The Future of Family Medicine in Texas

Why Are We Here 
Who Are We 
and 
Where Will We Go?

 
The inaugural address of TAFP's newly inducted president, F. David Schneider, MD, MSPH

 
So why are we here? Who are we, as family physicians? What does the future hold for our profession? What is the future of family medicine in Texas? These are important questions for our patients, our specialty and for medicine. Over this next year, we as a group will begin to attempt to develop the answer.

In the book Alice in Wonderland the Cheshire cat opined that, “If you don’t know where you are going, any road will take you there.” In family medicine, we are at a crossroads in our history. We are no longer an immature specialty, but we are a specialty that is undergoing significant change. Fiscal, scientific and political realities are pushing in on us from all directions, deciding for us how medicine, and more specifically how family medicine should be practiced.

The fiscal realities are fairly obvious.  Decreasing reimbursement, coupled with increasing overhead in a difficult economic time is forcing us to re-examine our business practices, the services we provide and the patients we care for.

Scientific discoveries are coming fast and furious, and are more difficult to keep up with than ever before. While addressing the incoming medical students, the former chair of the Department of Family Practice at UTHSC at San Antonio, Dr. Barry Weiss, commented that a few years ago half of what he had learned in medical school was no longer true. Information we take as gospel today will be found to be not quite as we thought within a few years. 

Public policy, and by extension politics probably impacts us more than even science.  This is a sad but true reality. For our academy and its leadership, most of this past year was focused on passing liability reform, prompt pay and saving Medicaid, CHIP, and medical education funding on the state level, and keeping Medicare reimbursement rates from being slashed and saving Title VII funding for family medicine nationally. We were more successful than most of us thought we would be, but still far from what was truly necessary. Medicine today is the most over-regulated industry that exists. A lot of this is our own fault, because we have allowed it to be. 

With all of these challenges, sometimes it’s hard to remember the road we took to get us here in the first place. 

A few weeks ago I attended the White Coat Ceremony at the medical school that I am a part of, UTHSC at San Antonio. Most of us probably never participated in such a ceremony when we attended medical school.  They didn’t have them then. Almost all medical schools have them now. The White Coat ceremony celebrates our new medical students receiving their first white coats. At UT, it occurs on the very first day of medical school. On the Sunday before the students begin orientation, parents, families, and friends, all those responsible for helping the students, get to where they are  attend the ceremony. It focuses on what being a doctor is really about. What it means to care for a patient and the significance of the white coat. Then in a ceremony not unlike the hooding they will go through in four years, each medical student walks across the stage, receives their white coat, and has it put on by a faculty member. For me, it was a poignant reminder of why I am here.

Dr. Carl Mangos, a pediatric pulmonologist and our former chairman of pediatrics received the Humanism in Medicine Award at the ceremony and gave the keynote address. He told a story of a child who had died of cystic fibrosis and how after her death a few days before Christmas, her family comforted him, rather than the other way around. It reminded me of how much I get from having the opportunity to care for my patients. I often feel that I get more from these relationships than they get. It’s what makes being a doctor a physician, the opportunity to care. What an amazing road that so few will ever travel.  

Who are we, we family physicians? Dr. Jesus Enrique Batani Omos, credited with being the grandfather of family practice in Mexico, developed the “10 Commandments of a Family Doctor.” I believe these describe us quite well: 

1. Love your patients and their families (healthy or ill), with constructive, deliberate and respectful love.

2. Develop your medical practice with a holistic approach based on ethics and humanism.

3. Listen, orient, and console. They are part of healing.

4. Educate for health and convince by example.

5. Make your clinical care appropriate and continuous.

6. Be constant in your academic pursuits. Cultivate good reading, be critical and contribute to the generation of new knowledge.

7. Be fair with your charges and do not forget charity.

8. Derive whatever is necessary from other specialists and seek support from your health care team.

9. Do not be blinded by professional practice. Never forget that you are also part of a family and community.

10. May the practice called Family Medicine help you to fully realize your potential as a human being and may you achieve balance in your life.

For me, these commandments are the signposts along the road that I travel as I practice medicine, and they help me pave the way for future family physicians as I teach our students, residents and colleagues.

As you all know, the AAFP commissioned a study on the Future of Family Medicine. This study will help provide a roadmap for our specialty’s future. It is nearly complete and the recommendations for change are forthcoming. Now it is our turn to take these recommendations and move family practice to the next level. Einstein once said, “We can't solve problems by using the same kind of thinking we used when we created them.” I believe we can use this study to move our specialty forward and provide a good practice environment for us and for our patients. 

One of the study’s findings is that there is no one answer to the question “Who are we?” There are some commonalities among our practices, but we don’t have a defined line of business that is consistent across all practices so that when you go to a family physician you know what you are getting. Some family doctors only see people over 12 years of age. Others see mostly kids. Some practice in hospitals. Some do a lot of procedures. Some deliver babies. Some are geriatricians. It’s difficult to sell our services as a specialty when it varies as much as it does from practice to practice. 

However, there are some things that are common to all of us. In a study called "Direct Observation of Primary Care," conducted at Case Western in Cleveland, researchers found that family physicians care for a wide variety of medical problems in a patient-centered manner and within the context of the family. According to the study, we develop long-term relationships -- five years on average. We prioritize our patients' problems from among their broad agendas of competing opportunities to meet our patients’ needs. We coordinate our patients’ care, provide a lot of patient education, and we pass along messages of all kinds about healthy habits. We use illness visits as an opportunity to practice prevention and we often treat our patients’ emotional as well as their physical distress.  We use our time efficiently, teach medical students in our private practice offices and practice the fundamental attributes that have been the foundation of family practice: interpersonal communication, continuous care, coordinated care, and first-contact care. This is the basis of who we are as family physicians.

