What is family medicine?

Science and Profession

From cradle to grave, family physicians have the ability to take care of patients from all age groups and manage a great variety of medical problems on a daily basis. As the primary care provider, they are central to a patient’s care, either by providing it directly (85 percent of all medical problems) or by consulting specialists and following their management recommendations. They act as the patient’s advocate even when healthy by providing preventive care services to find disease earlier in an attempt to eliminate it or slow its progression.

In the United States, there are approximately 80,000 practicing family physicians, accounting for more than 240 million annual office visits. More than a third of all US counties have access to only family physicians to provide medical care to their communities.

Family medicine is the direct descendant of general practice. For many years, most physicians were general practitioners. In the mid-to-late twentieth century, however, the explosion of medical knowledge led to the specialization of medicine. For example, increased knowledge of the function and diseases of the heart seemed to demand creation of the specialty of cardiology. The model of the country doctor or jack-of-all-trades physician taking care of a wide range of medical problems seemed doomed to sink in the sea of subspecialization in medicine. The general practitioner, the venerable physician who hung out his or her shingle after medical school and one or more years of internship or residency training, appeared to be headed for extinction. Indeed, in their then-existent forms, the general practitioner and general practice would not have survived. Several forces came into play which did result in the passing of general practice but which also changed general practice into family medicine.

The primary force pushing for general practice to survive and improve was the desire of the general public to retain the family doctor. The services that these physicians rendered and the relationships developed between physician and patients were held in high esteem. Through such voices as the Citizen Commission on Graduate Medical Education appointed by the
American Medical Association (AMA), the public requested the rescue of the family doctor.

Other major players in the movement to revive and reshape general practice included the AMA itself and the American Academy of General Practice. On February 8, 1969, approval was granted for the creation of family medicine as medicine’s twentieth official specialty. The American Academy of General Practice became the American Academy of Family Physicians (AAFP), and a certifying board, the American Board of Family Practice (ABFP), was established. The name has since been changed to the American Board of Family Medicine (ABFM). After these steps were completed, three-year training programs (residencies) in family medicine were established in medical universities and larger community hospitals to provide the necessary training for family physicians.

Family physicians are trained to provide comprehensive ongoing medical care and health maintenance for their patients. Those people who choose to become family physicians tend to value relationships over technology and service over high financial rewards. Many family physicians find themselves providing service to underserved populations and in mission work both inside and outside the United States. Family physicians often become advocates, providing counseling and advice to patients who are trying to sort out medical treatment options. They generally enjoy close relationships with their patients, who often hold them in high esteem.

Following graduation from medical school, students interested in a career in family medicine begin a three-year residency in the specialty. During the residency, these physicians train in actual practice settings under the supervision of faculty physicians. Family medicine residency training consists of three years of rotations with other medical specialties, such as internal medicine, pediatrics, surgery, and psychiatry. The unifying thread in family medicine residency training is the continuity clinic. Throughout their training, the residents see their own patients several days a week under the supervision of family medicine faculty physicians. Every effort is made to make this training as close as possible to experiences in the real world. Family medicine residents will deliver their patients’ babies, hospitalize their patients, and deal with the emotional issues of death and dying, chronic illness, and disability.

Family medicine residents receive intensive training in behavioral and psychosocial issues, as well as “bedside manner” training. Scientific research has shown that many patients who seek care from family physicians have problems that require the physician to be a good listener and a skilled counselor. Family medicine residency training emphasizes these skills. It also emphasizes the functioning (or malfunctioning) of the family as a system and the effect of major changes (such as the birth of a child or retirement) on the health and functioning of the family members.

The length of training (three years versus one year) and the emphasis on psychosocial and family systems training are two of the major differences in the training of a family physician and the training of a general practitioner. Moreover, family physicians spend up to 30 percent of their training time outside the hospital in a clinic. Family medicine was the first medical specialty to emphasize this type of training, and family physicians spend more time in ambulatory (clinic) training than virtually any other specialist.

Following the successful completion of a residency program, a family physician may take a competency examination devised and administered by the ABFM. Passing this examination allows the physician to assume the title of Diplomate of the American Board of Family Medicine and makes him or her eligible to join the American Academy of Family Physicians, the advocacy and educational organization of family medicine.

There are about 330 fellowships now available to graduating family medicine residents: faculty development, geriatrics, obstetrics, preventive medicine, research, rural medicine, sports medicine, and others such as occupational medicine.

