What Clinical and Social Needs Does the Public Need Family Medicine to Address?
4Cs of Primary Care Outcomes (plus a proposed 5th C)
There is substantial evidence that the four Cs-first contact care, continuity, comprehensiveness, coordination
of care are core functions of primary care and are critical for improving the health of populations and
addressing the quadruple aim. Training the 4Cs must thus be at the core of family medicine training.
- How should they be adapted for the 2020’s and beyond?
- What does first contact care and access to care mean in an age of increasing 24 x 7 video encounters
with strangers? - How should telehealth and urgent care fit into continuity?
- What should our approach be in training for comprehensiveness when multimorbidity and complex care drive
most morbidity and cost and obstetrical deserts are rapidly expanding? - What does care coordination mean when care managers without personal relationships with patients are
increasingly common?
In addition to the “4 Cs”, we believe that we need to include a 5th C—community engagement, to address unmet
social needs in our communities. Community has been a part of the family medicine movement since the 1960’s
Millis and Folsom reports.
- How do we train personal physicians to work in and with communities to address disparities and the
social drivers of health and to facilitate the lifestyle changes necessary to prevent and manage chronic
disease?
October 1, 2020
Jerry Jebaily, MD
Family Medicine fundamentals have been articulated and residency training stems from these elements. Why are
they being questioned now after fifty years? Somehow organization and education leaders have forgotten or never
embraced these core concepts or else this recurring “rediscovery” activity would not happen. Reiteration maybe
necessary. I reference only a few seminal documents these leaders should read or reread.
1. G Gayle Stephens. Intellectual Basis of Family Practice. AAFP Workshop, June 24, 1975.
2. Hiram B. Curry. Family Medicine/Family Practice: Why and How. Graduation address, Harvard Medical School,1980
3. Beasley, M.D. Ten Central Elements of Family Practice, Journal of Family Practice, 1983; Vol 16, No. 3: pp 551-555
4. Carmichael, Lynn. A Different Way of Doctoring, Family Medicine, 1985; Vol XVII No. 5: pp 185 – 187
5. John P. Guyman. The Family as the Object of Care. Journal of Family Practice, 1977; Vol 5 No. 4: pp 571 -575
6. John P. Guyman. Family Practice in Evolution: Progress, Problems, and Projections. N. Engl J Med, 1978,Vol 298, No. 11: pp 593 – 601.
October 1, 2020
Paul Lazar, MD
Our specialty has always been to some degree defined by others–we do what no one else feels like doing.Care of patients is becoming increasingly fractionated because of both insurance barriers and convenience. While continuity of care remains relevant for patients with chronic illness, it is little valued by relatively healthy patients.
In the urban world, we are finding very little demand for our OB skills in particular. I finally gave up OB at age 60, but had done very little in the five years before that. Now even my fellowship trained colleagues are getting very little practice. Although we have long provided same day access, urgent care has encroached to a great extent on this relatively easy and profitable work… because it is easy and profitable. So our same day access often consists of patients with complex medical and or mental health issues who require lots of time and provide little reimbursement relative to the effort. I don’t see ABFM/ACGME having much effect on this, unless a requirement is added for a substantial urgent care rotation so that graduates are prepared for a hybrid practice including some primary care and some urgent care. We have also experienced challenges in volume of care of children. Allowing acute visits in the urgent care setting to be an important part of the learning requirement would be helpful and relevant.
Rural/small town FM’s do more stuff because specialists don’t feel like living in rural areas and patients don’t feel like traveling (or in the case of labor, can’t make it there before the baby pops out) to where the specialist is. This is changing due to improved technology/broad acceptance of telemedicine, so rural FM’s will find more pressure to have a narrower scope over time. This can and should be ameliorated by changing the training of specialists, not FM’s, so that they are trained in providing truly collaborative care. Psychiatry is actively working on this. Perhaps other specialties can be brought along.
Finally, obviously the hospitalist problem is not going away. In fact, many of our graduates are going directly to hospitalist practice. One wonders if training should actually diverge at some point (this may also be true for IM) such that the third year is spent in hospital based rotations (including OB and Peds for people who started out in IM so they can attend to at least emergency care in those specialties) for those going into hospitalist practice and move to almost entirely office based practice for the ambulatorists in the bunch…..It’s a tough question.
October 4, 2020
Seneca Harberger, MD
As a “young” physician who was strongly attracted to family medicine for the breadth of training and responsibilities, I am particularly interested in discussions of comprehensive care. To me, 2 elements seem most salient in training for comprehensive care in family medicine:
1. The breadth of skills needed (and possible) for a particular family doctor is highly dependent on the community in which they practice. While residencies owe it to their trainees to anticipate needs they may face if they leave the community after graduation, they owe it to the communities they serve to collaborate explicitly to find the scope their population needs. This collaboration should occur on an organizational level, but residents must also be individually trained to develop this skill for their own future practice.
