By: Elizabeth G. Baxley, MD, Executive Vice President, American Board of Family Medicine; Andrew Bazemore, MD, MPH, Senior Vice President of Research and Policy, American Board of Family Medicine; and Robert Phillips, MD, MSPH, Executive Director, Center for Professionalism and Value in Healthcare
Reprinted from the spring 2020 Issue of The Ohio Family Physician.
The late Barbara Starfield declared comprehensiveness – caring for patients and families across the spectrum of their lives and providing most of the care that they need – to be one of the four foundational virtues of primary care. Family medicine has long prided itself as being the most comprehensive of the primary care disciplines, with training to care for patients across the widest array of health care delivery settings and services, and from “cradle to grave.” Many of us cherish this breadth and depth as fundamental to our specialty choice and attribute broad scope of care as one of the things that brings us joy in practice. Despite this, there has been a general reduction in the scope of practice among family physicians over the last 20 years. Fewer family physicians care for pregnant women; see children; and attend to the care of their hospitalized patients.1,2,3,4 The number of family physicians doing procedures in their practice is also declining.5 Amidst cries of primary care shortages, rising costs, increasing maternal mortality, and obstetrical deserts, why is this happening and what can be done to reverse this documented decline?
The improvements in outcomes associated with comprehensive care are often not touted in the case-building for family medicine. Numerous studies have produced good evidence that primary care is associated with better health outcomes, lower costs, and greater health equity.6 These findings should be considered before accepting that declines in broad scope practice are inevitable.
- Higher levels of family physician comprehensiveness of care are associated with lower costs of care and fewer hospitalizations.7
- Greater primary care physician supply that includes prevention, diagnosis, and the management and treatment of a wide array of conditions, is associated with lower mortality rates.8
- Physicians also benefit. Research has shown that comprehensiveness is associated with less burnout among early career family physicians.9 If we believe in the Quadruple Aim, which includes caring about, and for, those who provide care; it is critical that we better understand and support the desires of residency graduates, and other family physicians, to provide broad scope care as way to enhance access to quality, affordable care while maintaining physician
The reasons for declines in scope of practice are many, but particularly result from years of volume-based reimbursement models; underpayment for prenatal, obstetrical, and pediatric care; and obstetrical malpractice. Our residencies continue to prepare family physicians for broad scope care, but graduate practice intentions increasingly run contrary to the opportunities available in a job market dominated by salaried positions in health systems that clearly delineate service lines and the scope of practice tolerated in each.10,11,12 Given that comprehensive care is valued by physicians and patients, and valuable in a capitated or population-based payment model, the direction of most payment models could mean that broad scope care may become more viable. The concern is that payment change will not arrive fast enough to sustain broad scope training. There is a smoldering argument that training programs should give up broad scope to fit with the current, dominant model of care, and many community-based programs are already challenged to sustain it.
Some attribute the tension around scope of practice to family medicine traditionalists having difficulty letting go of an anachronistic self-image, while others are eager to redefine the meaning of comprehensiveness for family medicine in a system that needs it associated with benefits at the patient, population, and physician levels. For its part, the American Board of Family Medicine is committed to continually exploring the meaning and value of comprehensiveness in this age of rapidly evolving health systems. Given our awareness of the pressures that family physicians face from health systems and other employers, related to providing a more narrow scope of care, we also intend to drive the conversation about the degree to which comprehensiveness is a measure of high-value care, population-based outcomes, and payment programs.
Comprehensiveness is an important differentiator for family medicine from other primary care clinicians. Our greatest risk is not expansion of their scope, but a narrowing of ours. In fact, we should be making the case for having more robust care teams in order to support broadening the capacity of our practices to provide the breadth of care our patients need. The health of the population and the resilience of our physicians are both at risk if we passively allow further reductions to happen and fail to recommit to comprehensiveness. It is not just a legacy tradition of family medicine; it is part of the secret sauce of why we matter.
Rural Medicine and Scope of Practice: Ohio’s Family Physicians
Keith Lehman, MD
I have practiced family medicine for 37 years in Archbold, OH, a rural community of 4,500 people, that’s located 35 miles west of Toledo. For 27 years I practiced hospital medicine and did obstetrical deliveries. In addition to caring for patients of all ages, I continue as a nursing home director, administer physicals for the Federal Aviation Administration and the Department of Transportation, and do colposcopies and excisions. Providing comprehensive care has been a priority for my practice.
