By Larry Kravitz, MD, and Lily Cormier
Such high hopes when it all began in 1970, with a new specialty that renamed itself and decided to take primary care seriously. Family medicine is now more than 50 years old, with 133,000 physicians in the United States. Where will it all be 50 years from now?
There is an old African proverb, “Until the lion learns to write, every story will glorify the hunter.” We see our medical past in terms of our victories, but we minimize our failures. So we do as well with the future; we expect to build on our successes, and don’t understand that our failures tag along and can poison the wellspring of our dreams. As long as we keep applying the template of our distorted past to our expectations of the future, we will never see it coming. The future threatens to run over us from behind as we’re squinting our gaze to a glorious distant horizon. The future is all around us right now, but it is clouded by the rose-colored lenses we insist on wearing. We don’t need a false prophet nor do we need a harbinger of doom, but there are two conflicting futures ahead and we need to embrace them both.
What have we seen in these last 50 years? The world has endured seven pandemics — HIV, SARS, MERS, Zika, COVID, swine flu, and Ebola. The last 50 years did begin with eradication of smallpox in 1978, and tremendous vaccine-associated suppression of measles, hemophilus B, hepatitis B, pertussis, polio, hepatitis A, meningococcus, and varicella. With mRNA vaccines and other work already underway, we will probably soon have the capacity to conquer Zika, Ebola, influenza, RSV, tuberculosis, COVID, herpes simplex, dengue, chikungunya, malaria, gonorrhea, syphilis, and HIV.
The first genetically modified organism was only designed as recently as 1971. Now we are at the dawn of victories over multitudes of congenital and acquired disorders with gene therapy — scourges like hemophilia and sickle cell disease. We have seen a revolution in diagnostics — CT scan, to MRI, to PET scanners. The future will miniaturize imaging with family physicians able to scan with a 3D handheld ultrasound on an unfolded tablet that will slip back into the pockets of their white coat (a white coat that no longer contains a Merck Handbook or Washington Manual or a stethoscope, replaced also by an augmented reality device engineered within our spectacles.) Treatment techniques have metamorphosized — sutures into stapes, scalpels into laparoscopes, retractors into robotics, psychiatric medications into magnetic brain stimulation, chemotherapy into immunotherapy. Heart disease and cancer death rates have plummeted.
But there are some ominous forebodings as well. In 2014, life expectancy in the United States began to decline. The advances of science fell to the malevolence of income inequality, racial disparities, climate catastrophes, a broken health care system, and a fracturing political system. The excitement of the Information Age overwhelmed the populace and created an Information Overload Age, which allowed the rise of the Disinformation Age. A significant portion of the public turned away from our collective scientific achievements, and we have seen mushrooming distrust of traditional and well-established medical advice. This rejection of validated mainstream science is becoming an anchor around the neck of our progress.
Thus, there are really two futures for family medicine. The future of bright science, and the threat of potential social and environmental deterioration. We need to prepare for both. We need to study and learn, to strive to keep up with the medical science of genetics, biostatistics, and molecular biology, and with the technology of POCUS, diagnostics, fiberoptics, and robotics.
However, there also dark warnings that our promising future will languish, within a country failing to afford its medical system, failing to keep up with evolving diseases, and failing to sustain the faith and perseverance that it can solve its own problems. The COVID pandemic has been a stark reminder of our lack of national focus and self-control. Few seriously think we are in a position to make what are reasonably obvious and achievable changes to move forward against the health threats ahead.
Let us be prepared for the future of family medicine. In 2020, in the Journal of the American Board of Family Medicine, ABFM embraced the following changes for residency training, and in doing so, they made an implicit prediction of our future. Given that the scope of family medicine is changing, “… what new curricula should all residencies require? Educators and policy makers have nominated integrated behavioral health, population health, genomics, and medication-assisted therapy [treatment of substance abuse]. Employers and other stakeholders identify the need for expertise in teamwork, implementation of augmented intelligence, and tools such as point of care ultrasound, geospatial mapping [health care trends by location], and predictive analytics [using big data to predict medical outcomes].”
