morale and feelings about the current state of the medical profession as “very” or “somewhat positive.” The overall share may seem low, but it vastly exceeds the number of specialists (40.7%) who expressed the same optimism and is slightly higher than the overall rate for primary care physicians as a whole, a category that includes pediatricians and physicians practicing general internal medicine.
What’s more, it marks a dramatic improvement compared with the same survey conducted in 2012, when only 36.5% of primary care physicians said expressed similar optimism about the state of the medical profession.
Family physicians responding to Medscape’s survey were far less optimistic. Although they were among the most likely physicians to say they would again choose medicine as a career, only 32% said they would choose family medicine as a specialty if they had the decision to make again.
Do Family Physicians Still Face Barriers to Progress?
Although family physicians face an array of frustrations, including competition from advance practice nurses and restrictions on the scope of care their employers allow them to provide, by far the biggest barrier to progress is a financial one. Emerging delivery models promoted by the Affordable Care Act emphasize the need to reward primary care physicians for coordinating care, implementing preventive care, and reaching quality goals, but these new compensation models are largely experimental and are not yet making their financial impact felt.
“If somebody came up with a compensation formula that considered patient malady improvement, patient maintenance, patient satisfaction, administrative and governance responsibility, community outreach, peer review, chart maintenance, timely communications, and an individual’s performance in meeting departmental objectives while still meeting a target of a certain number of patients a day, they’d win the Nobel Prize for medicine,” says Mosely.
Not surprisingly, shifting to a comprehensive primary care payment system is one of the key strategic objectives outlined by Family Medicine 2.0, along with ensuring a strong primary care workforce, advancing the use of technology, and furthering the evolution of the patient-centered medical home model.
The initiative “is not about reshaping the specialty,” says Dr Glen Stream, who chairs the collaborative. It’s about being willing “to continually reevaluate not just the scientific part of healthcare, but also the process by which we deliver it.”
Marcus Welby isn’t dead, he says. He’s evolving to meet the changing needs of the times.
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Source: Medscape Business of Medicine © WebMD, LLC
Cite this article: Why Family Physicians Are Different From Other Doctors Medscape. Nov. 13, 2014
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