By Robert Youens, M.D., M.M.M.
TAFP President, 2008-2009
Hello again. This quarter’s missive is intended to provoke thought about family physicians’ position in the health care landscape of the future. My original intent was going to be to discuss little vs. big in the ideal provision of health care, making an argument that personal attention from a personal physician in a small practice environment is superior to attention from a team in a large bureaucratic institution. I’ll probably always feel this way but instead have some ideas to share about what the future may hold for our specialty and profession.
Throughout my career I have embraced the business of medicine and my fundamental belief that if we go out of business, we can’t provide care. It is also true that to manage a medical practice and achieve this outcome, someone must be in charge. It is my contention that the physician should be this someone.
In a small practice environment this individual is generally one of the physicians in the group with some interest in or inclination toward business. Sometimes it’s the group of physicians and they or the individual managing partner supervise and delegate to an office manager. This somewhat elementary business arrangement has been successfully used literally thousands of times as a core business model for medicine.
It is apparent to me that as health care becomes more process driven (witness the National Committee for Quality Assurance certification of the medical home) and institutionally focused (note the current favorable status of Federally Qualified Health Centers and the increasing number of family physicians desiring to be employees), we are at risk of losing competence and control in the business arena of medicine. We continually discuss losing core competencies and privileges for an expanded clinical scope, but rarely do we discuss losing control of our business. Losing scope of practice battles, either through training deficiencies or constricted practice patterns or privileging losses at hospitals, runs the risk of us losing significant control of the clinical aspects of patient care. I would argue that losing control of the business of medicine might be equally damaging to our specialty.
Some years ago, I obtained a Master of Medical Management from the Marshall School of Business at the University of Southern California. At the time I was the managing partner for a group of six primary care physicians and felt that this additional education would allow me to feel confident that I was doing the right thing from a business perspective for our practice. It did give me the confidence to help sustain an ongoing practice that is now in its 62nd year. Where I’m heading with this is the question of who will manage health care in the future. Will it be the business majors, the nurses who’ve moved to administration, the hospital administration folks, or will it be physicians? Believe me, most of these folks are way ahead of us in this game and they have the power to control your future. I don’t want us to be in the group that says, “I can’t believe that they are doing that to us.” I want us to be “they.”
My education included courses in finance and marketing, health law and ethics, health policy and health funding mechanisms, etc. As a clinical professor of family medicine at the University of Texas Medical Branch, I’ve tried to bring some management training to our residents. This has met with limited success, I think primarily because of the apparent lack of relevance of the topic for second- and third-year residents.
At the risk of sounding heretical, I’ve taken some favorable note of the curriculum of the Duke family medicine residency. This is the residency that crashed and burned a few years ago in an academic center and has been reborn with a management focus. Trust me, there’s lots about the Duke program that concerns me, but probably more so from an inherent negative reaction to trading clinical competency for administrative competency than from a clear view of exactly why it’s so bad.
So what’s in the curriculum? In the residency itself there are courses in change management and health care finance, medical informatics and operational management, quality measurement and management, and strategy implementation in health care. And in the optional fourth-year master’s program, there is clinical teaching and patient care as well as courses in population-based approaches to health care; introduction to health care policy; management of self; managing complex health care systems; health care operation; human resources; quality, law and ethics; and clinical leadership seminars.
My point is not necessarily that all physicians need all of this coursework, but I will maintain that if we are not positioned to manage the next iteration of health care, others will be, and we will continue to lose control, not only in the clinical arena but also in the management arena as well. Those individuals who manage health care will control your future and the future of our specialty. Please, let’s have those individuals be us.