Storylines of family medicine XII: family medicine and the healthcare system

Introduction

The history of family medicine has been a challenging one. The present circumstances of the discipline are not significantly different. There are many forces, cultural, institutional and economic, among others, that work against what family medicine offers: a wide and robust range of generalist services by well-trained clinicians committed to comprehensiveness, continuity, coordination and access to care—all expressed through the therapeutic power of the doctor-patient relationship. It will take new generations of family physicians to fully achieve the founding goal of family medicine: quality healthcare for all. No one discipline can realise that goal—it is imperative that we work together across the chasm between generalist and specialty care. Such collaboration is possible. We wish those who pursue this ambitious objective good luck, and may the lessons from these concluding essays help guide your way.

Leadership in family medicine

Jeannette South-Paul

Leadership is an intentional objective that family physicians can learn, develop and prioritise. Focused, informed and compassionate leadership is essential to providing optimal care for patients and nurturing healthcare teams.

Leadership is not something we usually think about early in our careers. We typically attribute it to someone older or more seasoned than ourselves. Yet those who enter the military, government, academics or community service recognise early on that leadership is expected by virtue of the choices they made and the skills they possess. Leadership does not require possession of a title but is associated with a commitment to the well-being of others, today and in the future.

The star performer model of leadership connects leaders to teams.1 It assumes that leaders possess appropriate cognitive abilities and technical competencies; it suggests that strong leaders must also take the initiative to move others forward. It also promotes ‘followership’ as an essential leadership quality (figure 1).

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Followership results from leaders who are able to listen and provide guidance simultaneously. Effective leaders encourage engagement among their followers by promoting such attributes as independent critical thinking, intelligent data interpretation and appropriate risk-taking. Such leaders act as a team’s courageous conscience by thoughtfully challenging the status quo, giving space and encouragement for team members to discuss and develop innovative solutions to vexing problems. In other words, energetic followership occurs in a culture of focused, informed and compassionate leadership.

Certain leadership flaws are best avoided. Examples include leaders who are overly ambitious, insensitive to the needs of others, lack integrity, fail to accept responsibility, discount the perspectives of others and disrespect those the team or organisation serves.

Most concerning is the flaw of inaction—the deals that never happened, the projects that failed to exist or the systemic weaknesses that were never identified. Such inaction can result from focusing on easily measurable outcomes while failing to recognise major issues that do not appear on traditional quality control dashboards.

The path to achieving quality performance as physician leaders begins by putting patients first.2 Every metric by which we are measured must begin with the patients, including time to closure of the electronic record, length of stay and efficiency of medication reconciliation. We must recognise pressures on performance that disadvantage patients, such as coding diagnoses for greater reimbursement (while likely increasing costs for individual patients). We should align referral patterns accordingly, identify system problems early and, once identified, resist waiting for someone else to address them. Stay focused on what is important. Realise you are part of the solution.

Life and leadership are a series of challenges and opportunities. Many of these challenges are battles that are part of a larger war. Run into the battle, not away. Focus on caring for the people for whom you are responsible—your patients, your colleagues and yourselves.

As the former US Secretary of Defence James Mattis once stated, ‘The most important six inches on the battlefield is between your ears.’3 General Mattis also noted the following: ‘In this age, I don’t care how tactically or operationally brilliant you are; if you cannot create harmony … based on trust across service lines, across coalition and national lines, and across civilian/military lines, you need to go home, because your leadership is obsolete.’3 Look to the future, and look to the future of family medicine.

Becoming an academic family physician

Kendall Campbell

Entering academic family medicine means nurturing the seeds of care, discovery and teaching that lie within us.

When I think back to my desire to go to medical school, I think back to my idea of a ‘family reunion doctor’. Entire families gather at family reunions—parents, siblings, grandparents, aunts, uncles, cousins, babies and even pets. Folks drive hundreds of miles to spend a few memorable hours together, all gathered by bonds of shared fellowship.

I remember my family’s reunions: every Christmas, my family got together at my grandmother’s home. We listened as my relatives told stories about growing up on the farm, replete with anecdotes about my grandfather’s mule; we recalled gathering eggs from chickens and planting and harvesting crops. We ate pies that my aunts had made and drew names for gift exchanges.