If family physicians wish to retain their diplomate status, they must take at least fifty hours per year of medical education. After a family physician fulfills all educational and other requirements of the ABFM, that physician must then retake the certifying examination every seven years or the certification will lapse. This periodic retesting is required by the ABFM to make sure that family physicians keep up their medical education and maintain their knowledge level and clinical skills. Family medicine was the first specialty to require periodic reexamination of its physicians. In fact, since family medicine has mandated reexaminations, many other medical specialty organizations now require periodic reexamination of their members or are considering such a move. Many former general practitioners who did not have a chance to do a three-year family medicine residency took the ABFM certifying examination and became diplomates based on their years of practice experience and successful completion of the certifying examination. This option was closed to general practitioners in 1988.

A new recertification program, called the Maintenance of Certification Program for Family Physicians (MC-FP), is being required by the ABFM starting with diplomates who recertified in 2003 and all diplomates phased in by 2010. To maintain certification, candidates must perform the following every seven years: submit an online application, maintain a valid medical license, verify completion of three hundred credits of accepted CME credits, and pass the cognitive exam.

Currently, the American Academy of Family Physicians requires new active physician members to be residency-trained in family medicine. Diplomate status reflects only an educational effort by the physician and does not directly affect medical licensure. Medical licensure is based on a different testing mechanism, and license requirements vary from state to state. According to a 2012 report published by the Association of American Medical Colleges, there are more than one-hundred thousand family physicians providing health care in the United States. Family medicine residency programs are approximately 460 in number and usually have about three thousand residents in training.

Diagnostic and Treatment Techniques

Service to patients is the primary concern of family medicine and all those who practice, teach, administer, or foster the specialty. Of all the family physicians in practice, more than 80 percent are involved in direct patient care. While family physicians by no means constitute a majority of physicians, they are among the busiest when measured in terms of ambulatory patient visits. Family physicians see 30 percent of all ambulatory patients in the United States, which is more than the number of ambulatory visits to the next two specialty groups combined. Because of their training, family physicians can successfully care for more than 85 percent of all patient problems they encounter. Consultation with other specialty physicians is sought for the problems that are outside the scope of the family physician’s knowledge or abilities. This level of consultation is not unique to family physicians, as other specialty physicians find it necessary to seek consultation for 10 to 15 percent of their patients as well.

Family physicians can be found in all areas of the United States and in virtually all types of practice situations, providing a wide range of medical services. Family physicians can successfully practice in metropolitan areas or rural communities of one thousand people (or less), and they can be found teaching or doing research in medical colleges. Because of their training and the fact that they see a truly undifferentiated patient population, family physicians deliver a wide range of medical services. Besides seeing many patients in their offices, family physicians care for patients in nursing homes, make house calls, and admit patients to the hospital. Within the hospital, many family physicians care for patients in intensive care and other special care units and assist in surgery when their patients have operations. A small number perform extensive surgical procedures in the hospital setting. A sizable minority of family physicians take care of pregnant women and deliver their children; some of these physicians also perform cesarean sections. Because family physicians see anyone that walks through the door, it is not unheard of for a family physician to deliver a child in the morning, see the siblings in the office in the afternoon, and make a house call to the grandparents in the evening. Over 80 percent of family physicians perform dermatologic procedures, musculoskeletal injections, and electrocardiograms (EKGs) in their own offices.

The thing that makes family physicians different from other physicians is their attention to the physician-patient relationship. The family physician has first contact with the patient and is in a position to bond with the patient. The family physician evaluates the patient’s complete health needs and provides personal care in one or more areas of medicine. Such care is not limited to any particular type of problem, be it biological, behavioral, or social, and the patients seen are not screened according to age, sex, or illness. The family physician utilizes knowledge of the patient’s functioning in the family and community and maintains continuity of care for the patient in a hospital, clinic, or nursing home or in the patient’s own home. Thus, in family medicine, the patient-physician relationship is initiated, established, and nurtured for both sexes, for all ages, and across time for many types of problems.

Because of their training, family physicians are highly sought-after care providers. Small rural communities, insurance companies, and government agencies at all levels actively seek family physicians to care for patients in a wide variety of settings. In this respect, family medicine is the most versatile medical specialty. Family physicians are able to practice and live in communities that are too small to support any other types of physician.

