FInd New Family Medicine Leaders?
Message to Family Medicine: Return Leaders to Family Medicine Focus
Annals of Family Medicine published an article about the Primary Care Medical Home that was not flattering. In many ways Annals has been cutting edge with regard to basic health care delivery and this article is no exception. Annals is also not alone in their critique. As with articles in other journals there was little difference demonstrated in Minnesota primary care practices with or without PCMH.
See also the December 2011 posting What Do Medical Home Studies Indicate? This highlights the Pediatrics promotion that demonstrates not the value of the continuity home, but the importance of social determinants that shape health access, cost, and quality.
Current family medicine leaders have groused about the methods and findings. Instead of complaints, they should understand why the Primary Care Medical Home or any innovation or reorganization is not likely to work, especially in a state with top health care quality already because of best starts for the children of the state. They should be leading Americans to understand the real reasons for health care quality and providers of any type are largely not a reason.
A number of innovations and reorganizations and certifications have resulted in substantially more cost for primary care practices. Should family physicians pay more and more when primary care reimbursement is being cut? One can assert that any design that sends more money into primary care practices can result in more and better primary care personnel - essential for at least more primary care delivery and at least maintaining the level of care.
Patients, patient decisions, and social determinants shape health outcomes before, during, and after health care encounters. Providers may well shape outcomes the least in the half of Americans left behind by US designs. Social determinants clearly shape health care outcomes the most, as noted by Hong in JAMA and others. Health outcomes are not shaped by innovations and reorganizations, even when academics design the innovations and reorganizations.
Family medicine has always taught that health is about what happens outside of academic settings most of all. Do family medicine leaders remember these sentinel basic health care lessons taught by those who resurrected family medicine? Not even family physicians are superior.
Also since family physicians are most likely to be found caring for those left behind, do family medicine leaders understand that Pay for Performance designs are most likely to adversely impact family physicians? Why would family medicine leaders promote designs that fail to work for family physicians? Why would family medicine leaders promote designs that fail to indicate improvement in quality as noted in Great Britain on entire populations of general practitioners incented to improve blood pressure control?
Family physicians and generalists can be correlated with higher quality outcomes, but this is not necessarily because of family practice or because of generalist practice. Internal medicine and pediatric primary care can be linked to lower quality, but this is clearly not due to pediatric or internal medicine physicians who just happen to be more concentrated in locations where Americans divide more into richer and poorer with higher costs and lower quality by design.
States that make investments in the right places do have more family physicians and more generalists because of these investments and because of better distributions of education, health, and other spending. Similarly the medical students from a broad range of income and parent education levels are most likely to be found in family medicine. Those who will become family physicians, family physicians, primary care workforce, populations left behind, and entire populations benefit by better distributions. This is a primary illustration that correlations are not causative.
The context of current family medicine and current family medicine leadership is important. Past efforts for family medicine departments in all medical schools and family medicine programs in each state were largely successful, but did little to improve health care or the status of family medicine. Family medicine relegated to just 3000 annual graduates per year for 30 years has not helped.
Current family medicine leaders wasted precious millions in studying the Future of Family Medicine - a focus that came up with innovation instead of more dollars for primary care and more family physicians. FFM was largely a marketing approach influenced by a marketing firm. Not suprisingly family medicine came up with a marketing approach that emphasized a new family medicine re-design. Frustrated leaders can sometimes make poor decisions. Perhaps influenced by the short term cure approach common to academics, family physician leaders attempted to break out. Note that no one demonstrated problems with the old family medicine design except too few family physicians and too little primary care spending - by design.
The Primary Care Medical Home was a great fit for this marketing approach. Soon Family Medicine leaders found a way to dedicate an entire floor of the Emerald Green palace (AAFP Headquarters) to the PCMH. After investing so much on "the Future of Family Medicine," it is not surprising that there are complaints. Of course these have more to do with leaders making the wrong decisions. The future of family medicine is as it always has been - more family physicians continuing to serve those most in need of care and supported by a nation that recognizes the need for designs that fit the most Americans not the fewest.
Family medicine is number 1 by far with no competitors regarding the delivery of basic health access over an entire career. Lack of staying power insures that all other primary care and non-primary care competitors fall far short of family medicine. United States health policy insures that any new competitors will end up 60% - 70% not primary care, as with the last few creations.
