Moving Family Medicine Forward by Embracing Disruption

Many recent conversations in the advancing world of health care delivery have integrated the term "Disruption". At first glance, this is perhaps quite jarring and counter-intuitive to the mind of the forward or progressive thinker. It is ever the more uncomfortable to the medical mind that is trained to carry on in the face of adversity, through exhaustion, and despite resistance. Paradigmatically, the medical world has recently been presented with progress and innovation through abrupt disruption of the modern model.

Much of the context and logistics have been borrowed from the business community, and the Harvard Business school's teaching on "Disruptive Innovation". To bring matters close to home, Clayton Christensen translated the idea directly to the medical community in 2008 with "The Innovator's Prescription - A Disruptive Solution for Health Care". The premise is that for health care to truly move forward, we cannot accept a gradual or trajectory change - we need to replace a broken system.

I think the book is brilliant, and students and physicians alike should at least look at an executive summary, such as this or this. I hope that this would be an appropriate forum to offer considerations as to how the family physician can successfully embrace such "Disruptive Innovation" for the future of health care.

The proposed solution includes discarding the current fee for health care service model, supplementing precision intervention with individualized-care, and facilitating patient-patient coalescence and interaction. Interestingly, a key for Christensen is the expansion of the primary care workforce - but his recommendations promote an increase in mid-level providers. Further, he hints at diminishing the scope of practice of the primary care physician. If there ever was a time for family physicians to wake up, take a deep swig of coffee, and prepare to be leaders riding the wave of change - it is now. Following, are my considerations, tailored to thoughts on how family physicians can integrate into a disruptive discussion.

1) Embrace technological change
Let me be frank - the days of the omniscient and omnipresent family doctor are past. We cannot argue this, because our patients now posses more information in the palm of their hands then we collectively engage during the duration of our training. This is great news! This change empowers us into the role of patient facilitator. We no longer need reside in a world of regurgitator of information - rather we can be an intuitive examiner that arrives on the scene to decipher information and make recommendations. 

In the greater conversation on "disruption" in medicine, this term of "intuition" keeps coming up.  It is a direct outgrowth of advances in technology that allow medicine to become ever more "precise", or "cook-book", if you like. As precision improves, skill, education, and experience become less requisite.  This is simply because we know that if we do X, we can almost certainly guarantee Y.  In contrast to this precision-focus is intuitive medicine; though the two do often work in concert.  Family physicians must continue to position themselves within the world as intuitive investigator - utilizing a unique skill-set that transcends technology and testing.

The next step is not limited to the acceptance of technological advancement - in effect the buying of new computers and electronic medical records.  Rather, it is taking these devices and their near limitless application and allowing the frame-shift to adaptively respond practice and expectation for the next generation of family physicians.

2) Be a "Patient Specialist"
The goals of disruptive change for medicine assume that increasing specialization will necessarily move the profession towards ever increasing division of responsibilities.  We have come quite a long way, already, in the past twenty years in this direction - and some would suggest we need to go further.  I think we must accept this as an inevitable consequence; one that springs from the aforementioned technological complexities thrown into a tornado of rapid turnover in evidence based medicine and treatment preferences. 

Framing family physicians as patient specialists removes the burden of the current trend towards super-specialization and subdividing care.

I suppose this can best be imagined as the focus of the lens one chooses to look at patients for whom they care.  Many physicians deftly employ the magnifying glass, or even a microscope, to analyze the minute and detailed aspect of a patient's condition.  I would like to consider that family physicians know how to pick up a microscope, when needed, but choose to look at the world with the naked eye.  Standing back, from this perspective, the whole patient comes into focus, and the examination extends to family, friends, community, and the long-range, big picture.

The perspective of diabetes, for example, is very different when viewed from that of practice, community, or population health as a whole, then when examining a renogram or even an individual nephron.  The instigating factors, barriers, complications, and burdens can look quite different, depending upon where one is standing.

Change, in any form, necessitates the overcoming of barriers. Altering habits, embracing new information and patterns, and investing time are challenging enough - then we add a price tag to the equation. I believe that much of medicine is based upon expectations - those that we have of ourselves and those that our patients hold. Choosing to ignore or slow play technology, we let our patients down and we cast an antiquated shadow on our practice. We should look to embrace the value of infinite access to information, the internet, and social networking - and allow these to transform both scope and practice. Proactivity, in this regard, is the best medicine - even if some see it as the toughest to swallow.

Is There an Underlying Specialty-Bias in Medical Schools?

A multitude of factors drive students towards, or away from, the path of family medicine. Much has been made recently of reimbursement schemes that incentivize specialty practice. Certainly, medical students strapped with debt are showing preference to more lucrative fields for residency. But is there more to this choice beyond the surface of financial incentive? What about the very environment that cultivates the growth and decision-making of our medical students? Does an underlying, or perhaps hidden, bias to specialty care exist within the modern academic community and curriculum?

First, consider the structure of the academic course itself. The systems-based approach to medical education remains the predominant curricular modality. Under this structure, organ systems are taught by specialists who are invited to profess the proceedings of their specialty. This leaves students with cardiologists teaching cardiology, pulmonologists teaching pulmonology, and family doctors, often, on the sidelines. Certainly, every school employs faculty to a differing degree. In fact, my medical school chooses to bring in primary care providers to approach a 1-2 hour discussion on the broad implications of each system. However, these brief family medicine lectures are all ultimately followed with 2-3 weeks of intensive specialist-driven lecture. This leaves the overwhelming prevalence of educators to be drawn from the specialty fields.

I understand and appreciate the necessity of this approach, but one cannot deny the potential effect on students. How does specialty-driven, systems-based curriculum effect student perception of medicine? Does this leave a dearth of primary care role models at the frontlines of our classrooms?

