Family Practice is Dying (and it's not their fault)

This is going to be controversial. I don't want to hurt anybody's feelings, but I do think that this is an issue that should be discussed.

Ok. Time for everybody to face reality. Family medicine as a "specialty" is dying. It's nobody's fault, but it's time to close the residencies and to redirect the medical students into other fields.

I didn't always think this way. I trained with some really amazing family practice docs because my ob/gyn residency also offered a family practice 1 year "c/s fellowship" so that family medicine docs could get cesarean section privileges.

However, what I've seen in the last almost 1 year as an attending at a hospital with a large number of fp docs with both ob and c/s privileges has changed my mind about the entire existence of family practice. Most of these docs, when they practice ob/gyn, don't really know what they're doing. They don't understand that a peripartum cardiomyopathy is a dilated cardiomyopathy. If a patient who had a baby 3 months ago has impaired diastolic relaxation, hypertension, and a low EF, that's not a peripartum cardiomyopathy. That's diastolic heart failure. That's a beta blocker deficiency in many cases. It's related to the patient's underlying severe chronic hypertension, not to their pregnancy.

They think it's appropriate for family practice docs to do complicated cesarean sections. Fourth and fifth repeats. Previas. They fail to refer moms with hemodynamically significant cardiac lesions to perinatology. They fail to offer 17 hydroxyprogesterone, or to send patients for a consultation to evaluate if they're candidates, when these patients have had very preterm deliveries.

There are a few docs who understand obstetrics enough to stay within their scope of care, but most of the family docs at our hospital go far beyond a reasonable family practice scope of care in ob/gyn (which should be limited to normal pregnancies). The problem is, their training in ob is just a few months (ok, maybe 6 months total if they complete the c/s fellowship which includes a lot of other stuff, it's marketed as a rural medicine fellowship). With that little training, they can't hope to have an appreciation for everything that can go wrong. I had over 1000 c/s under my belt before I graduated from residency. I did almost 2000 vaginal deliveries, 200 operative vaginal deliveries (prob about 100 forceps/100 vacuums). For a doc to think that they can do what a general ob gyn can do with about 10-20% as much operative experience is ludicrous. The answer then, would be for family docs who want to do ob/gyn to confine themselves to completely normal obstetrics, and arrange for an ob/gyn backup. The other problem is that there's no good compensation model for this, unless a procedure is required. Even then, in obstetrics, it's usually all about the global fee. So in some cases, the family practice docs risk loosing payment for the entire pregnancy if the patient is delivered by someone else. These global fees can get unbundled, but the person who provided the prenatal care invariably gets the short end of the stick when the fees get unbundled. Not only that, but malpractice costs can often provide a perverse incentive for FPs to practice outside of their scope of practice.

Once a doc's attentions are diverted to their entire practice and they're taking care of men, women, children, pregnant women, etc, maintaining competence within their scope of practice also dictates that they practice a very limited scope of practice. Physician training is so expensive that it may not make economic sense to train a bunch of docs who will then go on to have limited scopes of practice in several different fields. And while a lot of patients don't have complex medical needs (although many do), when you only have very shallow training in multiple fields, how do you know when a pregnant woman is sick? How do you know when a child is sick? It's experience that really allows people to see where the line between ok and not ok is and where you can really intervene and make a difference.

If people really wanted to have a limited practice and do well child checks and sore throats and uncomplicated hypertension and diabetes, that would likely be reaosnable but economically unsustainable. In any case, what I see are family practice residents who want to do procedures. They spend 6 weeks in Dillingham, Alaska doing colonoscopies. They ask if they can come do amniocenteses with me. They want to do my versions and operative deliveries with me. And I have to say "no", because these are procedures family practice docs should not be doing. The risk of complications with amniocentesis is higher with people who are less experienced. Version success rates are higher with more experience. And seriously? No family practice doc will be doing my next colonoscopy. Those are rightly in the hands of gastroenterologists who will be doing the treatment for abnormal findings. I suspect it is a search for higher reimbursement that drives these trainees to attempt to gain competence in procedures outside a reasonable scope of practice.

Now if we lived in a society that valued maintaining wellness as much as treating disease, well, it might be a different story. But even with respect to wellness, I don't think that the family practice docs would be any more effective at helping me loose my prednisone pudge (the almost 90 lbs I gained after 3 years on prednisone). I would be willing to guess that their scores with other types of wellness management would be similar to other primary care types (like internists and pediatricians). I do think that you do need to be able to spend real time with people in order to help them learn how to take care of themselves. Lecturing people about self control for 3 minutes is not helpful. Helping them learn what they can do to positively impact their health is helpful, but it also takes time that nobody in the US (including the patients themselves in many cases) are willing to pay for.

The advantage of the nature of training of family practice docs is that they have (if only brief) exposure to a wide variety of medical circumstances, which means that they may be even better than other primary care types (like internists) at quarterbacking the care of patients with lifelong chronic ilnesses, especially as they negotiate the transition into adulthood. However, this may not require visits, but it requires time in the office and phone calls (neither of which are things that our society cares to compensate doctors for because, you know, can't anybody make a phone call? *sarcasm intentional*).

So, the two natural niches of family practitioners, wellness and quarterbacking the care of patients with multiple medical problems, are not valued by our society at least in any monetary way.

But, attempting to extend their scope of care into procedures that are outside of a reasonable scope of practice for a fp doc will not fix this problem. I learned how to do appies in residency, just like anybody who operates in the pelvis does. However, if I get into trouble with an appendectomy or if I were to start an appendectomy and run into a different surgical problem in the abdomen, well, I just don't have the training for that. So I don't do appies. I leave them to the general surgeons. Doing c/s, colonoscopies, etc in an urban setting is simply deviating from the heart of what family practice is supposed to be. And the problem with doing them in a rural setting is that well, very few of the fp docs I know want to move to a rural setting (although those that do practice in a rural community without easy access to a tertiary care hospital seem to be exceptionally sharp), becuase well, no cable, no DVR, no ballet, no museums, no REI stores, etc.

For the record, a lot of the "scope of practice" stuff wouldn't apply to a rural area. If a patient needs a c/s and the local family doc is the only doc in.. .say... Coldfoot, Alaska I would want that doc to be able to do something. But in an odd coincidence, none of the "rural medicine" fellows are actually headed out to rural medicine. If they were actually going to go do rural medicine, I would have no problem with a more extended scope of practice, because even if they haven't had enough experience to be super skilled, they may still be the best option for many situations.

However, that's not the type of practice most family practice docs are training for. Most family practice residents are training for a practice model that doesn't actually exist in any compensated way.