Family physicians have 53% chosen to serve the nation where it most needs workforce - in 30,000 zip codes with 65% of the population left behind including higher proportions of elderly, poor, near poor, rural, lower income, middle income, less health covered, less health literate, less educated, and those with the least health spending by design (Ferrer, Rosenblatt, Bowman, Mold, others).
Granted that it is difficult to live and breath family medicine in academic centers where only 4% of faculty are family medicine by design (Barzansky, JAMA). Granted that much of the political capital is expended each year attempting to keep Title VII intact for family medicine leaders - a focus that continues to result in distraction away from improvements in primary care reimbursement for nearly all family physicians as well as more family physicians.
So why have family medicine leaders not been successful in promoting what really works for two-thirds of Americans?
- Why has family medicine leadership not specifically worked to increase the number of family physicians?
- Why is primary care reimbursement marginalized year after year for 30 of the last 35 years and soon to be 20 in a row?
- Why did family medicine leaders fail to hold Health Affairs accountable for entire issues dedicated to primary care and to maldistribution when there was no discussion at all of the workforce that would actually be needed to deliver the care?
- Why have family medicine leaders failed to expand family medicine when family medicine residency gradates clearly deliver the most primary care per graduate and the most health care where health care delivery is most need?
- Why do family medicine leaders persist in the support of an additional year of training that will result in a 4% cut in primary care delivery per graduate?
- Why have family medicine leaders allowed the termination of accelerated family medicine training - training that saved 12% of training costs, insured more family physicians, resulted in 30% - 50% greater family physicians where needed, and enhanced the front line clinician training of numerous accelerated graduates who have become family medicine faculty?
- Why have family medicine leaders failed to promote the Minnesota Rural Physician Associates Program nationwide - optimal family medicine training with rural family physicians that actually helps deliver more care where needed in addition to training more specifically for the front line family medicine, primary care, general surgeons, and women/'s health physicians needed? This is of course exactly the workforce most needed and most ignored.
- Why have family medicine leaders failed to establish family medicine medical schools that deliver 100% family medicine residency graduates specifically trained for the front lines and located 60% or more where 65% of Americans need health care? Even one such school will lead to substantial shakeups in health professional training.
- Why do physician assistants and nurse practitioners continue to attract attention when each passing class year and each year after graduation results in steady and substantial decline in the proportion in primary care, underserved areas, rural areas, and places in most need of health care?
- Why have family medicine leaders not called upon nurse practitioner and physician assistant training designs to be permanent - resulting in 80 - 90% remaining in family practice for entire careers as with family physician training? Only 20% of PAs entering family practice and less than 25% of NP employed in family practice is intolerable compared to 95% of family physicians remaining in family practice.
- Why do family medicine leaders support generic expansions - approaches that fail to result in more primary care because fewer of all other sources other than family medicine remain in primary care? Does family medicine understand that family medicine increasing from 40,000 to 100,000 actually resulted in fewer of other sources remaining in primary care because health spending on primary care did not support the necessary primary care and drove other flexible sources away from primary care to non-primary care careers?
Effective problem solving indicates that when the pathway to family medicine is blocked, other pathways will be created. More departments and programs are not solutions. Family medicine specific medical schools are a solution - for family medicine, for family medicine leaders, for those in need of primary care, and for Americans left behind by policy design.
It is not too late for existing family medicine leaders.Come back to family medicine and the essence of family medicine - health care for 65% of Americans left behind by design.
Family medicine has always been on the cutting edge of what is right. The last 30 years of changes have done nothing but make family medicine even more essential. Why can't family medicine leaders understand this? Why can't family medicine leaders experience the joy of being the right choice at this time and place in US health care and US health workforce?
The family medicine leaders who re-established family medicine working for 2 decades and the 100,000 family physicians deserve much better.
Spend less time arguing with journals, less time with government, and less time with academics.
Spend more time with 65% of the nation left behind - before, during, and after training just like family physicians.
If the pathway to becoming a family medicine leader results in leaders that do not understand what is most important - change the pathway to family medicine leadership.
If the pathway to becoming the physicians most needed by the nation is blocked - change the pathway to family medicine.
If 30 years of government program focus has continued to fail to address the health care needs of most Americans - change the focus to more family physicians and more primary care spending.
If the leaders of the last permanent primary care health access source fail to focus in this area, who remain to lead basic health access at all?
Thanks to all 12,000 who have visited Basic Health Access in 2011.
Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies
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