Though I did not know it at the time, during these reunions, I was already on my way to becoming a family physician. I wanted to know something about everything so that someday I could help each person in my family.

That is the real story of family medicine: to be generalist doctors who listen, who hear and who help; doctors who work beyond the confines of any one anatomical or physiological system to address whole people, holistically; doctors who work to make communities healthier; and doctors who are altruistic, compassionate and caring to all.

What about the family physicians who become medical educators?

For many, academic family medicine is the best profession there is. There is the comprehensiveness and longitudinal nature of family medicine, linked with the discovery, innovation, teaching and administrative work of academia. It is a mix of different roles on different days, with an abundance of challenges and opportunities to keep any family physician busy (figure 2).

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Academic family physicians provide clinical care; they explore through research and scholarship; they teach by precept and example. It is satisfying to witness the excitement junior faculty members feel when their studies get underway or, even better, when the results of their studies are accepted as peer-reviewed manuscripts. It is rewarding to watch students’ light bulbs of understanding become illuminated at hospital bedsides or in clinic exam rooms. It is fulfilling to advocate for the specialty and for our patients.

I come from a long line of teachers. My great-grandfather, an educator, founded a high school that still bears his name today. My mother and most of my aunts were teachers, and education was encouraged, supported and valued in my family. I believe we all can nurture the skill of teaching within ourselves to inspire the lives of others—our students—through discovery, learning, belonging, care and community presence.

From serving across many domains of medical education to being a researcher, scholar and advocate for patients and family medicine, becoming a family physician educator has been a great journey for me. Best of all, however, I get to do this all while being a family physician, fuelled by the desire to contribute to a healthier world for all to enjoy.

Advocare—our call to act

Aerial Petty and Hima Ekanadham

When we advocate for our patients as family medicine physicians, we answer a call—a call to care, a call to stand up against social injustice, a call to responsibly use physician privilege to speak for those who have not been heard.

When I applied for residency, there was a section on my application form to include hobbies and interests. I listed a few things I love: exploring bakeries, event planning and calligraphy. I added linguistics and etymology, the study of the origin of words and the way in which their meanings have changed throughout history. My interest in medicine came from my love for people and the human connection. For me, language is a key part of that connection.

Now as a family medicine resident, I often think of medicine in terms of its linguistics and etymology. Family medicine has an interesting background. The word family comes from the Latin word familia, which means ‘household’. When combined with the Latin word medicus for ‘medicine’, family medicine translates to ‘medicine of the household’. I plan to pursue a career based on health policy and advocacy, and I often think about the origin of this last word as well: advocacy (figure 3).

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From the Latin word advocare, advocacy is quite literally ‘a call to one’s aid’. Advocacy is intrinsic to family medicine, and when I think about it this way, it adds depth and richness to the field and its potential healing impact.

Unfortunately, advocacy within our current society and healthcare system is no easy task and, often, a gruelling one. My residency advisor, Dr Ekanadham, nearly quit medicine in her third year of medical school, frustrated by how a profession filled with knowledge about the intricacies of the human body could be so complacent and powerless against social ills leading to health inequities; however, during her last rotation of the year, in family medicine, she saw a glimmer of hope—this unique specialty not only prided itself on evidence-based medicine but also in its dedication to understanding how social determinants of health influence patients and communities.

Later, in residency, Dr Ekanadham read A J Cronin’s 1937 novel The Citadel. The book captures much of what we struggle with today. Cronin himself once commented, ‘I have written in The Citadel all I feel about the medical profession, its injustices, its hide-bound unscientific stubbornness, its humbug…. The horrors and inequities detailed in the story I have personally witnessed. This is not an attack against individuals, but against a system.’4

Today, we see similar signs of distress. We learn there are patients whose complex needs are often overwhelming, facing as they do the many challenges of present-day existence: medication affordability, housing and food insecurity, and reproductive health access, to name a few.

As family physicians, however, we can choose to advocate for our patients. While we rarely have an abundance of time, our multilevel access—to patients in clinics and hospitals and to the communities in which they live—puts us in an influential position to stand up against social injustices that our patients currently endure.