Seeing patients in outpatient, inpatient, and nursing home settings allows for excellent continuity and coordination of care. This has allowed me to develop strong relationships with my patients, which leads to their better care and health outcomes. My relationship with my patients also helps me stay motivated and interested in my practice both personally and professionally.
Limiting the scope of family medicine would certainly make schedules less chaotic, and keep work and family life in better balance. Unfortunately, this comes at a price. Less involvement with the physician leads to more disconnected care for patients. Limiting the broad scope of skills practiced by the physician leads to less practice satisfaction.
As long as relative value units (RVUs) are the primary determinate of the value of care, and the production of RVUs are the sole measure of compensation, it will be difficult for family physicians to provide comprehensive care and still have adequate compensation and a balanced lifestyle.
We need to advocate for the value of longitudinal, comprehensive family medicine with insurers, health systems, and the government on behalf of our patients and for the good of the specialty. We need to do this as individuals and come together collectively as the Ohio Academy of Family Physicians and the American Academy of Family Physicians.
Mary E. Krebs, MD, FAAFP
I practice in a solo, rural, federally qualified health center. Many of my patients struggle with transportation. They often lack a reliable vehicle or cannot afford the gas to travel far. In addition, some of my patients do not have insurance, or if they do, it is typically not accepted by specialists. My scope of practice is critically helpful to these patients, because, as a family physician, I can meet their various needs.
I have training in pediatrics, psychiatry, cardiology, dermatology, and many other areas. When I am able to take care of multiple problems for a patient, it improves their care through continuity and at a lower cost. This also translates to better outcomes because I am well aware of all the patient’s problems, as I am the one managing them.
I recently had a patient come in requesting “referrals” to an orthopedic surgeon, a dermatologist, a gynecologist, and a psychiatrist. When I spoke to her, I realized she was frustrated with her hip pain, acne, depression, and needed a pap. I did a proper history and physical, and diagnosed her with trochanteric bursitis, acne, and generalized anxiety disorder. I gave her medication for acne and anxiety, counseled her on both; and scheduled her for a pap and an injection of her trochanteric bursa, both to be performed by me. She left my office without any of the referrals she had requested, but was extremely happy.
While it is often easier and quicker to refer to specialists than manage problems, it is so much more satisfying to be a “real doctor” who is often able to meet most or all of my patients’ needs.
Evan Howe, MD, MPH, PhD
For the past five years, I have addressed health equity by practicing a broad scope of medicine in my hometown of Jefferson, OH. With a population of 3,100 people, Jefferson is the county seat of rural Ashtabula County. Providing comprehensive care in this community requires me to understand my patients’ variety of backgrounds.
The largest barriers I see to health equity are distance and transportation. For some, a trip of 10 miles from their farmhouse to my office is the longest journey that they will undertake all year, and the idea of traveling on the highway to a specialist’s office is terrifying. There are times that the cost of gas is too great to be able to travel to the next town over that has X-ray facilities. Having come from this area and continuing to live in the community, I try my best to be aware of what resources are available and how to adjust care plans based on the ability of a patient to travel.
I see patients from the newborn nursery to the nursing home, including office, hospital, and home care. Being able to follow patients between settings and having 24/7 availability have proven invaluable to avoiding unnecessary trips to the emergency room. Frequently, I will encounter patients in the lobby and can clarify plans for medication refills or follow-up appointments, avoiding the need for further travel. I have been able to discharge patients home to their families more quickly by checking-up via phone the next day and having my staff follow-up on necessary testing and equipment. By positioning myself across the care spectrum, I am able to not only provide care, but avoid unnecessary care that is often impractical due to transportation restrictions in my rural setting.
References are available on the OAFP website.
I agree that we need to strive to continue our scope of practice.
For a lot of reasons, most out of my control, my group stopped hospital care 15 yrs ago.
I continue to visit nursing homes and do house calls–both against the wishes of my employer.
I have a much more predictable life now, but a much less satisfying professional one.
I also practice in a city and the present configuration of local hospitals makes providing hospital care almost impossible.
We need to train FP’S that strive to be as comprehensive in their patient care as possible; so that we do not lose our place in the medical world to midlevels.
in the current climate hospital systems are looking for an adequate number of physicians with current inpatient skills to help manage in the pandemic. in the meantime they have put most of their eggs in the basket of hospitalists. it is important to the community that we maintain a range of skills to meet the needs of our patients in normal and abnormal times.