Family practice in the United States is under threat. Patient demand for direct access to specialists is growing, which reflects the population’s insatiable appetite for high-technology medicine and may also be indicative of a backlash against the gatekeeper model imposed by managed care. The hospitalist movement is further removing family physicians from the inpatient care setting. The number of advanced nurse practitioners and physicians’ assistants claiming to deliver primary medical care of equivalent quality to and lower cost than family physicians is also growing. Patients also have ready access to a broad array of health and medical care information services through the Internet, which may provide the opportunity for them to decide what kind of specialized medical care they need.
Many managed care organizations (MCOs) have instituted demand management programs that give patients direct access to telephone triage centers staffed by nurses 24 hours. MCOs have also instituted chronic disease management programs for managing patients with specific chronic diseases (diabetes, asthma, heart failure) in a more cost-effective manner, often “carving out” that part of their care away from the primary care physician.1
There are more and more published studies that purport to show that the outcomes of care for patients with certain chronic diseases are better when provided by specialists compared with generalist physicians.2 Wagner and colleagues3 believe that improved outcomes of care by specialists are probably related to better-organized processes of care and not necessarily to superior specialist knowledge or expertise. They note that studies comparing usual generalist care with usual specialist care have found no differences in care outcomes.
Family physicians find that their level of reimbursement is decreasing, while the amount of regulation, paperwork, and office overhead is increasing. They have to see more patients in less time to maintain their incomes. Sometimes feeling like hamsters on a wheel, they are becoming more dissatisfied with their practice. This is not going unnoticed by medical students; the number of US medical school graduates matching in family practice residency programs has declined for 4 years in a row. Family practice as we know and practice it today is in peril.
Health care in the 21st century
Many forces are reshaping the way health care will be delivered in the United States in this century.4 Both the purchasers and the consumers of health care are demanding evidence of quality, while the drive to contain spiraling costs continues. Growing consumerism is resulting in patient demands for better (ie, quicker) access to care and better service from providers. These new consumers are looking for choice among providers. They are demanding more and better information about their health and more participation in decision making about their care. They are becoming sophisticated in the use of the Internet, gaining experience with e-commerce and expecting to gain access to health information, provider appointments, their medical records, and their physicians through e-health applications. There is a growing emphasis on improving the prevention of disease and the management of chronic illnesses. There is more attention to the health of populations of patients and entire communities. There is also a federal government campaign underway to reduce the errors in health care and improve patient safety.
Redesigning family practice
Since the current family practice model is under threat and health care is being reshaped at a rapid pace, family practice must be redesigned for it to survive. What role will the family physician have in the evolving health care system? Morrison5 anticipates that physicians are likely to perform 6 core functions in the new medical care system: clinical data collector, shaman, health advisor and wellness coach, knowledge navigator, proceduralist, and diagnostician.
Although diagnostic technologies will continue to evolve and enhance our abilities to detect disease, the patient’s history will continue to be our most important diagnostic tool for the foreseeable future. Despite the expanding armamentarium of therapeutic technologies, the physician’s role as healer will continue to be paramount. The physician-patient relationship that is the cornerstone of family practice will continue to be our most powerful therapeutic tool. Health behavior and lifestyle modification will assume more importance as a way of preventing and treating chronic diseases. Family physicians will need to become experts in helping their patients eat better, exercise more, and avoid using noxious substances. Patients and families will have more access to health care information through the Internet and will need help and guidance in managing, interpreting, and customizing that information. Family physicians will need to know how to harness the power of these tools to better serve their patients. Evolving medical technology will introduce new diagnostic and therapeutic procedures into medical practice. Some of these will be disruptive: simpler, less invasive, and more cost-effective than the technologies they replace.6 Family physicians should seize these disruptive technologies and implement them in their practices, improving the quality and cost-effectiveness of their care. Advances in information technology will enhance the physician’s ability to make more accurate diagnoses on the basis of available diagnostic test inputs. Electronic medical records (EMRs) that are linked to clinical data repositories, expert systems based on neural networks, and just-in-time information systems available at the point of care will significantly improve the family physician’s diagnostic acumen.