Are New Departments of FM Necessary?

A story out of Boston (or New York, or...) brings attention to a long term dream of academic family medicine - having a family medicine department in every medical school. Not surprisingly the latest article or blog is soon promoted and passed around by FM associations. For decades the Family Medicine journal has listed family medicine results once a year and has categorized by department - keeping this focus alive. The question remains...

Are new departments helpful for family medicine or not? 

Payment Design = Workforce, Regardless of Training

Can departments of family medicine boost family medicine? Apparently not since the most rapid increase in family medicine residency growth from 1970 to 1980 was the period of fewest family medicine departments. What really fueled the rapid growth of family medicine was substantially more payment going to increase primary care. Since family medicine is the most dependent upon primary care payment (cognitive, office, basic services), family medicine is most shaped by payment. Others not specific to primary care (IM, NP, PA) have many other options and have taken them - away from primary care, family practice, and care where needed - all lowest paid by design.

Since the 1980s, the payment design has been most about cost cutting with those least organized losing out the most (small practices, small hospitals, care where needed).

Payment shapes workforce. Payment and workforce shape training and all work together to shape training outcomes. Unfortunately payment design shapes all factors and in ways away from local, primary care, family medicine, care where needed, and support for those who care. Federal Cause of Shortage Areas and Access Barriers

So once again - Why should family medicine push to have departments in every medical school such as top ranked (US News) schools that may only have less than 10% primary care result due to
  • one to three family physicians produced a class year for maybe 2 in primary care
  • three in internal medicine PC out of 25 choosing IM training 
  • three in pediatric primary care out of 14 choosing PD training
per 100 in a class for actual results of 8 to 10% for primary care. These are outcomes consistent for many class years of graduates - more evidence of the power of payment design impacting all. 

Isn't this another distraction away from real growth of FM - that requires substantial increases in payment, decreases in cost of delivery, and especially both?

Only One Historical Period of Real Progress for Primary Care and for Family Medicine

The period of time most associated with advancement of family medicine was the period with the fewest departments of FM. From 1950 to 1978, family medicine made progress fueled by the hard work of FPGPs state to state to establish the need for FM, training programs, and payment. There was success in attention and in needed action. There was widespread awareness of the need for family doctors. This was supplemented by National Health Service Corps NHSC expansion and funding specific to FM training. These additional interventions all looked good too, as long as there was expansion of payment supporting more positions in more places. Sadly these interventions do not seem to do much other than rearrange the deck chairs because of the limitations of payment that place a ceiling upon primary care delivery capacity.

The initial building period was the initial and only major growth of FM to 3000 annual grads by 1980 and FM has stayed at 3000 except for a few years in the 1990s when payment was temporarily changed and when medical students feared to enter hospital careers. 

What Happened to Family Medicine Leadership?

The leadership of FM changed substantially during its early years. The leadership that built FM was family practice experienced. The rapid growth of FM resulted in the next generation of leadership that was often not practice experienced except for academic practice exposures. The initial building leaders acting across this period of time 1960 to 1980 shaped FM to what it is today at 90,000 active family physicians. Since this beginning period of time, academic focus has been limiting for family medicine and health access.

What Happened to the 1960s and 1970s Medical Schools?

Once upon a time there were even primary care medical schools that were funded with family medicine as a major focus. These efforts have essentially been marginalized and only one small school (Duluth) remains somewhat effective for primary care, family medicine, and care where needed. 

Mercer has been a glaring example of payment plus academization taking out the best health access medical school in the southeast in just a few years with FM choice plummeting from 30% to 3% - and despite an active department of family medicine and a family medicine dean. Top health access results in the Southeast US where deficits have been greatest made Mercer a top choice for care where needed (along with West Virginia School of Osteopathic Medicine). But care where needed is predominantly about family medicine choice and less than 5% for FM lands schools in the bottom for health access result.

Osteopathic expansions have doubled graduation numbers twice since the 1960s graduates, but each doubling has been accompanied by half as many choosing family medicine - for no gain in FM despite two doublings of family medicine departments. DO schools in the northeast and most urban areas have had particularly poor showings in family medicine despite departments and numerous activities and a key role in DO schools - in contrast to MD schools.