But first, I would like to focus on population health in the most radical way. To move into the future, we will have to abandon our proud, but now progressively obsolete, past. In 1970, we needed the “family” in family medicine. Now, not really. The family has been redefined, not that it was ever more than a hopeful but faulty convention. We are now grappling with myriad variations of gender identity and sexual preference. Family units are far from stable, with 50% of marriages ending in divorce, and 25% of children in America living in single parent homes. Our specialty, which aimed to elevate general practice to a serious scholarly path, attached itself to a construct that was inherently flawed and distorted.
Now it is time to move away. Although we need not abandon our logo, our shingle as it were, we do need to find our way to newer frameworks, population health, community medicine, public health, primary care, and health care management. Otherwise, we will paint ourselves into an irrelevant corner of the health care system as real trends and medical realities create the future professional landscape.
And what of the other dark side of the future? Where does the family physician fit in the future of pandemics, climate disasters, war, governmental failure, and health system decline? We fit on the front lines. We answer the call of all the threatening changes. We can be the canaries in the coal mine and the sentinels at the gates. We can be the scouts and the foot soldiers of the medical trends of the future. But we need the courage to step up and understand that our cozy but overworked offices must be promptly adaptable to transform into crisis management centers for our practice families. Because the COVID pandemic and the opioid epidemic aren’t a one-time exercise; they are the first wave of the future of family medicine.
One true thing — no matter how well or poorly we prepare, there will be a tremendous need for family medicine in the future. As the great Dr. Barbara Starfield and her colleagues wrote back in 2005, the “… evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies.” Fortunately, whether we lead or lag behind medical trends, there will still be continuing demand for family medicine. Family medicine and internal medicine are among the most in-demand physician specialties, as confirmed by a 2019 Physician Employment report by Doximity. Rounding out the top five most in-demand physician specialties, according to the report, are emergency medicine, psychiatry, and obstetrics and gynecology.
However, there is serious risk that we may stumble going forward. The demand is for primary care, and not necessarily family practice. Family physicians are prepared to do the best at delivering primary care — that is my sincere opinion. But many specialties make up primary care, and specialists encroach on our territory — or should I say, poach our territory. We are woefully unprepared to turn out the necessary family practice workforce. Medical schools have failed to increase the flow of students matching into family medicine. And we are not even developing residencies to keep up with the small percentage of medical students that choose our specialty. If we had infinite residency slots, we could open the foreign medical graduate floodgates to fill our needs, just as the high-tech industry found extensive eager applicants from overseas to meet their exploding needs. And looking additionally down the pipeline, family medicine is the third lowest paid specialty. It averages the same number of hours a week as the highly rewarded specialties — 50 to 55 hours per week. It has the fifth highest burnout rate among specialties at 46%. We are not at all positioned to take charge of primary care in the future.
But others are waiting in the wings to pounce on new opportunities. In the worst-case scenario, niche solutions like stand-alone urgent care, independent telemedicine services, concierge care, cosmetic and lifestyle practices will all drain off resources for staffing core clinical practices that actually take care of sick people, straining the system and making it harder for the average person to get comprehensive and integrated care. And since there are not nearly enough primary care physicians being trained to meet the demand, primary care physicians will need extenders — advanced practice clinicians. That is a plausible solution, but advanced practice clinicians are often poorly trained and being turned out by the truckload with inadequate knowledge or skills.
We must also review the issue of family medicine versus primary care. Primary care specialties include family medicine, general internal medicine, general pediatrics, combined internal medicine and pediatrics (med/peds), and general obstetrics and gynecology. Besides the 133,000 family physicians in the U.S., there are 55,000 OB-GYNs, 90,000 pediatricians, and 1,500 geriatricians. There are 120,000 general internists, and there are 325,000 nurse practitioners in the U.S., 70% of whom work in primary care. According to the 2020 NCCPA statistical profile, 148,560 physician assistants are practicing across the U.S. The proportion of PAs in primary care has declined over the past two decades, from 51% in 1996 to 24% in 2015.