And the FoFM study found that this is what America wants. But will our patients, third party payers, or the government pay for it? Almost all of you are familiar with Barbara Starfield’s work, which showed that we by far have the highest expenditure of money per capita on health care in the world, but as far as health outcomes go, we rank approximately 37^th in the world. What are we getting for our health care dollars? The study showed that countries with the best-developed primary care systems get the most bang for their buck. 

So where do we go from here? First, we need to make patient care more consistent and safer. Who ever heard of patient safety 10 years ago, but today all of our patients think about it. If the airline industry allowed as much human error to occur as we do, there’d be multiple large jet crashes every day. One of my colleagues estimated it at about 22 full jets daily, and that’s in the United States alone. 

There are things we can do to change this. In this age of automation, we in medicine have done little to apply new technologies to how we practice. Imagine using an electronic medical record in your office to track every aspect of your patients’ care. If you prescribe a medicine that will interact with another medicine or is contraindicated because of a comorbid illness, a pop-up will alert you. As the physician, you can over-ride this, but you do it knowingly and can initial your acknowledgement.  

Your prescription gets electronically transmitted to the pharmacy and is ready when your patient gets there to pick it up. Talk about efficiency! The pharmacy gets the patient’s insurance information along with the prescription and all the patient has to do when they get to the pharmacy is pay the co-pay! Imagine this: As you document the visit, the payment information is automatically sent to the insurance company and payment is transmitted immediately. Talk about prompt pay!

We are committed to excellence in patient care. Nobody would quarrel with this. But how we get there, we haven’t quite figured out yet – and not just us, but all of medicine. When we allow avoidable errors to be made, with the availability of today’s technology, we are failing our patients – and thereby ourselves.

Second, the financing of medicine needs to make sense. Primary care must be paid as it is valued in this health care system. Currently, costly technology gets reimbursed at a much greater rate than cognitive skills. Taking a history, making a diagnosis and treating a patient without the use of high tech medicine is undervalued. We have two choices, change the relative value of this type of service or integrate more high tech services into family practice to subsidize these undervalued services. We need to look at new revenue streams for our practices.

One of our colleagues recently looked into purchasing a CT scanner for their family practice. When I’ve mentioned this to some of my other colleagues, their first reaction is, “Doesn’t that violate Stark rules?” On the surface it might, but when you really think about it, the CT scanner today is what a plain X-ray was 30 years ago. The legitimate indications for a CT scan are numerous and if you have a high enough volume of patients in your practice, you should be able to support its use full time. It is time to rethink primary care services.

Third, we need to better define our value to our patients. While I believe we think we know who we are and what we practice, the FoFM study found that our patients don’t know. How many of you have spoken to a person who asked you what kind of doctor are and when you said, “Family Physician,” they retorted, “Oh, a GP!” When we started this study, we thought the general public didn’t know who we were and we were right. More than one-third of patients who regularly see a family physician did not know their doctor was a family physician, conversely one third of patients who regularly see another type of physician, usually an internist thought they were seeing a family physician. The public doesn’t know who we are. It might be because when you’ve seen a family practice, you’ve seen one family practice. There’s no consistency. One of the upcoming debates will be whether we should better define what a family physician does and should we limit our diversity. I believe this will be one of the toughest questions that will come out of FoFM. 

Fourth, is the current face-to-face practice of medicine outdated? I believe it is. With the advent of the Internet, our patients are finding out about their medical problems in a completely different way. They all know how to do a Google search. Communication has many more possibilities than it used to: fax, e-mail, chat, instant messenger, cell phones, etc. How many of you communicate with some of your patients via e-mail? Maybe we don’t need to actually see every patient in the office as often as we used to. One big complaint of physicians is that we don’t have enough time with our patients when we do see them. If we could take care of the mundane, routine problems via other means of communication, then maybe we could free up time for longer visits with those who truly need it. But, we need to be reimbursed for those communications so that we can afford the longer face-to-face visits with the patients who need them.

In January, the Future of Family Medicine project will conclude and the project leadership will finalize their recommendations. During the first week of February, the TAFP will convene the Future of Family Medicine in Texas conference. This conference will be used to begin the process of turning FoFM into reality, to make the changes to our practices and educational programs that are sorely needed. We will develop a template for the rest of the country, for the future of our specialty, and for the future of the practice of medicine in general. This will be the beginning of how medicine moves ahead. I envision policy and practice changes that will become a part of our everyday lives. But what they are and the road we take to get there will be up to this group to decide upon. There is funding for approximately 70 of our state and national leaders. Invitations will go out shortly, but space will be limited to those who register first.

It’s time to redesign our specialty and the profession of medicine. Abraham Lincoln said, “You cannot escape the responsibility of tomorrow by evading it today.” Today is our time, today is our opportunity and it is our responsibility, not only to our colleagues, not only to our patients, but to future family physicians to make the practice environment one that provides high quality primary health care and supports family medicine. 

There are chances that we need to take to make family medicine a thriving specialty in the future. One of my colleagues, Karla Burkholtz recently said, “If you are not living on the edge, you’re taking up too much room.” Well, our specialty started on the edge and we are known for living here. We need to keep making family medicine what we all know is the best specialty in American medicine.