The Academization of Family Medicine

The time of academic focus has resulted in more departments and more families of family medicine (Family Medicine Associations). The growth has provided a number of opportunities for consultants, association staff, and those developing products, services, and marketing opportunities. The Family Medicine board has required more from family physicians to keep board certified, despite the lack of an evidence basis for the Maintenance of Certification process. The time, effort, and cost to member family physicians has been substantial. The Real Kerfuffle

Only the recent government regulations have disrupted family physicians from care to a greater degree than distractions created by family medicine leaders. 

If you are a family physician aware of what really matters, every time you see the word quality you should expect more cost and more distraction without any real hope of making a difference in local care and care where needed. Quality translates to higher cost of delivery, payment cuts, and more costly regulation. The failures in recent CMS Innovations are numerous and specific to family medicine, small hospitals, small practices, and care where needed.

In the last few years, family medicine associations and academics have led the charge to innovation, rearrangement, consultation, promotion, marketing - and away from care that matters. CMS Innovations consistently detrimental to most family physicians are promoted as soon as announced.

Killing Off Primary Care Delivery Capacity

Stagnant revenue in primary care chopped up by staggering increases in the cost of delivery - this is what is defeating family medicine, primary care, mental health, geriatrics, care where needed, and care for rural or underserved or minority populations. This is what is hurting most family physicians. This is the reason for the rise of Concierge, Urgent, Retail, and Direct Primary Care for better payment, decreased costs of delivery, or both.

There has not been growth in graduates or payment as cost increases have continued to negate whatever incremental increases in payments were provided. 

M & M Focus - Marketing and Meeting

Marketing and meeting focus compromises the focus upon increased payment. Family medicine has hitched its star to marketing - the reason for overemphasis on Primary Care Medical Home and Health is Primary. PCMH has been a way for larger more urban practices facing competition to market their services - a reason for support from pediatric and family medicine leaders. Sometimes associations promote areas not in the best interest of a majority of members. For example the Primary Care Medical Home focus of family medicine leaders is not a good choice for small and solo practices - practice types that are over half of family physicians.

The growth of associations and their activities is linked to consultants, advertising, and meeting revenues. Associations sell information and member access to recruiters and many others that make money off of family physicians. So much is generated from M & M that dues are a small portion of association revenue. 

This takes associations away from a focus on members.  In fact the ACA/CMS plan has been called the attack of the aggregators 

Money talks and the needs of most members walks. 

Such is the tradition of physician associations. 

Family Physicians and Care Where Needed in the Crosshairs

Value based payment has become a favorite of FM leaders, perhaps eager to appear to be the best proponents of quality. Apparently they did not get the memo about evidence basis for real quality shaped by patient factors such as situations, determinants, relationships, and barriers. And apparently they have forgotten that family physicians are serving the populations with all factors shaped toward lower quality metric measurements. Studies have indicated advantages for caring for the advantaged and disadvantages for the rest. Hong did one of the better studies published in JAMA:

Among primary care physicians practicing within the same large academic primary care system, patient panels with greater proportions of underinsured, minority, and non–English-speaking patients were associated with lower quality rankings for primary care physicians.

To the extent that health systems reward physicians for higher measured quality of care, lack of adjustment for patient panel characteristics may penalize physicians for taking care of more vulnerable patients, incentivize physicians to select patients to improve their quality scores, and result in the misallocation of resources away from physicians taking care of more vulnerable populations

A payment design that will pay less to primary care and to care where needed will impact family physicians more than any other type. Are We Moving Away from Achieving Value in Primary Care? 

There have been a constant stream of distractions from what is most specific to FM.

Family Medicine as a Poor Fit for Traditional Medical Education

Academic focus has resulted in substantial funding for research, graduate medical education, and highly specialized care. As academic influences became ever stronger, generalists and general specialties have been marginalized. Academic, association, and corporation interests have dominated payment design - a design that pays according to how much academic training you have. The end result has been less local, primary care, and health access - by design.