2. The breadth of truly comprehensive care is honestly too wide to effectively train for mastery within a 3-year program, which means that either training should expand to provide more time or the goals of training should focus more on residents’ empowerment to continue to learn and to expand in areas as needed by their patients. I favor the second path as the more practical and efficient approach since individual settings typically do not benefit from having a single doctor who can expertly provide all aspects of their care, but rather, they benefit from having a physician who can adjust into the specific variety of care most needed by their particular community. That means explicit training in the skills of community coordination and responsive, self-directed learning.
Addressing these two elements would entail increasing our focus and direction to provide training in community engagement and collaboration, increasing our explicit training in augmenting or developing new skills after graduation, and introducing more flexibility in our requirements for scope of care.
October 11, 2020
Dan McCarter, MD
In the Current Outcomes… Milestones brief—The first point talks about outcomes based GME. I have always told
patients, and learners that the only dumb questions are the ones that go un-asked. So, I would love if
someone
could explain to me what the definition of Outcome(s) in this context is/are?
Jim Collins in his book talks about the importance of a business understanding their denominator. I think we have all been whipsawed by the many denominators in medicine– whether it be the many different quality metrics. (I recently heard a faculty member in the southeast talking about the over 400 quality metrics they were responsible for.) In my mind, this over complicates things, when in fact the outcome we are looking for is how well we can give our patients more healthy days now and in the future.
I think it is worth having a discussion if FM education was knocked out of the park, what is the equivalent of more healthy days. Or in information mastery terms, how do we help the future family physicians have more fulfilling careers that allow them to help more people, without suffering burnout or undo economic harm to themselves or their family.
November 4, 2020
Kathleen Dunckel, MD
Under a discussion of the 4C’s of primary care, this question was posed: “What does care coordination mean when care managers without personal relationships with patients are increasingly common?”
I strongly disagree that our Care Managers do not have personal relationships with their patients. I am an employed family physician working in a rural FQHC in northern Michigan. We hired our first care managers under the Michigan Primary Care Transformation (MiPCT) Demonstration, and have continued to expand care management/care coordination services. Our RN Care Managers most definitely have personal relationships with their patients, and have been successful in decreasing ED visits, decreasing ambulatory-care sensitive inpatient admissions, and improving patient outcomes.
Please clarify what type of care managers are being referred to in this question.
November 9, 2020
Drew Keister, MD
In response to clinical and social needs FM needs to address. I agree with many of the suggestions contained herein, and yet I think that it fails to capture the largest issues at hand. Our society is growing into junk food and sedentary lifestyles. We are killing ourselves, and there is no end in sight. Family Physicians have little way to impact this patient by patient. We are spitting into the wind through that approach. We need to find larger solutions to encourage change in our communities. I do not have the answer of how to do it, but we need to make sure that our residents see this (and other large societal problems) as a necessary calling. The Family Physician can no longer be just the doc in the office. We need to be active and working in our communities to make the change the public needs.
January 14, 2021
Hannah Fields, MD, MSPH
It is interesting that practicing in multiple settings in addition to primary setting reduces burnout.
1. Have we looked at expansion of scope beyond the traditional hospital settings of OB and inpatient medicine? What about school-based health, community and public health, mental health and addiction treatment settings, palliative care, etc? By 2040 the huge need in these types of ambulatory settings will continue to grow. Family medicine has an important role in improving the well-being of individuals and communities, preventing infectious and chronic disease, and lowering healthcare costs; working toward these goals means shifting our (family medicine) focus away from hospitals and expensive high-acuity treatments. Hospitalists, medical and surgical sub-specialists are centered around sick-care and acute. Are interventions. If we in primary care do not pursue prevention and community health, then no one will.
2. In my experience, “additional practice settings” means additional hours…. if we really want to prevent burnout and address the quadruple aim, we need to advocate for an end to fee-for-service care and volume-based reimbursement. These methods of allocating and paying physician time only incentivize illness, poor quality care, eroded therapeutic relationships, and overwork that leads to burnout. If we are to be part of a necessary cultural shift away from medicine as a sick care business toward medicine as integral in the ongoing health and quality of life of individuals and communities, we should start by showing our trainees that activities which prevent visits are AT LEAST as valuable as seeing patient after patient in scheduled appointments; this means dividing professional schedules in stead of asking or even pressuring family MD’s to add on such practice activities outside of their work schedule.
January 18, 2021
Esgar Guarin, MD
It is time for the FM organizations to demand recognition of those who practice obstetrics. We are definitely better positioned to provide such a basic care for families. We do know the families, we do have a relationship with them; why is it that we have so much trouble to have and maintain hospital privileges, particularly when midwives are not under the same scrutiny?
February 5, 2021
Timothy LaHood, MD
I’ve been a family practitioner for over 27 years. The changes which have occurred to date have not supported family medicine. My ob/gyn peers have forced me out of privileges to deliver babies and daily i struggle to get my patients the tests and medicines they need. If the future of family medicine consists of increasing struggles than why continue to have family medicine residencies? Where will our support come from? I believe mentors involved in family medicine residencies have their hearts in the right spot but are unable to advance the future of family medicine. Please allow me to help fight for the future of family medicine or be honest and admit if politics of medicine have already abolished our future.