Saturday, April 30, 2011

How Do I Define Family Medicine?

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


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.


Judy Y Choi said...

I like your definition. I think the first feature you mention should be emphasized - that FPs take undifferentiated symptoms/complaints and do this for any patient regardless of age/gender/body part, as you mentioned, because essentially that puts FM in the unique category of true diagnostic medicine. Sadly, the image that is often conveyed by the specialty of Family Medicine does not seem to attract many med students b/c this feature is so often de-emphasized or missed (except those of us who are maybe more community-minded). This carries over even to the general public ("You're nice, but can I see my specialist now?"). When I talk to those outside of medicine, many of them do not understand how PCPs/FPs are anything more than "coordinators" --which, of course, is an especially vital aspect of primary care right now in a fragmented system -but "coordination of care" carries an administrative tone that downplays the true cognitive level of medical diagnoses and treatment for the unknown patient. I think in order to counter the loathed "gatekeeper" image of family docs, & to help find a rightful place for NP/PAs to provide many primary care services that they can, the AAFP & all primary care physicians ought to emphasize the role of being the only doc that has the knowledge to see anyone who walks through the door, the true diagnosticians of medicine. FM will never win in the "technical skills" battle w/ specialists, but we can as the only doctors that know how to take care of 90% of patients regardless of organ system or age. It's hard to change opinions, but I suggest as just an idea--maybe we can provide a little extra broad-based residency training (maybe extra required derm/endocrine/rheum rotations), offer more fellowships, or just emphasize this oft- forgotten feature of FM. I just say this because, as a 4th year med student at an allophatic school that turned out only 15 students going into primary care (out of 190), I've what has detracted my friends from choosing FM (probably second to the $$ factor). I am excited to start FM internship this summer, but I think the specialty could use a major image makeover.

Anonymous said...

Excellent points. I debated with a hospital specialist who started off explaining to a lay audience that there was no difference between specialists and GPs (as well call ourselves here) My response was very close to the first part of your definition. We shoulder our patients' anxieties and protect them from the misuse of invasive medicine. In common with our ancient medical predecessors who acted as intermediaries bewteen worlds we interpret our patients' stories for our colleagues and vice-versa.

mark said...

Judy: those of us in Family Medicine have realized that patients still have difficulty understanding what the specialty is all about. Although most patients know who *their* family doctor is, patients have difficulty explaining what a "generic" family doc does. "Coordination of care" can be more usefully described as "ongoing supportive relationship with patients and helping patents navigate our healthcare system"--this better explains our role as more accessible to patients.

abetternhs: Your comment reminds me of the book "A Fortunate Man". The GP/FP's role of forming supportive relationships with our patients and helping them negotiate the system to *their* final benefit is a critical one.

Carla said...

I like what Bob Phillips said when he spoke at STFM yesterday, the family physician's role is to take care of complex patients and manage relationships. Not only do I consider myself a good diagnostician, but once my patient has been diagnosed with 3, 4, 5+ chronic illnesses, I am the provider who thinks about all of them and the interactions of their various treatments. We keep the whole patient in mind (and his/her goals) the whole time.

We also value our relationship with the patient and help him/her to navigate the health care system. Managing relationships is more complicated than just coordinating care. Or maybe it just sounds better.

An important discussion.

mark said...

Carla--completely agree. Long-term relationships is a critical part of family medicine, and hence inherent in the definition. Differentiates us from ER docs and those in acute-care settings.

A quote that I paraphrase a lot: "Never underestimate the therapeutic power of self."

Salvador Casado said...

Good definition. We need to go on thinking about the care we suply. About the boundaries and stresors, about ourselves as physicians and human beings.

I like to be a general practitioner, and I think this fact is important to my patients.

(I retweeted your post, gook work)

Jennifer L. Middleton MD MPH said...

Really like the 4 bullets you put forth! How about adding something explictly about managing chronic disease? Also wouldn't mind seeing evidence-based medicine in there somewhere (though it could be argued that EBM is not unique to our specialty).

Maybe "Manage chronic illnesses collaboratively with patients and their families, communities, and consultants" and/or "Tailor the best available medical evidence to each individual patient's situation and needs within the context of their families and communities" ?

Agree with soon-to-be Dr. Bernstein that family medicine is difficult to distill into a few phrases - if it wasn't, surely it would have been done well by now! But I agree with you, also, that there is value in defining ourselves, not the least of which is that WE will define our specialty and not others. Think you have us off to an excellent start - thanks for the post!

mark said...

Jen--Maybe modify the final point?

"Work with patients' chronic illnesses, treatments, and ongoing health needs while in the contexts of their family and community settings"?

We could also adjust the third bullet point:

"Develop long-term therapeutic relationships with patients and emphasize continuity and coordination of care with necessary specialists."

Dr Synonymous said...

Great start to a continuing quest. The elusive nature of a tight definition of Family Medicine reflects the elusive nature of the Human Condition that we co-celebrate with our patients. The vast array of phenomena in individuals, families and communities are all opportunities for engagement with a Family Physician. We're relationship specialists with Humans, through the five senses across the Biopsychosocial Model (of George Engel), questing for shared truths about what it means to be human. We shift from Healer to Teacher to Warrior to Visionary and back again as the need arises, then allow the person(s) with the phenomena to continue their worldly or eternal life. BLOG ON!

Jennifer L. Middleton MD MPH said...

Really like how you reworded my draft bullets - couldn't have said it better. :)