‘Family’, ‘medicine’ and ‘advocate’, all wonderful words. Still, let us add one more: ‘grit’. When we advocate as family physicians, we reach past our knowledge and into our compassion and our drive—we show our grit as we strive for a more accessible, high-quality healthcare system for all.

The paradox of primary care and three simple rules

Kurt Stange, Becca Etz, Will Miller and Bob Ferrer

The paradox of primary care is that healthcare systems based on primary care have healthier populations, fewer health inequities, lower healthcare expenditures and better quality of care, despite apparently less evidence-based care for individual diseases.5

Apparently, something more happens when family physicians and other primary care clinicians focus on the whole person and the relationship, in addition to providing commodities of disease care.6 That something is the complex craft of generalist practice.7

Sometimes, complex behaviour can be explained by simple rules.8 For example, when clinicians act as specialists, they:

1. Identify and classify diseases for management.

2. Interpret through specialised knowledge.

3. Generate and implement management plans.

When clinicians act as generalists9—more specifically, as family physicians—they consider the individual or individuals in front of them and their larger context (including how family, community and other determinants influence health outcomes). They:

1. Recognise a broad range of problems, opportunities and capacities.

2. Prioritise attention and action with the intent of promoting health, healing and connection.

3. Personalise care based on the particulars of the individual or family in their local context.

These rules allow generalists to attend to what matters most for each patient at any given time in any given situation (figure 4).

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• Recognising requires foraging for salient information based on a comprehensive generalist perspective10—watching for teachable moments, undifferentiated illness clues, potential risks and opportunities for fostering clinical improvement.9

• Prioritising begins with the broad, inclusive generalist perspective and then sorts, ranks and negotiates what is most important; generalists can use this information to determine what action has the greatest potential to advance health, healing and connection.9 11

• Personalising care moves from the statistical generalities of evidence-based medicine to the particulars of this person or family in this moment, place and context.9

These three simple rules of a generalist operate iteratively in a cyclical process of repetition and reevaluation. New information reframes problems and opportunities. What is most important evolves. New hypotheses emerge. These rules emphasise the intent to promote health, healing and connection—sometimes just one but, when possible, all three.

The cumulative effect of actualising these rules is an investment in a relationship bank that generalist physicians and their patients can both draw on, with interest, when challenging events threaten the health of individuals, families and communities.

The paradox of primary care is not a paradox if we understand that generalist practice—comprehensive, relationship-centred care attending to the needs of whole people over time—can be combined with the selective use of more narrow expertise, as needed.5 This results in an overall care of patients that is prioritised, personalised and integrated.11 This approach not only fosters healthy individuals, families and communities but also results in a more fair, effective and sustainable healthcare system.6 7

The quadruple aim—melding the patient and the healthcare system

Marianna Kong and Tom Bodenheimer

The quadruple aim embraces four interrelated facets of ideal, high-functioning healthcare systems. It provides a roadmap for redesigning these systems to best meet the needs of patients, healthcare personnel, communities and populations.

Patients influence how we—individually and collectively—make sense of our work. Take this example.

We will never forget caring for our mutual patient Rodolfo Alvarez, a cheerful 56-year-old immigrant from Guatemala with coronary heart disease. Living in a food desert and experiencing the stress of violence in his neighbourhood, his diabetes and hypertension were difficult to control, and his episodes of angina became more frequent. Our plan was to send him to a cardiologist for clinically appropriate medication management. Unfortunately, the only cardiologist who accepted Medicaid convinced Mr Alvarez that he needed coronary artery bypass surgery. Mr Alvarez died on the operating table. His family was devastated. We felt terrible that we failed to take charge of his care.

On the surface, Mr Alvarez’s outcome may seem to be the result of a single decision; however, examining the case of Mr Alvarez from a systems perspective exemplifies the quadruple aim (figure 5).12

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The bedrock of the quadruple aim is population health. Indeed, Mr Alvarez’s social environment contributed to his illness. Upstream interventions addressing food insecurity or community violence would have improved not only Mr Alvarez’s health but that of his entire community by preventing or limiting complications of chronic disease.

