I remember the moment I chose family medicine as my specialty. My medical school class had just experienced a tragedy: the sudden and accidental death of a beloved classmate. In the context of that grievance, I was on my internal medicine rotation at the Veterans Affairs hospital and was disillusioned with how transactional the care seemed to be. Our patients entered acutely ill, our team would tune them up, send them out, and they would return a month later, unable to maintain themselves outside the structure of the hospital. I questioned whether anything about medicine could feel fulfilling as a career. During that rotation, I spent a day at a local hospice, learning about end-of-life care with another classmate. That day, we faced our class’s collective grievance and I had a glimmer of insight into understanding health in the context of mortality. The hospice director was a family physician who had a deep understanding of the beauty of a life well lived, from birth to death. By the day’s end, 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 aggregating similar stories in his book Searching for the Family Doctor, and contextualizes them within the historical development of Family Medicine as a specialty, while piecing out the cognitive dissonance of practicing family medicine in a broken health care system. He spends many chapters profiling med students and physicians at different periods of their careers, painting a picture of the tension between mission-driven altruism and the pragmatism of financial stability. He ties that tension to why today’s family physicians struggle to embody the grand vision of well-trained physicians who render diagnostic and therapeutic measures to all ages, serve as the primary decision maker for illness inside and outside the hospital, and take the role of community advocate and specialty liaison.
As an outsider looking into the specialty, Hoff offers his own insight in the final chapter: A Top Ten List for Saving Family Doctors. In it, he includes a number of fascinating thoughts and suggestions, some that should likely be considered by the specialty. One suggestion is to consider renaming the specialty to reflect the full-spectrum care that family physicians are capable of — a rebranding if you will. Hoff notes that he wasn’t sure where the name “family medicine” comes from, so I took that that opportunity to see if I could learn for myself.
Serendipitously, 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 writes, “it is not the family as entity or institution that is of central concern, but ‘family’ as a metaphoric designation for primary, largely self-regulated human systems. Thus, family medicine is concerned with any group that makes a significant difference in its members’ lives. More important…is ‘family mindedness’ among providers, as health problems are conceptualized, defined, and addressed in relation to their specific contexts. Thus, family medicine is concerned with the formal as well as the concrete and personal aspects of human health and relatedness.”
Compared with internal medicine residency programs, for example, family medicine is unique in its requirement to incorporate behavioral health into clinical care, with an emphasis on the biopsychosocial model of health. This emphasis is rivaled only in pediatric training, where understanding the health of a child demands a knowledge of family systems. Even so, family medicine is the only specialty where an understanding of both the family and the community is explicitly codified into the Accreditation Council for Graduate Medical Education training requirements, beyond the basic boilerplate template.
This understanding of family medicine was exemplified for me during 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 20s, who was distraught throughout the whole procedure. No amount of reassurance or expectation-setting could console her.
After the visit, Dr. Fink and I wondered about Linda’s emotional response 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 had ultimately died.
A week later, we saw Linda again to discuss her biopsy results, which were normal. Dr. Fink was able to connect with Linda on her family history, insight that Linda would not have shared otherwise.
In this case, knowing the direct family member was instrumental in getting to the root cause of Linda’s tension. Such long-term relationships are rarely the norm anymore, where relationships with the primary care physician are cut short based on employment status, insurance changes, and changes in employer benefits. Reprioritizing relationships and longevity, and creating sustainable practices for physicians, are key in building out and improved primary care infrastructure in the United States.
In today’s health care system we also talk about family medicine as though it is synonymous with primary care. But family medicine is not just about whether cancer screenings are met, or HEDIS scores are measured. It is about understanding the patient within the context of their community and family system and providing the care they need, whether that is blood pressure management, or a biopsy, and to balance that outlook within the context of the health care system.
Can this only be done if family doctors, as Hoff professes, treat families? According to Hoff, family medicine-trained physicians who choose to be hospitalists or urgent care physicians do so due to financial pragmatism. However, if we view family systems as the base 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 primed not just to make sure screenings are done, but also to address the behavioral aspect of addiction, stress, and other epigenetic factors that impact the expression of disease states. In understanding the “family” in family medicine, I have a better grasp on what it is that I actually do, how I show up for my patients, and maybe even how to change the health care system.
Lalita Abhyankar, MD MHS is Employed by Carbon Health. Shis is District Director and Board Member for California Academy of Family Physicians, and a Board Member for the California Academy of Family Physicians Foundation.
By Timothy J. Hoff
Baltimore (MD): Johns Hopkins University Press, 2022
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