Outcomes shape the training. Medical schools produce so few for primary care that they cannot possibly prepare well for primary care. The hospitalist movement not only stole 50,000 primary care trained physicians, it also now plays a large role in primary care training. Numerous workforce influences continue to marginalize FM and primary care in the practice, research, and other areas. 

New Departments or a New Model for FM Training?

There is no logic to the focus on family medicine departments in a few remaining schools. The only logic to family medicine medical education is replacing aberrant preparation, selection, and medical school. The new design should be the best fit with FM residency training and practice - 9 years of specific FM preparation and training can replace 11 or 12 years of costly and nonspecific training.

FM has always been specific to local - not medical school, state, regional, or national. FM associations have lost this focus, but we should not. Most of us are still in small practices working locally. We innovate with each patient - a contrast to the mess of national level innovation that fits few or none. The academic mentality is why we have the insurance coverage focus and the forced quality - doomed from the start because of local failure in access and integration and coordination and comprehensiveness.

True reform begins and ends locally with patients and local populations. This requires universal access to basic care - local care arising locally and focused locally.

Traditional medical education will never get it with total lack of local focus and a top priority focus on just a few years of training rather than preparation for a lifetime of learning. There will never be more than student interest rather than the involvement before, during, and after medical school that really matters.

Sadly it is FM associations that have also bought into the same scenario. Instead of reshaping medical education, medical education has reshaped them.

Payment Shapes All Clinical Workforce

This is not surprising because the same process has absorbed nurse practitioners. Those truly delivering access have long been marginalized. An opportunity to be entirely family practice has been missed - and now only 20% will be active in family practice for a career as every other career has consumed more graduates into new training and new specialties and subspecialties. This is also about payment design plus academization.

The care of most Americans depends upon an entirely different process - one that fits them and not the needs of a few, not the needs of 1100 zip codes with half of physician workforce, not the needs of corporate medicine, not the needs of association medicine. Bigger and more academic is better for bigger and more academic, but not local, personal, efficient, and effective.

Fighting Against the Payment and Training Designs Is Most Difficult When Funded By Same

Academic family medicine is funded by the same payment and training excesses that help to defeat primary care, family practice, and care where needed. When you understand that multiple lines of revenue with the highest reimbursement in each line go to academic and largest centers, then you understand inequities, lack of access, and distractions. With this understanding, you see the socialization process of health leaders, especially physicians, who proceed across institutions, associations, corporations, meetings, and similar screenings to become ineffective for local, health access, and care where needed. Why would you want family medicine departments speaking out against what is best for family physicians?

Bigger and more academic is better for bigger and more academic, but not for local, personal, efficient, and effective.

We need more promotions of family docs of the year, those in the field on the cutting edge of health access. FM docs, FM research, and FM payment should be focused locally and on access. The same should be true of FM training and associations.

Family physicians need local preparation, local training, and support for local practice. The opposite focus is a distraction from what is needed.

Primary care can be recovered and should be recovered,
but cannot be recovered when moving the wrong directions.

Recent Posts and References  

The Consequences of Innovation Procrastination - Delays in indicated care result in harm to patients. Distractions due to innovation result in harm to millions who need care delivery, not rearrangements, confusion, reorganization, and rapid change.

The Massive Failure that is Primary Care Payment
Like past policies, ACA did not address cognitive vs procedural to balance workforce but it did take on quality payment with costs and questionable benefit.

Lack of Accountability for Accountable Care
Health Care Who Is it Good For? Count the billions in corporate earnings and the millions in CEO salaries to see who wins and who loses 2010 to 2016 and beyond

Innovation Incapacitation
Safety Net Must Sunset and Front Line Health Access Should Rise

Experimental Innovation or Basic Infrastructure? Wouldn't it be nice if we actually funded infrastructure and basics instead of trying to substitute innovation or other distractions?

For Better or For Worse in Quality - More for fewer and less for more - thus continues the new innovative designs - same as the old designs

The Federal Cause of Shortage Areas and Access Barriers - It is the Federal Design for payment that shapes the breadth, depth, and locations of shortage areas. It is about concentrations of Medicaid and Medicare patients with lowest payment for health access by federal design.


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