Do Family Medicine Leaders Deserve the Trust of the Students Choosing FM?

Current medical students are investing much more in a decision for family medicine now. They need to know that family medicine leaders are doing everything possible so that they have a better future. Most importantly, a better future for those choosing family medicine is a better future for those in the nation that most need care.


Medical students choosing FM should have assurance of revenue increasing to family practices at or above the cost of delivery increases. This is the true route to financially viable practices, more and better team members, increased productivity, and increases in the higher primary care functions. It is also the route to more family physicians, higher retention of graduates in family medicine and in primary care, and resolution of the great and growing access barriers. Financial viability has deteriorated steadily.

Where the nation most needs family physicians, there are five degrees of payment discrimination and a sixth (pay for performance) has been added since 2010. Designs that compromise most family physicians and most Americans should not be supported or promoted. Six Degrees of Discrimination By Health Care Payment Design

Despite the deteriorations, family medicine has survived based upon the dedication of the medical students choosing family medicine. They deserve the full attention of FM and much better dedication regarding family medicine leaders.

Family medicine faces an unprecedented time. All sources of primary care have steadily departed with fewer entering after training and even fewer remaining. This is entirely about the financial design - a design that insures that no training intervention can resolve access woes despite many and increasing failed promises.

Family medicine has not remained unscathed. After an entire generation of 95% of active graduates remaining in family medicine positions, family medicine graduates are pursuing other types of positions, other specialties, and other careers. The erosion has pushed past 12% of FM grads found in emergency medicine and 4% each into urgent and hospitalist care. The levels are likely higher than noted in this Graham Center data. An additional 5 – 10% have faded from active family practice based on training in other specialties, changes in gender, retirement changes, and movements to other careers. It is likely that one-third of family physicians who are active in health care delivery are somewhere else compared to 10 – 15 years ago.

Rural proportions of family physicians have been fading from the initial 30% down to 24% in the 1990s down to 20% for active FM grads. This would actually be lower but the increasing FM components listing themselves as hospital based (ER, hospitalists, some others) has a 26% rural distribution. Family physicians still distribute at levels slightly above the rural population level, but distribution has been declining in rural and urban settings of need. Active FM grads are down to 36% found where 40% of Americans are in most need of care – in 2621 lowest physician concentration counties.

Family medicine should not fade from areas where family physicians make outstanding and unique contributions. This is not the fault of family physicians. It is entirely about designs not accountable to more than a majority of Americans and their basic health care needs. FM leaders share the failures in this area and have failed to teach future family physicians about this area. They have failed to pass on the most important lessons of those that built FM.


FM leaders should not be supportive of government leaders that have promised much and delivered little. The builders of FM learned not to trust politicians or academic institutions. The restoration of family medicine and the support of the first decade of graduates was about building coalitions – coalitions of the patients and populations most served by family physicians.

Family medicine must redirect its many priorities to some very basic ones. FM leaders should ask themselves every day and multiple times a day, “What did I do today to deserve the trust of the medical students that are the future of family medicine?”

Whatever piece of property, program, conference, government relationship, foundation relationship, or promotional effort that gets in the way of this priority - needs to be sacrificed for a pure focus on what matters most. Any strategy of value must actually result in better value for students choosing FM and FM docs. This must substantially involve an outstanding payment design - something missing for too many decades for FM, primary care, mental health, generalists, and most Americans falling further behind.

Of all the forms of inequality,  
injustice in health care is the most shocking and inhumane.
Martin Luther King, Jr.


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What Is Stunning in Primary Care Is No Change By Design - Numerous failed attempts to recover primary care all point to insufficient payment made worse by accelerating cost of care. 

Six Degrees of Discrimination By Health Care Payment Design - Medicare payment transparency exposes Medicare as paying less for primary care, less in the states in most need of workforce, less in counties in most need of workforce, and even less with Pay for Performance designs. Also places with concentrations of patients with plans least supportive of local care receive the fewest lines of revenue and have deficits of workforce by design.

Managed Care to Dartmouth to ACA to MACRA innovators have failed to focus on the patient factor changes that could improve outcomes but the innovators have managed to change physician behavior -  the wrong way to turnover, retirement, closures of practices, larger practices, avoidance of complex patients, disengagement, lower productivity  

 Value Failure By Those Who Promote Value - Rapid change, confusing changes, costly change without outcome improvement, adverse impacts of quality measures, forced decisions for mergers or closures, failure to support most needed generalists and general surgical specialties to meet demographic changes, and greater challenges due to declining health and social resources where most Americans need care 


Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

The blogs represent the opinion of the blogger alone.

Copyright 2017


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