According to Mr Alvarez’s family, he was highly dissatisfied with his visits to the cardiologist. Patient experience highlights the ways our health institutions succeed or fail at meeting patients’ needs. For example, is there prompt access to care or months-long waits for appointments? Does the care team really know the patient and family? Is the patient treated with respect, taking into account language and cultural preferences? We should centre patients as the experts of their own lives, partnering with them to improve their health. Prioritising the patient experience may have changed Mr Alvarez’s outcome.

Compared with other nations, our healthcare system is high cost and low quality. We reward expensive interventional care over prevention. Mr Alvarez’s unnecessary surgery was incentivised by a medical system that reimburses physicians, clinics and hospitals more per work hour for high-risk surgery than for safe, comprehensive primary care. If we invest in preventative care, address social determinants of health and support primary care services before resorting to high-cost subspecialised interventions, we could reduce costs and achieve better outcomes.

Lastly, joy in work for those providing healthcare is essential to keeping the above aims sustainable. We attempted to care for Mr Alvarez’s complex illness in the midst of harried days with too many too-short visits. It was not possible to spend the time and mental energy needed to thoughtfully approach his management. Stress and burnout of healthcare professionals lead to poorer outcomes and unsatisfying patient experiences, even more so when burnout forces members of the healthcare team out of the field entirely.

The example of Mr Alvarez reveals the four components of the quadruple aim and how they interact with one another. The quadruple aim is not an esoteric policy formulation. It is manifest in countless patient-clinician interactions that are shaped by the larger systems around them. Creating a high-functioning healthcare system requires us to achieve the quadruple aim.

Fit-for-purpose medical workforce

Roger Strasser

High-quality healthcare that meets the health needs of the population requires physicians with the right skills providing the right care, in the right place, at the right time.

Society grants physicians privileges in return for ensuring the health of society.13 This arrangement is nothing new. Long ago, early groups of hunter-gatherers differentiated certain individuals as ‘medicine men’—each group provided their ‘medicine man’ with food and protection in return for aid in restoring the sick to health and full functioning.14

Today, society places expectations on physicians not only in terms of personal and professional behaviour but also in terms of protecting the health of the public.15 This expectation is sometimes referred to as the social contract of physicians, and in the 21st century, it translates into social accountability of health services.16

At the local level, people expect high-quality healthcare close to home. Health systems in countries with comprehensive primary healthcare (PHC) are the most efficient and effective in terms of lower overall costs and generally healthier populations. At the national level, countries with higher availability of primary care physicians relative to the availability of specialists have healthier populations. Additionally, the greater the availability of primary care physicians, the fewer the adverse effects of social inequality. At both the national and international levels, healthcare systems with robust primary care services (in contrast to those that emphasise specialty services) are associated with a more equitable distribution of population health outcomes.6

Local comprehensive PHC—meaning geographically and socially accessible healthcare that meets the needs of a community—helps people live healthy, fulfilling and productive lives. PHC combines public health’s focus on education, health promotion and illness prevention with robust clinical services that attend to essential health-related concerns of local populations.

These clinical services encompass the treatment of acute illnesses and injuries, chronic conditions and mental health issues, all facilitated by ongoing relationships between generalist practitioners, other healthcare professionals, patients and the broader community. Communities with thriving PHC systems rely on generalist clinicians with a broad range of knowledge and clinical skills who work together in cohesive teams and develop long-term, engaged relationships in their community.

Clearly, generalists do not work in isolation—no modern healthcare practitioner does. Successful PHC systems rely on respectful, collaborative relationships and organisational support from specialist physicians and regional hospitals, ensuring that patients have access to specialist expertise and services when needed.17 They also collaborate with community health workers and other community-based educators and behavioural health consultants to extend the provision of services.

Consequently, a fit-for-purpose medical workforce involves clinicians with the right skills, providing care in the right place and at the right time. A fit-for-purpose medical workforce means having the right mix of generalists and specialists, the right combination of specialists within each subspecialty discipline and the right distribution of clinicians across all disciplines, geographic regions and levels within the healthcare system (figure 6).18

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Family physicians provide robust, high-quality frontline healthcare close to home, in communities everywhere. They are fit-for-purpose as the generalist cornerstone for local, comprehensive PHC. They are ready to fulfil modern medicine’s social contract for all in society.