In two reports released by Merritt Hawkins, a national recruiting company, requests for family physicians surged by 55 percent, more than all other specialties. According to data from the Massachussetts Medical Society, community hospitals reported family physicians constituted their “most critical shortage.”

While the vast majority of family physicians find themselves providing care for patients, there is a minority of family physicians who serve in other, equally important roles. Roughly 1.5 percent of family physicians serve as administrators and educators. They can be found working in state, federal, and local governments; in the insurance industry; and in residency programs and medical schools. Family physicians in residency programs provide instruction and role modeling for family medicine residents in community-based and university-based residency programs. Family physicians in medical colleges design, implement, administer, and evaluate educational programs for medical students during the four years of medical school. The Society of Teachers of Family Medicine (STFM) is the organization that supports family physicians in their teaching role.

One problem facing the specialty of family medicine is the very small percentage who are dedicated to research: only 0.2 percent of all family physicians. There is a large need for research in family medicine to determine the natural course of illnesses, how best to treat them, and the effects of illness on the functioning of the family unit. The need for research in the ambulatory setting is especially acute because, while most medical research is done in the hospital setting, most medical care in the United States is provided in clinics and offices. This problem will not be easily solved because of the service focus of family medicine training and the small number of family physicians dedicated to research.

Perspective and Prospects

Family medicine developed as a medical specialty because of the demands of the citizens of the United States; it is the only medical specialty with that claim. The ancestor of family medicine was general practice, and there is a direct link from the family physician to the general practitioner. Family medicine has grown and evolved into the specialty best suited to provide for the primary health care needs of most patients. Because of their broad scope of practice, cost-effective methods, and versatility, family physicians are found in virtually every type of medical and administrative setting. Family physicians provide a large portion of all ambulatory health care in the United States, and in some settings they are the sole providers of health care. General practice has been around as long as there have been physicians—Hippocrates was a general practitioner—but family medicine has a definite point of origin. It was created from general practice on February 8, 1969.

In January 2000, a leadership team consisting of seven national family medicine organizations began the Future of Family Medicine (FMM) Project, with its goal being “to develop a strategy to transform and renew the specialty of family medicine to meet the needs of patients in a changing health care environment.” Six task forces were created as a result, with each one formed to address specific issues that aid in meeting the core needs of the people receiving care, the family physicians delivering that care, and shaping a quality health care delivery system. The FFM Leadership Committee has focused on improving the American health care system by implementing the following strategies:
taking steps to ensure that every American has a personal medical home, has health care coverage for basic services and protection against extraordinary health care costs, promoting the use and reporting of quality measures to improve performance and service, advancing research that supports the clinical decision making of family physicians, developing reimbursement models to sustain family medicine and primary care offices, and asserting family medicine’s leadership to help transform the US health care system.

The present role of the family physician is and will continue to be to seek to improve the health of the people of the United States at all levels. Major problems exist for family medicine, including attrition as older family physicians retire or die, lack of medical student interest in family medicine as a career choice, and the lack of a solid cadre of researchers to advance medical knowledge in family medicine. The major strengths supporting family medicine are its service ethic, attention to the physician-patient relationship, and cost-effectiveness.

After their near demise as a recognizable group in the mid-twentieth century, family physicians have a number of reasons to expect that they will have expanded opportunities to provide for the health care needs of their patients in the future. As the United States, for example, examines its system of health care, which is the most costly and the least effective of any health care system in the developed world, many medical and political leaders look to generalism, and particularly family medicine, to provide answers. Research has shown that, for many medical problems, family physicians can provide outcomes very similar to those provided by specialists. When one couples that fact with the versatility and cost-effectiveness of generalist physicians, it can be argued that to save health care dollars the nation must reverse the 30 percent to 70 percent ratio of generalist to specialist physicians. A ratio of 50 percent to 50 percent generalist to specialist physicians has been proposed at many levels in medicine and government.

As the population ages due to improved mortality statistics and the addition of baby boomers to the geriatric age group, a further shortage of general practitioners such as family physicians is inevitable. This situation will force the United States to deal with its health care issues in order to provide its citizens with cost-effective and adequate coverage. The shortage of family physicians specifically in rural areas has led to approximately 65 million Americans living in federally designated health professions shortage areas (HPSAs), defined as less than 1 primary care physician per 3,500 people. A growing challenge exists for those physicians living in rural areas as a lack of training and preparation for practice in their medical education and residency training has led to a steady decline in their choosing to practice there.

Bibliography

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