Tuesday, May 29, 2012

FM, IM, peds & the state of primary care in the US

In general, most people don't understand what Family Medicine is, maybe because family docs tend not to share who they are and what they do as much as other specialists.  For example, have you seen the ads touting the importance of having a skin exam by a dermatologist?  Yet there has been no such widely recognized campaign by Family Medicine.

Yet family docs toil on, unaware that our failure to share the value of our specialty, and of primary care in general, is leaving a sizable gap in the conversation happening around health care reform in the U.S.  I am frequently asked by patients "what exactly is family medicine?" and "aren't you the same as an internist?"

So, the Singing Pen presents the lay person's guide to primary care specialties:
(For a general overview of medical training, see my previous post on that topic.)

Family Medicine: family doctors complete a three-year residency in Family Medicine. Family doctors see themselves as physicians for the whole person across the lifespan.  We take care of newborns, octogenarians, and everyone in between.  We receive comprehensive behavioral training which comes in handy, since so many of the diseases that we deal with are related, at least in some way, to lifestyle.  The vast majority of graduates from Family Medicine residency programs will go on to practice Family Medicine, though a few will go on to fellowships for more in-depth exposure in topics such as sports medicine, obstetrics, adolescent medicine, geriatrics, and faculty development.

Internal Medicine: internists complete a three-year residency in internal medicine. Internists care for patients age 18 and older.  Most internal medicine residency programs are quite hospital-intensive; residents spend most of their time in the hospital setting rotating through the Internal Medicine subspecialties along with doing general internal medicine.  Although internists used to make up a sizable percentage of the primary care providers in the U.S., those numbers are dramatically dropping as most (80% [1]) internal medicine residency grads choose fellowships to subspecialize in fields such as cardiology, GI, endocrinology, nephrology, etc.

Pediatrics: pediatricians complete a three-year residency in Pediatrics. Pediatricians typically provide care from birth to age 18, though there are some who will see patients in their early 20s.  Pediatrics residencies are varied regarding the amount of time spent in the hospital versus in the outpatient setting, but most lean more heavily toward the inpatient end of the spectrum.  Similarly to Internal Medicine, fewer Pediatrics residency grads are choosing to practice general pediatrics, choosing instead fellowships in many of the same categories as Internal Medicine (cardiology, GI, endocrine, nephro, etc).

We need all three of these specialties in the house of medicine.  I am grateful that training programs exist to accommodate those medical school grads interested in primary care, but only at one end of the lifespan.  And, despite my frequent exhortations about the importance of Family Medicine, we need those subspecialized folks, too.

The balance is just off.  The U.S. probably needs at least 40% of its doctors to be providing primary care (2); the current percentage is a little under 30% (3, 4).  Last year, though, only about 15% of medical school grads chose a primary care specialty (4), and we already know that most of the Internal Medicine folks, and quite a few of the Peds, will choose subspecialties and not practice primary care.

Where are all of these future primary care providers going to come from?  Well, unless the proportions of internists and pediatricians choosing primary care change dramatically in the next few years, most of them will come from Family Medicine.  We need more family doctors if we're going to get that percentage up to 40%.  So, how do we bolster medical student interest in Family Medicine?

Yes, payment reform is important.  Yes, the big high-faloutin' medical schools need to stop closing their Family Medicine departments and telling their students that primary care is "a waste of your talent."

But maybe, too, the dermatologists shouldn't be the only ones with fancy ads in women's magazines.  Maybe it's time for Family Medicine to speak loudly and persistently until we are heard.  We need to supply an image of Family Medicine and primary care to our nation that reflects all that we do and how we can help the nation's health.

Primary care providers, speak loudly and with pride.  Share with your patients, your families, your politicians - anyone who will listen! - why you chose primary care. Together, we can reverse the fallacies that primary care isn't for smart people and isn't rewarding.

Together, we can change the conversation about health care.

(1) http://www.nejm.org/doi/full/10.1056/NEJMp068155
(2) http://www.aafp.org/online/en/home/publications/news/news-now/resident-student-focus/20110205cogmereport.html
(3) http://www.ahrq.gov/research/pcwork1.htm
(4) http://www.washingtonpost.com/wp-dyn/content/article/2009/06/19/AR2009061903583.html.  Also great stats in this article about the income gap between primary care and the subspecialties...in case there was any doubt about why most medical school grads don't choose primary care.

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