The question is whether this bigger pie of primary care can meet our upcoming medical care demands. Looking toward a time when we can embrace universal health care, the expected primary care workforce will be inadequate. Even without universal coverage, according to the most recent update from the Association of American Medical Colleges, the U.S. is expected to face a shortage of primary care physicians ranging from 21,400 to 55,200 by 2033. Please let us not circle the wagons around family medicine. Rather let us come together to make sure we create not only a primary care workforce big enough to handle that number, but also flexible and adaptable enough to jump into the next crisis where we are needed.
Talking about our future requires talking about our scope of practice. We are in an age of specialization, and like it or not, our scope of practice has diminished. Even in the specialties, the scope is fragmenting. Orthopedics is an example, with hand surgery, foot specialists, spine specialists, joint replacement specialists, orthopedic oncologists, and pediatric orthopedists. Look at all the family medicine scope that has melted away: obstetrics, neonatology, endoscopy, hospital surgery, and even hospital care. Not everyone wants to practice in a stark, underserved area where you might still handle all the broad fields that we used to encompass.
And even in these bastions of independent full scope practice, the concept is still wrong. The goal is to create access to state-of-the-art medical care through technological advancement, rather than just to glorify a medical desert as a holy grail of unlimited practice. We must capture new niches into our scope of practice. POCUS, Point of Care Ultrasound, is a perfect example of a new practice realm that expands our specialty scope. Management of health care delivery is within our new scope of practice. We need to reach beyond supervising a nurse practitioner within our office, and make sure we are also partnering to supervise home health care, “home tech,” remote monitoring, and telemedicine. As purveyors of prevention, we should be streamlining our pharmacologic proficiency in the precision medicine of pharmacogenetics. Thus, we will be able to ward off the ravages of late-stage disease with the foresight of genetic screening.
What then is our niche? One future role of the family physician is to provide a portal for patients lost in the disinformation wilderness back to the world of sound medical care. Family physicians will have a vital role in translational medicine, being a vital link in the chain between cutting edge research and generalized deployment of advances in medicine. No more will we be prey to the false trumpeters of pharmaceutical reps and direct-to-consumer advertising. As primary care providers, we should work hard to facilitate a new era of valid conduits between research breakthroughs and mainstream standard of care.
In my own world, the health care system in Austin, Texas successfully updated COVID pandemic care daily, linking together the state medical board, the county medical society, the state health department, and our internal emergency medical committees. We have mastered Zoom meetings, Tiger texting, and social media discussion groups to stay on top of the lightning-fast changes in treatment and public health.
In this new world of family medicine, we will need to spend more time on the CME of technology than the CME of medical facts. My generation of physicians was measured by our knowledge of medical facts. This current generation of physicians is measured by their facile skills at accessing medical facts. The next generation of family physicians will be measured by their ability to manage systems of artificial intelligence that integrate the medical facts that facilitate delivery of medical care.
Wherever we are going, I hope family medicine can embrace the bigger picture of population health. As AAFP EVP and CEO Shawn Martin wrote, let’s be aware “that family medicine stands clearly for developing a health care system that seeks the ideal of comprehensive health care for all people regardless of socioeconomic status. We intend to be leaders in population health, not just padding our own power and wealth in medicine.” AAFP recently joined more than 100 health care organizations in declaring climate change a public health emergency. In the last 10 years, climate change has been calculated to account for 5,000,000 deaths per year globally, about 10% of the yearly death rate. It is common knowledge that the cost of care in the United States is the highest in the world. This is coincident with accelerating income inequality, leading to larger and larger segments of our population disenfranchised from the health care system. Family medicine needs to speak up or move aside. Sometimes the only way to change population health is to step into the political arena. We need to be front line advocates for science and equitable health care delivery in the face of frustrating political stagnation.
To sum it up, there will be a huge need for family physicians for the foreseeable future. And there will be a huge need for family physicians to be leaders in medicine. There are new frontiers in our scope of practice if we reach for them rather than clinging to services that are no longer in our range. We need to be adaptable and keep our eyes open to the new issues of the day instead of clutching to a medical nostalgia of what we used to do. We need to embrace the new technologies that keep us up to date, open new pathways to stay relevant within translational changes, and work hard to be part of delivering true progress in population health. We are the right people to change the world for the better. We just need to stay attuned to that reality.