The Academic Family Medicine Mismatch

Family medicine leaders still cling to traditional academic medicine. Many of the major family medicine efforts arise from family medicine departments and from medical school based family medicine programs. Soon family medicine will have a 50th anniversary. Should family medicine tolerate another 50 years of stagnation? 
 
Constant Strain in the Academic Family
 
The relationship between academic institutions and family medicine has always been strained - when academia was getting started, when formal family medicine training was started, and continuing to the present.
 
Family practice general practice predates modern academia in the United States. The dominant physician 100 years ago were connected to local populations across origin, training, and practice. The academic designers consistently built up what became formal academic training. The consequences of such training were seen in just a few decades. Flexner conceded that the distribution of physicians was impaired by the new model, but the designers remained firm in their resolve to become more academic - and elimination of preceptorship and other forms of training was a top priority.

Over the decades, academic changes continued to dictate declines in health access where needed. There were fewer general practice physicians, but their importance was clear. They represented the people in most need of care. This was something that academic medicine ignored. Academization led to centralization and institutionalization. The original family medicine leaders did double duty - they maintained their practices while organizing across the nation to bring formal family medicine to life. 

The campaigns clearly stated that family physicians were America's physicians and this has been true past and present. But can this be maintained with an academic straitjacket?

Caught Between Academic Communities and Communities of Need

Family medicine efforts tried to patch together rifts between academic communities and communities in need of physicians (rural medical education, full scope family medicine, pipeline programs, state recruitment and retention efforts) but the efforts were always short of access needs. Family medicine was always stretching budgets to attempt to meet these needs and faculty were often stretched most. Chairs, program directors, and faculty were forced into multiple duties. There was just not an alignment of the academic mission with the family medicine mission.

Sometimes state efforts provided some resources to try to create partnerships or collaborative efforts to bring the various communities together (West Virginia, Nebraska, Minnesota) but consistent support has been difficult to maintain. One reason is that states have been hard pressed to contribute to anything except the rising cost of health care - for employees, for Medicaid patients, and for academic centers. More and more for health care has compromised other state spending - for decades.

Beneath Academic Medicine or Family Medicine Shaping Its Own

Is family medicine better off under the restraints of academic medicine or would it be better off with control of the entire process of preparation, training, and practice?
 
Before dismissing this as impossible, consider that the current design fails for health access for most Americans. Turnover has been increased by design and has increased to over $320,000 lost per lost primary care physician. The debts of family physicians will soon be as much as the cost of turnover. The contributions of a trainee to local health care delivery can be substantial during preparation, training, and a seven year obligation. A locally financed medical education model offers more for communities in need of access and more for graduates as long as they are devoted to careers of access - which they experience prior to the beginning of formal training. Even better, this is the best route to the graduates who are dedicated to health access, family medicine, and changing health outcomes at the personal and local level.

Family Medicine Must Replace Failed Financial and Training Designs

We have long known that the process does not prepare, select, or train specific to family medicine.
 
We should know that the financial designs shaped largely by them, do not work for us or for basic care for most Americans. 
  • We rule where 50% of Americans most need care. We suffer when academic interests fail for most Americans. 
  • They (academics) rule where 45% of physicians are found, where 55% of health spending is concentrated as has been dictated by previous academic efforts - the same efforts that have resulted in us paid least and them paid most.
  • We need a culture of health and a society of well being. This benefits our patients most, makes our jobs easier, facilitates the higher primary care functions, and contributes to truly better health, education, economic, and
  • They need a substantial portion of 3 trillion dollars that literally suck the life out of most Americans - the ones that we are most likely to care for, those most complex and most left behind in resources. The trillions that have been added to health care costs have deprived state and federal budgets of the spending to address housing, public health, nutrition, economic development, child development, support for the elderly, Social Security, and jobs where most needed. 
  • We have a high probability of understanding health access, care where needed, and the real determinants of health outcomes. 
  • They never lacked for access growing up, avoid access careers, have had specialized existences all of their lives, have rarely experienced generalism or generalists, and think that they are the determinants of health outcomes. 
  • They have no clue that their cost overruns are making outcomes in health, education, and economics worse for most Americans. 
  • When they talk about social determinants, they think in the usual terms of hospitals or systems or insurance and have no clue regarding a culture of health shaped by a focus on well being in numerous dimensions.
Health Outcomes Improvements Require a Culture of Health Shaped by Well Being in Multiple Dimensions Far Beyond Health Care
 
