Friday, June 8, 2012

Family medicine is "total medicine"

A terrific article in today's Huffington Post by two of my colleagues, Dr. Ranit Mishori and Family Medicine Education Consortium executive Larry Bauer, argues that family physicians need to "get out of the shadows" and advocate for a larger role in fixing America's health care problems. Instead of subdividing patients by age or body system, family medicine is the specialty trained to handle "diagnostic complexity," which requires a broad and varied skill set:

Every day we treat children, mend bones, manage chronic diseases, deal with hypertension, diagnose intestinal conditions, carry out eye exams, deliver babies, help control diabetes, take skin biopsies, inject aching joints, evaluate stroke victims, monitor depression and in some cases perform minor surgeries. And yes, this range of skills, while broad, does constitute a genuine and focused medical specialty -- the specialty of knowing your patient inside out and over years. We are meant to be experts as much in the person who comes to see as we are in the medical procedures we employ, to build a shared trust with our patients, to be partners with them toward the lifelong goal of staying healthy -- enough, by the way, to avoid too often the need for one those other specialists, whose practices often depend on people being very sick in the first place.

There is an odd logic that diminishes the status of family doctors. It is also faulty logic. People think that the more a physician knows about a specific medical problem or body part and the higher that physician's salary, the better care they will receive. Leaving aside whether that's actually true, it sets up a phony reverse corollary -- the belief that a doctor whose knowledge is more generalized, and whose pay scale is lower, is therefore providing inferior care. This is just wrong. As generalists, we believe the ability to see the patient's big picture; knowing "enough" about most problems; and understanding the preferences, past medical history and the resources of the person seeking care is far more important in most situations than narrow expertise.

Mishori and Bauer go on to ask whether family medicine (which not that long ago was called "family practice") should be renamed "total medicine" to better represent everything that family physicians do. But I think that family medicine needs more than a simple re-branding. When 1/3rd of the U.S. physician work force consists of generalists and 2/3rds consists of subspecialists, patients not only receive less value for their money (since subspecialists have higher salaries), but poorer health outcomes to show for it. A 50/50 ratio, which is the norm in much of the world, would not only save health care dollars, but likely result in fewer illnesses and deaths from preventable conditions. So let me say this as clearly as possible to those who are predicting a vast physician shortage in the upcoming years: America does not need more physicians, it needs more family physicians.