Family Medicine Needs a New Beginning

Family practice is needed more than ever. 
  • Only family practice positions filled are specific to the locations in need of workforce and are specific to the populations in need of care - for elderly, for veterans, and for counties and zip codes with lowest concentrations of clinicians
  • Family medicine is the only 90% family practice position result for a career - less than a permanent family practice result shapes less primary care and less distribution where needed
  • Family medicine is a choice prevented by designs for medical education and designs for payment
  • Family medicine has the right ending in terms of outcomes and residency training, but preparation and medical school designs are not specific to family practice.
Family medicine needs a new beginning

A new beginning is required when the old beginning prevents family medicine choice. A beginning, a middle, and an ending specific to family practice results in multiple times more primary care result and multiple times more workforce where needed. A different and better beginning can be more specific to family practice, add more years to a career, reduce debt, and increase care delivery where needed. 

I was reviewing a recent AAFP posting about the Appalachian Preceptorship - the creation of my mentor Forrest Lang MD. This former National Health Service Corps volunteer created a great beginning for a career involving family medicine and health access where needed. It was always a highlight of our time as faculty at ETSU. These fourth year medical students were pursuing a calling - and the Appalachian Preceptorship was a reinforcement. The students were open to needed change, they had some training to look at practice and communities differently, then they had time with rural preceptors who were also interested in making a difference. Their presence each year encouraged us all to do more. Even more time with interactions between students, faculty, preceptors, and community can help do even more. 

What family medicine needs is what our nation needs
  • An Appalachian Preceptorship for Appalachian result
  • A Community Health Center Preceptorship for CHC result
  • A family practice beginning and middle to go with the family practice ending
A complete package of preparation and all training for family practice is what is needed. One hundred years has moved medical education far away from the care that is needed. Every thing that has been added has diluted the family practice preparation and training.

 Health access must be designed and should never be a side effect of some other training. 

America needs specific family practice by design

Half of the American population needs health access and they need clinicians that understand them.

The United States needs clinicians permanent to family practice more than ever. 
  1. The populations are increasing faster where family practice clinicians are by far the most available - past, present, and for the future
  2. The populations increasing fastest in primary care demand are more likely to be seen by family practice clinicians and reside in places where family practice clinicians are multiple times more likely to be found than other sources of primary care or basic services.
There is no direct route to family practice from MD, DO, NP, and PA training
  1. Medical students must gain admission and somehow choose family medicine - a two step process that prevents family medicine choice with only 7% result for MD and 17% result for DO schools.
  2. No physician assistant program is specific to family practice position result, with declines to 21% family practice and further reductions likely 
  3. No nurse practitioner program is specific to family practice. Even though 45% train as family nurse practitioners only about 25% of the career result of NP grads is specific to family practice positions.
Family physicians are 90% family practice result by design. Physician assistant and nurse practitioner programs cannot reach such a result without rolling back 40 years and numerous pieces of legislation.

A new beginning for family medicine is specific to the origins and initial training required - the best beginning prior to family medicine residency and a lifetime of family practice where care is needed. 

The Wrong Beginning Prevents the Right Ending

Preparation and training specific to the needs of most Americans cannot begin the way that United States medical schools select and train medical students. Students that do best on standardized test and that access the most prestigious colleges are chosen - but they tend to be highest income, most urban, children of professionals. Such origins are associated with 3 - 4% choice of family medicine, lowest proportion of primary care result, and greatest concentration in zip codes and counties where clinicians are most concentrated. There origins are least associated with family practice clinicians, generalists, or general approaches. They have led a life highly specialized from birth and least likely most Americans in need of care.

Nebraska needs family physicians. Other states have 25% of rural workforce provided by family physicians. Nebraska has 40% family medicine as rural workforce. The collapse of internal medicine primary care and the poor distribution of pediatrics fails most Nebraskans, as does far too many leaving Nebraska for graduate medical education in other states.