Does FM Understand the Adverse Impacts of Innovations on FM Docs?
  • If we truly understood the determinants of health, we would not tolerate pay for performance, value based, MACRA, or readmissions penalties - payment designs that pay less to the fewer remaining providers that care for patients that are more complex, have inherently lower outcomes, and reside where the nation has the fewest resources and the lowest levels of health workforce and health spending.  
  • Would family medicine leaders support innovative payments if they understood that family physicians and those most associated with them are most likely to be impacted?
  • If they truly understood the determinants of health and education, they would understand that improved outcomes cannot proceed from clinical intervention, digital clinical intervention, or payment based upon outcomes - outcomes shaped predominantly by personal, local, community, and other non-clinical factors.
Has Family Medicine Moved Beyond the Initial Phase - Beyond Beginning?
 
The family medicine builders used their practice building skills to build family medicine, but family medicine has not proceeded much beyond this phase. The Builders avoided academic institutions as much as possible. The academic family medicine leaders embraced academic institutions and the immersion has impacted their thinking and their decisions. Our initial growth to 3000 annual graduates was a function of the early phase - and we have not proceeded beyond this level. The financial design for family medicine has also remained stagnant. We applaud family physicians who rise to academic leadership positions, but they are not able to make the changes needed by their leadership.
 
We have done well as family physicians only for a short period of time, when America focused attention upon most Americans - in the 1960s and 1970s. This is also the only significant time of expansion of FM grads. This is also the best illustration of the basic requirements for access improvements - the requirement of better support for most Americans and most family physicians.

We developed funding for family medicine. They kept that funding forcing us to get funding directly from the legislature.

We realized they were stealing training funds rather than distributing the funds to the programs doing the training. They hid the funds and continue to control the funds and the specialties trained and the locations of training.

They promised family medicine departments the necessary funding but reneged on their promise. Many departments have had 1 year in 10 to negotiate more funding - usually when the chair is recruited.

Continual Sacrifice
 
Our programs have always been the most expendable and conversions of our slots to theirs have been a way to benefit most from more GME dollars - under designs that they adore and we abhor.

We talk about workforce distribution which requires payment distributions. They talk about training solutions and prevent payment distributions, which result in the need for more to be trained, which results in more that concentrate and failure in distribution, which results in calls for more to be trained...

We need designs for payment and training exactly the opposite of those that exist. They have done well by the past century of designs that they have shaped, and they have teamed up with corporations, institutions, managed care, micromanagers, associations, and insurance companies to continue to do well.

We still applaud sharing of information and the benefits of new information and many of us abhor the hoarding of information and the profiteering from drug and technical research.

They create a myriad of for profit and not for profit ventures and compete over patents and profits from discoveries - quite different from a few decades ago when discoveries were shared and faculty were blackballed for self-serving or profit motivated discoveries.

We need a home field advantage across preparation, admissions, training, and the first seven years of practice for graduates that best understand health access, primary care, basic services, and determinants of health.

They need ever bigger training concentrations which they control with one size fits none training design. This makes it difficult to serve a diverse nation and insures that physicians are quite different from most Americans. 
 
Over 70% of physicians arise from origins and situations different from normal Americans in many dimensions. It is not surprising that it is so hard to choose careers so involved with people in places where most Americans are quite different from them.

They need to produce technicians focused on changing bodies and disease.

We need change agents capable of changing behaviors, environments, situations,

Primary care is 55% of services compromised by only 6% of health spending - via designs shaped by academic centers - who also design themselves the most lines of revenue and the highest reimbursements in each line.

 
What can they do to actually improve outcomes? 
  • The solution is to take 1 trillion from health spending and invest it where environments, situations, and resources are needed. They will never agree to these changes after a century of manifest destiny - a century of ever higher spending for little improvement in outcomes.
It should not be surprising that they embrace value based and other innovative designs - because they can cherry pick in many different ways.

What is surprising is that family medicine leaders embrace the same innovative designs - that end up penalizing most family physicians who are already lowest paid and least supported and have the most complex patients.

Would family medicine leaders serving, teaching, and researching where people most need care side with academics and micromanagers and others not evidence based - or would they side with most family physicians?
 
 
Academics are not going to change payment designs in favor of us and those we represent - the half of Americans most behind by design. They are far too focused upon concentrating dollars in few places serving few for a few days of time.

Academics are not going to train family physicians as they need to be trained.

Family medicine requires a major change so that family medicine can be what it should be. There is little that academics can do for us and there is much that we must do for family medicine and for our patients.

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