How Do I Define Family Medicine?

(Edited 3/16/12, much for the better, with deep thanks to Emily Lu)

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While at the STFM meeting this weekend, some of us discussed how best to define family medicine.  This is increasingly important, as there is a dire need for more primary care physicians over the coming years and Family Medicine must make up a significant part of that increased workforce.

There are various definitions out there already:

• American Academy of Family Physicians: "Family medicine is the medical specialty which provides continuing, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity."
• WONCA Europe has a long definition (pdf here) which is comprehensive but not very accessible.
• Kevin Bernstein (@MDStudent31 on Twitter) wrote a blog post in which he notes that family medicine is very difficult to define.

I would argue that the first two definitions are insufficient.  The first, although accurate, is a mouthful of jargon that does not really resonate.  The second is 9 pages long--and that's the short version.  I also accept Kevin's thoughts that the nature of family medicine is that the scope of training and scope of practice is very broad and individual providers' practices differ significantly from one to another.  Having said that, I think there is value in trying to define what family medicine is and what role family physicians play (and should play) in health care.

Here are what I think are the key features that define family physicians:

• Help all patients, regardless of age, gender, complaint or social situation.
• Evaluate undifferentiated symptoms and patient complaints about any/many organ systems, and determine a holistic, appropriate and cost-effective treatment plan.
• Develop long-term therapeutic relationships with patients, and emphasize continuity and coordination of care with necessary specialists, counselors, and community resources.
• Manage patients' chronic illnesses, treatments, and ongoing health needs within the context of their family and community settings.

These core principles help describe the scope of practice, the importance of continuity of care, the importance of community-oriented primary care, and the importance of the bio-psycho-social model that define family medicine.

So: that's my current try at the definition.  I would love to discuss further in the comments below.

How Will Virginia Benefit From Healthcare Reform?

(Originally posted on the National Physicians Alliance Virginia Local Network page, April 16, 2010)

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The Kaiser Family Foundation has developed a resource to show the current status of health care coverage and access in each of the 50 states.  The overall site is here; the page detailing Virginia's information is here.  This data shows that Virginia has an overall lower % of uninsured non-elderly adults, slightly higher % of residents receiving health care insurance through their employer, and slightly lower % of publicly-insured residents compared to the nation overall.  This might lead one to ask how much Virginia stands to gain from the Patient Protection and Affordable Care Act (PPACA).  Fortunately, the University of Virginia (UVA)'s Weldon Cooper Center for Public Service has tried to answer this question.

In a report titled "Economic Effects of Health Care Reform On Virginia", the center reports that:

• Reform will have "significant positive employment effects for Virginia" with over 27,000 jobs created by 2019.  Most of these of these jobs will be in the healthcare field.
• Healthcare reform will create a $3.3 billion increase in the state's GDP between 2010 and 2019.
• The report suggests that the PPACA's potential to reduce health care costs extends its benefits to Virginia beyond the direct impacts noted above.  The report indicates that if health care costs can be controlled and these savings are passed along to employers then the employment benefits could nearly double.

If improving access to healthcare to our fellow Virginians isn't enough of a reason to support the PPACA, maybe these economic benefits will help.  People are more important than numbers, but sometimes numbers matter.  By either measure (access to care or economics), the reforms in the PPACA will benefit Virginia and Virginia's residents.

How Much Proof Do We Need To Support Healthcare Reform?

(Originally posted on the National Physicians Alliance blog April 16, 2011)

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Just over  year after the Patient Protection and Affordable Care Act (PPACA) was passed, surveys show that many Americans are still unsure of what the law will mean for them.  A recent Kaiser Family Foundation poll (pdf) showed that 52% of respondents feel that they lack sufficient information to assess the PPACA's impact--a proportion similar to that seen after the law was passed last year.  At the same time, there is increasing understanding that our current health care system is dysfunctional and needs to be reformed: the Commonwealth Fund recently found that 72% of Americans believe that the current system needs fundamental change or major reform.  To support this, poll respondents noted "difficulties accessing care, poor care coordination, and struggles with the costs and administrative hassles of health insurance."

In this context, it is revealing to review an earlier Commonwealth Fund publication titled "Help on the Horizon: How the Recession Has Left Millions of Workers Without Health Insurance, and How Health Reform Will Bring Relief."  This report found the following:

• Millions of Americans lost their jobs and health benefits in the last 2 years: nearly 60% of those who had health benefits through their job lost those benefits, and only 14% kept their coverage through COBRA.
• There are few affordable options for health insurance for workers who lost their jobs and benefits: 60% of Americans who sought coverage in the individual market reported great difficulties finding affordable coverage, and 35% were excluded from coverage or faced higher costs due to a preexisting health condition.
• The number of adults who have spent time without health insurance has increased in recent years: 52 million people reported being uninsured during at least part of the previous year in 2010 (up from 38 million in 2001).  People were more likely to have gone without insurance if they reported low or moderate incomes, if they were members of a minority group, or if they were young adults.
• People are spending large proportions of their income on healthcare costs: nearly 1/3 of respondents reported spending at least 10% of their income on healthcare costs, up from 1/5 in 2001.
• More and more Americans report facing significant medical debt: 40% reported financial problems related to the costs of their health care.
• Americans are foregoing needed care because of costs, and are less likely to get preventive care: 40% reported skipping needed care (avoiding doctors' visits, prescriptions, tests, etc) due to costs, and rates of recommended preventive care were notably lower among uninsured individuals.

Clearly, the system we have had is broken, and the current recession has only made things work.  Unemployed Americans lack the necessary leverage to get affordable and comprehensive coverage, resulting in deferred care, financial hardship, and presumably increased risk of illness and harm over time.  The 72% in the Commonwealth Fund noted above clearly have a reason to feel our system needs to be changed.

Fortunately, that change is already underway.  The PPACA will address these issues once it is fully in effect in 2014.  In 2014, the PPACA will provide for nearly universal coverage for American citizens by expanding Medicaid eligibility, subsidizing private health plans with more robust patient protections, and spurring new options for health insurance through the state health care exchanges.  Once fully in effect, the PPACA will also prevent insurers from charging more or denying care for individuals with preexisting health problems.  The early reforms already in effect allow young adults to stay on parents' insurance until they turn 26, eliminates lifetime caps on benefits, and requires health insurance plans to provide preventive care without requiring patient copays.

The better the existing healthcare system's problems are defined, and the more information we gather about those affected and harmed as a result, the more clear the need for reform is.  As this need becomes increasingly clear, it is also increasingly clear that the PPACA's major reforms are targeted at addressing the current system's most crucial problems.

We need to stop trying to justify the PPACA by finding more and more proof reform is needed--we have that proof.  We also need to stop trying to prove the PPACA is the answer--we have that proof.  What we need to do is to continue working to ensure that all Americans understand the law's benefits and how it will help them.  We already have all the proof we need.

Happy 1st birthday, ACA!

March 23rd marked the first anniversary of the passage of the Patient Protection and Affordable Care Act (PPACA).  The PPACA has already expanded coverage to young adults and those unable to afford health insurance to the high costs of individual premiums due to preexisting conditions.  Health insurance companies will need to reform their business practices, including ending the policy of revoking care if a policyholder is diagnosed with a serious illness (so-called rescissions) and requiring that 80-85% of premiums paid by policyholders be used to provide care and benefits (instead of paying executives' salaries, etc).

On March 22nd, I was able to participate in an event sponsored by Virginia Organizing to discuss the benefits of the PPACA.  Please take a look at my post on the National Physicians Alliance Virginia Network's page for more detail.

And join me in celebrating a very important birthday.