I remember when I chose family medicine as my specialty. My medical class had just experienced a tragedy: the sudden and accidental death of a beloved classmate. In the context of this bereavement, I was on an internal medicine rotation at the Veterans Affairs Hospital and was disappointed in how the care seemed transactional. Our patients came in seriously ill, our team adjusted them, sent them out, and they came back a month later, unable to stay outside the hospital structure. I wondered if anything in medicine could be fulfilling as a career. During this rotation, I spent a day at a local hospice, learning about end-of-life care with another classmate. That day we faced the collective grief of our class and I had a glimmer of insight to understand health in the context of mortality. The director of the hospice was a family physician who had a deep understanding of the beauty of a life well lived, from birth to death. At the end of the day, I felt like the philosophy of family medicine was the only way to practice as holistically as I wanted.
Dr. Timothy Hoff does a remarkable job of bringing together similar stories in his book Family doctor search, and places them in the context of the historical development of family medicine as a specialty, while highlighting the cognitive dissonance of practicing family medicine in a failing health system. He spends many chapters profiling medical students and physicians at different periods in their careers, painting a picture of the tension between mission-driven altruism and financial stability pragmatism. He relates this tension to why today’s family physicians struggle to embody the grand vision of well-trained physicians who render diagnostic and therapeutic measures at all ages, serve as primary decision makers for diseases at inside and outside the hospital and assume the role of community advocate and specialist liaison.
As an outsider in search of the specialty, Hoff offers his own insight in the final chapter: A Top Ten List to Save Family Physicians. He includes a number of fascinating thoughts and suggestions, some of which should probably be considered by the specialty. One suggestion is to consider renaming the specialty to reflect the full spectrum of care that family physicians are capable of — a brand change if you will. Hoff notes that he wasn’t sure where the name “family medicine” came from, so I took the opportunity to see if I could learn on my own.
By chance, I was directed to a quote from Dr. Dan Ransom, a behavioral psychiatrist and an early influencer of family medicine as a specialty. In his 1981 essay “The Rise of Family Medicine”, he wrote: “It is not the family as an entity or institution that is the central concern, but the ‘family’ as a metaphorical designation of systems primary humans, largely self-regulating. Thus, family medicine is interested in any group that makes a significant difference in the lives of its members. More important…is the “family spirit” among providers, as health problems are conceptualized, defined and treated in relation to their specific contexts. Thus, family medicine is concerned with the formal aspects as well as the concrete and personal aspects of human health and its relationships.
Compared to internal medicine residency programs, for example, family medicine is unique in its requirement to integrate behavioral health into clinical care, emphasizing the biopsychosocial model of health. This emphasis is matched only in pediatric training, where understanding a child’s health requires knowledge of family systems. Even so, family medicine is the only specialty where an understanding of both family and community is explicitly codified in the training requirements of the Accreditation Council for Higher Medical Education, beyond the standard model of base.
This understanding of family medicine became evident to me in the third year of my residency program. My preceptor for the day, Dr. Mary Jo Fink, ran the Friday colposcopy clinic. Colposcopy is how cervical biopsies are obtained after an abnormal Pap smear. One Friday we had a young patient, Linda, in her late twenties, who was distraught throughout the procedure. No amount of comforting or setting expectations could console her.
After the visit, Dr. Fink and I wondered about Linda’s emotional reaction to this procedure. We later realized that about 15 years prior, Dr. Fink had diagnosed Linda’s mother with cervical cancer, from which her mother eventually died.
A week later, we saw Linda again to discuss her biopsy results, which were normal. Dr. Fink was able to connect with Linda about her family history, insight that Linda would not otherwise have shared.
In this case, knowing the direct family member was instrumental in identifying the root cause of Linda’s tension. Such long-term relationships are rarely the norm, where relationships with the primary care physician are interrupted based on employment status, changes in insurance, and changes in employer benefits. Reprioritizing relationships and longevity, and creating sustainable practices for physicians, are key to developing and improving the primary care infrastructure in the United States.
In today’s health care system, we also talk about family medicine as if it were synonymous with primary care. But family medicine isn’t just about whether cancer screening tests are met or HEDIS scores are measured. It’s about understanding the patient in the context of their community and family system and providing the care they need, whether it’s blood pressure management or a biopsy, and balancing this perspective in the context of the health care system.
Can this only be done if family physicians, as Hoff professes, treat families? According to Hoff, physicians trained in family medicine who choose to be hospitalists or emergency care physicians do so out of financial pragmatism. However, if one considers family systems as the basis of family medicine, “family” medicine can still be practiced without significant continuity. It is a philosophical approach that incorporates an understanding of a patient’s social structure to develop innovative solutions to their individual care.
Thus, family physicians are prepared not only to ensure that screenings are done, but also to address the behavioral aspect of addiction, stress, and other epigenetic factors that impact the expression of states. pathological. By understanding the “family” in family medicine, I better understand what I actually do, how I present myself to my patients, and perhaps even how to change the health care system.
Lalita Abhyankar, MD MHS is employed by Carbon Health. Shis is a District Director and Board Member of the California Academy of Family Physicians and a Board Member of the California Academy of Family Physicians Foundation.
By Timothy J. Hoff
Baltimore (MD): Johns Hopkins University Press, 2022
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