It was my privilege to be in Nebraska after decades of planning resulted in substantial family medicine choice with graduate medical education providing family medicine training across the state. This design is prevented by medical students at UNMC that have increasingly dominated admissions, student types with only 2% family medicine choice. This increasing proportion has been admitted from out of state, from those new to the state, from other nations, and from Omaha/Lincoln/suburbs. The students most specific to family practice and care for half the state have been replaced by those least specific. A school that provided 50% of the workforce of the state cannot supply this workforce without specificity for family medicine and the students specific for state needs.

Failure of FM choice, failure of awareness of the needs of most Americans, training least specific to family practice, and worst distribution will not fix health access in the United States.

Specific to States in Need of Workforce, Specific to Primary Care, Specific to Where Needed

Preparation, medical school, and family medicine residency must all be specific to the locations in need of workforce. Exclusive colleges are not specific to care where needed or even the type of preparation needed for a family practice career. Preparation should begin in family practices. Medical school learning should not be disconnected from practice. All learning should be applied immediately for best retention. Also the learning should be specific to the care being delivered. The training should acquire a debt of service - in family practice and where needed. The design is entirely specific to optimal health access recovery.
  1. Instate workforce - reinforced by origins, training, and obligation
  2. Primary care - permanent due to family medicine by design
  3. Where needed - also origins, training, family practice, and obligation are all specific
Unlike incremental approaches with incremental results, this is a specific solution. A specific beginning to the end of family practice for an entire career. 

Enhancing the Beginning

Once again the Appalachian Preceptorship points the way. So did the Health Promotion and Disease Prevention Project by AMSA involving students and Community Health Centers. The Nebraska SEARCH program prepared MD, NP, and PA students for a community experience with a mentor that connected them to the community - and the community needs.

Immersion in the community is required for understanding of the community and the determinants of health and health outcomes. 

Ideally preparation for family practice begins with middle school. Students are ready for social and societal interactions at that time - sadly their current life experiences may shrink them from what their development requires at this stage of life.

Students interested in making a difference with their lives in areas such as education or health care would work together on community projects - needs assessments and improving resources. Schools and health access practices link students to community needs and careers involving health or education. Students can also be the link out in the community to make a difference at home, after hospitalization, in nutrition, and many areas involving support. 

Continuing Involvement Rather Than Isolation

Students should not have their important family practice, community, and patient specific learning interrupted by admissions and basic sciences. Those interested in health access move to the next stage. During family practice medical school, future family physicians should continue to interact with people in the community and with other members of the health care team. More than just basic science is involved and so must family practice medical school be about more than just typical basic sciences. Specific preparation for a career in family practice is aided by preparation and training specific to such a career.

Studies indicate the value of continuity longitudinal integrated curricula, and continued expansion of this concept should be a best practices result. 

Medical education often separates curricular and extracurricular activities and learning. Isolation and separation should be eliminated. 

Numerous attempts have been made to address health access. Family medicine rapidly expanded to 3000 annual graduates by 1980. The most recent class years also have only 3000 annual graduates.

What happened to the best solution for primary care and workforce where needed? Designs for payment and training essentially have not been specific to family medicine or primary care.

The only remaining permanent primary care choice has long been prevented by policies that fail to support primary care clinicians. Even a brief improvement in the 1990s was more than enough to demonstrate an increased FM choice - lasting as long as the few years of support. Decades of poor primary care support have resulted in failing family medicine choice and declines in primary care retention in the other five sources.

Even worse, designers now attempt to conjure up primary care from nothing - electronic records, primary care continuity home, and other reorganizations are promoted as solutions. Real workforce solutions takes those who work and solve problems by interacting with patients and with community.

Americans can no longer wait for workforce specific for their state, specific for primary care, and specific for care where most Americans need care. Training must be instate, permanent for broadest generalist primary care, and most specific for care where needed.

If physician assistants or nurse practitioners make their graduates 90% family practice in a state or from a program - 90% for an entire career - then this would also be a solution. Until that time, a specific family medicine result is a 90% family practice solution - and the best solution for health access recovery in the United States. 


Recent Works

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Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.

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