Universal healthcare—coverage for all

Sharon Reece and Josh Freeman

Is healthcare a right or a commodity? Every country must address this fundamental question about its healthcare system.

Every high-income country, with one notable exception, provides government-funded healthcare as a right that accompanies citizenship or permanent residency. That exception? The USA.19

The benefits of treating healthcare as a right for all should be obvious. From the first point of contact with primary care clinicians through services such as surgery, cancer treatment and end-of-life care, healthcare costs are often the main obstacle people face when seeking medical care. Although some describe government-funded healthcare systems as ‘free healthcare’, taxpayers do in fact pay for healthcare. In such systems, costs are shared by everyone rather than borne by each individual.20

Some have argued that the US approach to treating healthcare as a commodity enhances competition and leads to scientific discovery; however, the evidence for this is minimal. Reimbursement for healthcare in the USA comes from patients who can pay, mostly through insurance plans. Without such plans, those in need of medical services face major barriers to healthcare access.

The ostensible assumption of the US system is that patients are fully informed consumers and can accurately determine the financial value of the healthcare services they receive; however, shopping for the best value is near impossible given constraints such as organisational complexity and the absence of posted prices, all while facing the challenges of being sick. As a result, healthcare spending in the USA is the highest in the world while providing comparatively poor health outcomes. In terms of population-based measures of health, the US return on investment is decidedly less than all other similar high-income countries (figure 7).21

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It is true that the USA has implemented improvements in health coverage through the 1965 establishment of Medicare and Medicaid and the 2010 enactment of the Affordable Care Act, which expanded Medicaid to provide healthcare coverage for many working people without employer-sponsored insurance.

Medicare is a federal programme that covers all citizens 65 years old and older plus certain younger people with disabilities. Medicaid, funded by both federal and state governments, insures some people with low incomes—who is eligible for Medicaid and the degree of coverage vary from state to state. The Affordable Care Act expanded healthcare coverage for many working people without employer-sponsored insurance.22 Other specific groups, including veterans, Native Americans living on reservations and incarcerated persons also have government health coverage.22 Nonetheless, these programmes remain far from the type of universal health coverage offered in other countries.

The USA remains the only wealthy country that does not guarantee financial access to healthcare for all its people. Tens of millions are uninsured, and at least as many have woefully inadequate coverage. Many political, economic, cultural, geographic and medical barriers to universal healthcare exist in the USA, and the current programmes are constantly at risk of retrenchment.

Discussions about healthcare funding are particularly relevant to family physicians, for they not only often act as patients’ first contacts with the healthcare system but also manage patients’ ongoing care. Given that family medicine emerged as a socially responsible way to provide comprehensive and cost-effective care, it is important that family physicians support universal healthcare coverage for all.

The futures of family medicine

Jack Westfall

‘It is a full and happy life. It may, of course, be a mere repetition of irksome tasks, but this is probably the fault of the practitioner who like Bunyan’s man with the muck rake, rakes to himself the straws and sticks and dust of the floor and can look no way but downward regardless of the crown which is being held over his head.’23—Will Pickles, British general practitioner

Family medicine has always existed. That is, the nature of family medicine—family medicine-ness—has always existed, well before the discipline was established as a board-certified specialty.24 Family medicine-ness signifies the sacred relationships healers have with those they heal; physicians develop these sacred relationships with the patients in their practices and with the people in their communities.

Examples of what we now call family physicians are scattered throughout history and prehistory: individuals who took on mantles of confidant, expert, counsellor, guide and purveyor of treatments, willing to attend to the physical, mental and spiritual concerns of the people they served.

What does the future hold for family medicine? I do not believe in just one future. There is no perfect version of the discipline. There is no one ‘right’ path that leads to the ‘ideal’ form of family practice.

Moving forward in time, we will undoubtedly face many uncertainties, and numerous questions will come up. Some will require individual answers and some our collective effort. Who will be our patients? How will we attend to them? Where will we practice? Will we practice in hospitals, in emergency rooms and on labour decks? Will we call ourselves family doctors, providers, clinicians or healers?25 How will we build teams, and who will be on them?26 How will we be remunerated, and how much will we get paid?

