Family physicians caring for fewer children: reversing the trend

"How did you choose family medicine?" I've lost count of the number of times I've been asked this question by a medical student. The truth is, I entered medical school thinking that I would become a general pediatrician and focus my energies on keeping children healthy. It was only after I realized how much I also enjoyed adult medicine and well-woman care that I decided to enter the only specialty that would allow me to provide continuous, relationship-centered primary care to patients from their first until their last day of life.

In 2005, a Robert Graham Center report, whose key findings later appeared as a Policy One-Pager in American Family Physician, sounded an alarm. The authors reported that the share of children who saw family physicians for primary care had declined from one in four to one in six since the early 1990s. A subsequent article in Family Practice Management (now FPM) explored some reasons for the decline: expansion of the pediatrician workforce; fewer family physicians providing prenatal, newborn, and pediatric inpatient care; and a lack of awareness among the public and the media about the broad scope of family medicine training. The FPM article recommended several strategies for individual family physicians to increase their opportunities to recruit children to their practices:

- Build relationships with Ob/Gyns and pediatricians in your community.
- Heighten your visibility in the hospital.
- Get to know the nurses in labor and delivery and the nursery.
- Don't rely solely on word-of-mouth marketing.
- Talk with patients whose children might be outgrowing their pediatrician's office about transferring.
- Create a kid-friendly environment.
- Make sure your hours and appointment access are sensitive to the needs of young families in your community.

Nearly 15 years later, according to the American Academy of Family Physicians member census, 80 percent of family physicians are still caring for adolescents, while 74 percent see infants and younger children. But a recent population-based analysis of an all-payer claims database in Vermont suggested that family physicians' share of children's health care has continued to erode. Between 2009 and 2016, children residing in Vermont were 5% less likely to be attributed to a family physician practice, a trend that included urban and rural areas. Older children, girls, and children with Medicaid were somewhat more likely than others to see family physicians.

Caring for children benefits family physicians and their patients. In an article in the September/October issue of FPM, Drs. Sumana Reddy and Jaydeep Mahasamudram observed that "the satisfaction that comes from taking care of children shouldn't be underestimated in a time of increasing physician burnout." Not only can family physicians smooth young patients' transitions from child to adult care, but by caring for parents and grandparents, they gain perspectives on inter-generational social interactions that pediatricians don't. One example: "As family physicians, we can see all of the ill members together, we can care for both the newborn and the breastfeeding mother with postpartum depression, and we can understand the teenager's mood disorder because we know the parents have been dealing with severe stressors even if the teen doesn't disclose this."

So how can family physicians counter national trends and provide care to more children? In addition to the strategies already mentioned, Drs. Reddy and Mahasamudram suggested taking advantage of opportunities to refresh one's knowledge on child-specific issues (e.g., Kawasaki disease); asking local internists and obstetricians for referrals; volunteering to give community talks on child health topics; and becoming more familiar with Current Procedural Terminology (CPT) codes for visits with young patients, especially those for vaccine administration.

Incidentally, my personal doctor is a family physician, and my wife and children all see a longtime family physician colleague of mine for primary care. Although primary care should stick together to provide a counterweight to the subspecialist-oriented U.S. health system, I also think that it's important for the future of our specialty that patients don't perceive family physicians to simply be another flavor of general internists.

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A slightly different version of this post first appeared on the AFP Community Blog.