Next, consider the content and focus of standardized examinations, such as “shelf” exams and USMLE step exams. Exam passages often tell a story, starting with something along the lines of,

“Mr. Smith is a 76 year old male who was referred by his family doctor for difficulty swallowing. He presents to your office today with…”

In my experience, I have rarely come across questions that highlight the role and duties of the family physician. The implication is reasonable – test-writers hope to hone in on minute details of pathology or physiologic consequences of disease. However, in doing so, is their an unintentional belittling or underplay on the value of the family doctor? Does this continued focus on the details and complexities of disease have the effect of placing an unintentional bias towards specialty care in medicine?

Further, consider a medical student’s experience in clinical rotations. Take myself for example – I am now a full ten months into my third year of medical school. Meanwhile, I have spent approximately nine of those months working on inpatient wards or in the operating room. Like most of my colleagues, I have reached the point in academic career in which I must make a decision on my residency path. Yet, is it reasonable for me to do so with 4-6 weeks of total outpatient family medicine exposure? Certainly, I would never argue with the necessity for medical student exposure to the fullest array of clinical experiences. However, does a built-in bias towards inpatient, hospital, and specialty medicine exist within this process?

Certainly, in my experience, specialists do not necessarily paint the best picture of family physicians. Far too often, I hear comments such as, “Oh boy, would you look at what their PCP did? I guess we’ll have to clean up the mess”. These sort of comments are rarely balanced by accolades or praise for general practitioner care or referral. I often found the family physician to be portrayed as a guy on the outside looking in. Ultimately, does the prevailing impression of the inpatient experience in clinical rotations generate a bias towards specialty care?

An article published in the New England Journal of Medicine on February 10th addressed the importance of the involvement of medical schools in the encouragement of primary care selection. The paramount responsibility that was implicated was that the school should place primary care physicians in leadership roles within the administration and deans offices1. This further emphasizes the importance of the medical school curriculum and environment in the process of supporting and advancing the mission of primary care.

I have asked many questions in the preceding paragraphs – this was purposeful. I believe these are all questions that remain to be answered, or questions that could be answered differently depending on the academic institution or environment. Certainly, the modern world of academic medicine provides for limitless variation. I am confident that many medical schools exist that take a balanced approach to exposure and encouragement of residency choice.

The sentiments that I have expressed are drawn from my experience, as well as discussions with my peers. I encourage you to help me answer some of these questions and contribute to a robust discussion below. At the very least, keep these considerations in your mind as you move through your training, or think about the training of others. Does this underlying bias towards specialty training exist in academic medicine?

1. Smith, Stephen R. “A Recipe for Medical Schools to Produce Primary Care Physicians”. New England Journal of Medicine, Feb. 10 2011. Vol. 364;pg 496-497.

What Is Family Medicine?

Going into medicine from a suburban community in the northeast, I never really knew exactly what family medicine was as a specialty. I had heard of it before, but did not see it in action until going to undergraduate school in the middle of Pennsylvania. It was there when I began to understand that family physicians could do a little bit of everything...

But what really is family medicine? I needed an exact definition... as one to memorize for an exam.

Before medical school began, I went to Honduras with a group of family physicians and general internists. It was there where we delivered 2 babies, sutured small wounds, treated rare infectious diseases, helped children in an orphanage, and provided acute and chronic care to people of all ages and stages. This is not something I experienced in my suburban community in the northeast. Family physicians providing comprehensive care in obstetrics, treating obscure infectious disease, all while taking care of pediatric and geriatric patients? What IS this specialty??

I searched for the truth early on in medical school - a difficult task considering I go to a school in a large city in the northeast. It was here where I learned that family medicine physicians were very undervalued, overlooked, overworked, and underfunded. Although competent in all areas, family physicians mostly taught public and community health, physical exam skills, and patient communication skills... interesting since family physicians also provided care in all of the other subject areas during the first two years of medical school, but did not give lectures in any of the core content areas. (sidebar - I would argue that the entire family medicine faculty had better presentation and communication skills than several of the proceduralists that lectured us.)

Later on during my clinical years, I traveled to family medicine conferences, networking with a variety of family physicians throughout the country. I have also spent time on a number of clinical rotations in family medicine away from the big cities, traveling to the subrural community 45 minutes away as well as venturing to the south for an away elective. It is amazing how different family physicians practice depending on the location and proximity to specialist-driven care.

One of my future colleagues, a family physician in the rural midwest, practices in a small community located more than an hour away from most of the specialists located in an academic center within a small city. He does full-scope family medicine, providing full scope care in obstetrics, performs C-Sections, colposcopy and gynecological care, performs colonoscopy, ultrasound, helps in the emergency department, rounds on patients in the hospital/taking call, takes house calls, and by the way, sees patients in the typical northeast fashion - outpatient practice. He does all of this mainly because it is too much of a hassle for the patients and specialists to get together at the specialty-driven academic center located over an hour away. Is this family medicine?

My conclusion is that you cannot really define family medicine.

Another family medicine colleague said that you, as the family physician, are defined by the needs of your patients.

Furthermore, we are defined by the number of specialists required to refer to in order to practice proper defensive medicine when involved in a malpractice case when asked

"'x' specialist was located in close proximity as an 'expert' for 'y' condition. Why did you choose to follow evidence-based medicine instead of referring your patient to 'x' specialist to follow the same evidence-based medicine?"

When it comes down to it, a family physician can do whatever they want to do, as long as they are flexible in their location for practice and are providing services that others are not willing to practice within that given area. The most important thing to remember is knowing when to refer to that academic center - inconveniently located in an area that already has at least 2 other of its kind within walking distance.