Regardless, there are certainties to family medicine we should not abandon—those characteristics that make up family medicine-ness. At the top of this list are the 4Cs of primary care: first contact (accessibility), continuity, comprehensiveness and coordination. These 4Cs are worth protecting from others’ efforts to limit our work.27 Above all, practitioners of family medicine should, and I believe will, continue to aspire to build relationships over time that promote cure, when possible, and foster connection and care, always.

There will be battles to face. The scope of our practice, our sites of care, the procedures we perform and the diagnoses included in our daily work—these are under assault from both within and outside our discipline. We see recent graduates choosing a balanced life of career and family, too often forced to abandon some of their clinical aspirations; others continue the push to practice at the full scope of family medicine. Externally, some large hospital systems see only our potential to make referrals for high-cost services. Additionally, other clinicians claim to do what we do better and cheaper.

Family medicine is facing an existential moment. Will we become part of a medical industrial complex relegated to a limited scope of practice, obligated to a transactional model of practice designed to feed profit-driven enterprises?28 Or will we continue to walk the path we create, a counterculture reminiscent of our professional forbearers, eschewing greed, holding tight to relational care and boldly bearing witness to our patients’ joys and pains?29 How will we put our knowledge, attitudes, skills, intentions and relationships to best use (figure 8)?

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The futures of family medicine are not so much about the destination, defining where family medicine will be in 25 years. The futures are about the journey, in search of answers along the way. What paths will family medicine explore? How will it grow and develop? Can it step up, look up from the daily muck and lead a healthcare system towards a focus on patients, families and the communities in which they live?

The 100th essay

Bill Ventres and Leslie Stone

This, the 99^th essay in Storylines of Family Medicine, is not the final word on family medicine.

The mini-essays and illustrations in Storylines of Family Medicine reflect the current beliefs of many family medicine leaders from around the USA and several other countries. However, as in any other discipline, times change, situations evolve and people move both in and on. The main reason for holding tight to histories of origin, theories of practice or approaches to patient care is neither to celebrate success nor lament the barriers that stand in the way of success. Rather, it is to recognise the dynamic nature of the world—scientifically, politically, socially, culturally and relationally—in order to respond effectively, efficiently and equitably, using histories, theories and approaches as radiant touchstones to illuminate current and future areas of need.

For family medicine—in fact, for all of medicine—that means standing up for what has long been known, as evidenced in the pages of this series: healthcare systems built on robust primary care services are highly effective, socially inclusive and cost-efficient. That means promoting the delivery of patient-centred, relationship-centred and community-centred care, not by endlessly mouthing these words as self-evident platitudes but by honestly, authentically and courageously integrating them into the fabric of one’s daily work. That means helping people, individually and collectively, move towards health by not only employing biomedical approaches to diagnose and treat pathologies but also imagining and implementing an expansive philosophy of care that incorporates medical knowledge, practical wisdom and a deep understanding of persons and people in the context of their life circumstances.

What is the foundational core of that expansive philosophy of medical care? We believe it is family medicine!

Family medicine is not the sole answer to all the problems of today’s modern medical environment, and family physicians need not take on all the burdens of our dysfunctional healthcare system. Nevertheless, family medicine is one important answer, and family physicians can attend with compassion and integrity to every patient they serve. It is our job—all our jobs—to stand for what matters, to do our part and to speak and act in ways that embody the therapeutic power that comes with being a physician who works with others, patients and professionals alike, to help ameliorate suffering and enhance well-being over the course of people’s lives.

We hope Storylines of Family Medicine has provided readers a window through which to see and appreciate the heartfelt values and thoughtful insights that have guided many leaders in the family medicine movement. We hope Storylines of Family Medicine has encouraged some to see the family medicine’s elegant beauty, as it was and is meant to be practised. We hope Storylines of Family Medicine has given pause to all so that they do not go about their work as cogs in a capital-intensive, technologically fixated, institutionally focused corporate machine, intentionally blind to the human dimensions of medicine. We hope this series has inspired all to fully embrace the richness and joy that comes with genuine connection and—yes!—the capacity to heal.

Most of all, we hope that Storylines of Family Medicine has motivated readers to imagine medicine as it can be, so as to engage with its future. After all, the 100th essay is yours to write (figure 9).

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