Personal Physicians? Larry A. Green, MD Professor and Epperson Zorn Chair for Innovation in Family Medicine and Primary Care Association of Departments of Family Medicine I want to thank ADFM and the conference planning committee for inviting me back to this year’s meeting. I hold department chairs in a special place in my heart, surrounded there by gratitude for what you do, and especially my own department chairman, Dr. Frank deGruy. You ladies and gentlemen are special people, power players in the structures of Academic Health Centers and health care delivery systems, facing hard choices concerning the use of the very substantial resources you manage and sometimes control. You do so while serving multiple masters and dealing with an unusual scale and pace of constant change in the medical-industrial complex that now dwarfs all other sectors of our society. The health care industry dominates the economy of the richest nation on the planet. You and your predecessors fought hard to be a legitimate part of this amazing complex, and academic departments of family medicine now dwell within it as it produces a dazzling array of knowledge, technology, and services provided by a giant and growing workforce. This unprecedented enterprise thrives on insatiable consumption of its products by a public expecting to be cured of their diseases and relieved of their suffering and investors expecting a return on investment. I know you yearn to lead your departments to help advance affordable healthcare that actually produces health and that you have important ideas about what that means. I lack confidence, however, that departments of family medicine have discerned and agreed on what if anything they MUST do to help create proper versions of health care—because they are indeed departments of family medicine, not departments of population health, primary care, adult medicine, ambulatory care, health care management, PCMH’s. My aim with this presentation is to stimulate chairpersons of academic departments of family medicine and their colleagues to think about whether or not in the coming years the people of the United States will have a doctor, and more specifically if there will be a place and a role for the personal physician in the health care organizations now evolving into the information age. If so, what is that place and role—and—most importantly, what might such a personal physician promise to do, to be, for her or his patients. I hope you will join together in a few minutes in conversation about this question, not dismissing it as rhetorical, narcissistic, or nostalgic. Rather, I hope you 1 ¡ ¡
will think carefully about this question so you can decide for your department whether or not it will contribute to producing the best personal physicians in human history or if instead, you will guide your department to steward your resources to contribute to preferable replacements for personal physicians, such as call centers, navigators, health coaches, spiritual advisors, interdisciplinary teams, interprofessional teams, pcmh’s, aco’s, avatars, robots and nanobots, machine counseling, google and amazon- health, and IBM’s Watson. Here we go. What is a personal physician? We know that many people have no idea, having never spotted one in the wild, including many residents and students, including family medicine residents. Some of you will recall the Future of Family Medicine finding more than a decade ago that a representative sample of the US population really wanted a physician they could go to with any problem who would stick with them—and also that they seemed to not exist anymore. In 1960 T. F. Fox published a characterization of the personal physician in the Lancet, used to guide the recent initiative known as Preparing the Personal Physician for Practice, P 4 . He wrote using masculine pronouns: The doctor we have in mind, then, is no longer a general practitioner and by no means always a family practitioner. His essential characteristic, surely, is that he is looking after people as people and not as problems. He is what our grandfathers called “my medical attendant” or “my personal physician”; and his function is to meet what is really the primary medical need. A person in difficulties wants in the first place the help of another person on whom he can rely as a friend—someone with knowledge of what is feasible but also with good judgment on what is desirable in the particular circumstances, and an understanding of what the circumstances are. The more complex medicine becomes, the stronger are the reasons why everyone should have a personal doctor who will take continuous responsibility for him, and, knowing how he lives, will keep things in proportion—protecting him, if need be, from the zealous specialist. The personal doctor is of no use unless he is good enough to justify his independent status. An irreplaceable attribute of personal physicians is the feeling of warm personal regard and concern of doctor for patient, the feeling that the doctor treats people, not illnesses, and wants to help his patients not because of the interesting medical problems they may present but because they are human beings in need of help. [Ref Fox TF. The personal doctor and his relation to the hospital. Lancet. 1960;2:743–760. There are other candidate definitions. For example: “A personal physician is a doctor in active medical practice who grants his patients direct access to him as their initial source of medical care.” This definition stands in contrast to an accompanying definition of a specialist, “A specialist is a physician who predetermines the kind of disease which his patients can have.” Yet another version is: “The personal physician is the first 2 ¡ ¡
contact physician who gives continuing care, who takes continuing responsibility and is readily available to his patients.” With these definitions in mind, for our purposes, there is no need to belabor all the variations to be found, nor to fret over the distractions produced by other concepts known as principle physician, primary physician, general practitioner, family physician, primary care physician, and the unfortunate acronym “PCP.” There is, however, a need to have some shared understanding amongst us as to the role that a personal physician might fulfill. Fortunately, thanks to extraordinary efforts by Dr. Robert Phillips et al and the considerations of the national organizations of family medicine involved in Family Medicine for America’s Health, we have a published role definition for family physicians that can be used for our purposes now because it states that “family physicians are personal doctors:” “Family physicians are personal doctors for people of all ages and health conditions. They are a reliable first contact for health concerns and directly address most health care needs. Through enduring partnerships, family physicians help patients prevent, understand, and manage illness, navigate the health system and set health goals. Family physicians and their staff adapt their care to the unique needs of their patients and communities. They use data to monitor and manage their patient population, and use best science to prioritize services most likely to benefit health. They are ideal leaders of health care systems and partners for public health.” [Ref: Phillips RL Jr, Brungardt S, Lesko SE, et al. The future role of the family physician in the United States: a rigorous exercise in definition. AnnFamMed 2014;12:250-5] These authors helped everyone understand this proposed role by contrasting it with what they called a foil role definition: “The role of the US family physician is to provide episodic outpatient care in 15-minute blocks with coincidental continuity and a reducing scope of care. The family physician surrenders care coordination to care management functions divorced from practices, and works in small, ill- defined teams whose members have little training and few in-depth relationships with the physician and patients. The family physician serves as the agent of a larger system whose role is to feed patients to subspecialty services and hospital beds. The family physician is not responsible for patient panel management, community health, or collaboration with public health.” With these definitions and role in mind, why bother to have a discussion among the chairs of academic departments of family medicine? As I pursue my work involving various re-design projects across and beyond our country, I am privileged to peer into things going on in health care, interact with students, residents, fellows and multiple 3 ¡ ¡
Recommend
More recommend
