The subtitle of a 2014 JAMA editorial on accountable care caught my attention: "The paradox of primary care physician leadership." The authors observed that although a typical family physician's or general internist's patient panel accounts for about $10 million in annual health care spending (of which only $500,000 is primary care revenue), primary care physicians have been "underused" as role players in health system reform. They further suggested that claiming leadership positions in accountable care organizations could be "a powerful opportunity [for family physicians] to retain their autonomy and make a positive difference for their patients - as well as their practices' bottom lines."
The editorial’s urging that family physicians take on more leadership in health care brought to mind the American Academy of Family Physicians’ ongoing initiative Family Medicine for America's Health, an effort to define family medicine’s role in the current health care system. One of the key questions considered by this initiative is "What are the core attributes of family medicine today?" Dr. Robert L. Phillips, Jr., and colleagues from seven U.S. family medicine organizations answered the question in a special article on the future role of the family physician in the Annals of Family Medicine:
Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and they use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health.
This forward-looking definition of family physicians as natural health system leaders contrasts the "foil definition" that the researchers envisioned family physicians fitting if they were to accept passive roles and allow themselves to be acted on by the various forces changing American health care:
The role of the US family physician is to provide episodic outpatient care in 15-minute blocks with coincidental continuity and a reducing scope of care. The family physician surrenders care coordination to care management functions divorced from practices, and works in small, ill-defined teams whose members have little training and few in-depth relationships with the physician and patients. The family physician serves as the agent of a larger system whose role is to feed patients to subspecialty services and hospital beds. The family physician is not responsible for patient-panel management, community health, or collaboration with public health.
But are tomorrow's family physicians prepared to be leaders instead of followers?
A research study published in Family Medicine explored relationships between specialty plans and clinical decision making in a national survey of 4,656 senior medical students. Students were asked to choose between management options in patient vignettes that exemplified principles of health reform: evidence-based care, cost-conscious care, and patient-centered care. Compared to all others, students entering family medicine were statistically more likely to recommend generic over brand-name medications and favor initial lifestyle-change counseling to starting medication for a mild chronic condition. Future family physicians were also more likely to prefer U.S. Preventive Services Task Force recommendations on preventive care to those from disease-oriented or patient advocacy groups, although this finding was not statistically significant.
This study’s take-home message is that future family physicians are well positioned to take the lead in implementing health system reforms that improve value and patient-oriented outcomes. Primary care physician leadership is not a paradox; on the contrary, it’s hard to imagine health reform succeeding in the long term without family doctors at the helm.
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A version of this post was first published on the AFP Community Blog and then appeared in Progress Notes on July 24, 2014.