History Of Family Medicine and Its Impact on US Health Care Delivery Presented by Cecilia Gutierrez, MD & Peter Scheid, MD Academic Project for NIPDD National Institute for Program Director Development

Historical Perspective “Medicine is always the child of its time and cannot escape being influenced and shaped by contemporary ideas and social trends” G Stephens

Objectives To stimulate interest in Family Medicine as a career choice To demonstrate the fundamental role of Family Medicine in health care delivery in this country To encourage personal commitment to promote our specialty To stimulate discussion among ourselves at the end of this session and future ones To incorporate this presentation as a didactic unit into our curriculum as part of our formal education

Medicine in the late 1800s US population was settled in small towns, and farming and production of goods were the major foundations of the economy People usually lived a few miles away from small towns that provided access to the trains and Post Office, legal offices and small government offices Health care was unstructured; the doctor often visited his patients by horse and buggy

The Horse and Buggy Doctor He knew his patients very well, he delivered babies, set fractures, treated a multitude of illnesses, and helped those dying; some did surgery and took care of traumatic injuries Many of them were astute clinicians, with great knowledge and capabilities, they were very committed to serving their people The payment was fee for service and often goods were brought to the doctors as a form of payment

Continued Although many doctors were outstanding physicians, there were also many who claimed incredible healing powers; there was a lot of “quackery” Most doctors did not have formal training; some learned the job as apprentices working with older physicians, or attending small courses and workshops The problem was that there were neither medical schools nor organized medicine

Organization As cities grew, physicians got together, and began to see the need for organization to address on a larger scale the needs of the growing society, and to establish formal medical education The AMA was established in One major goal was to organize and regulate medical education JAMA was founded in 1882

1 st issue of JAMA, 1882 AMA Foundation Meeting May 7, 1847 Philadelphia, Pennsylvania Nathan S. Davis, MD AMA’s founder

The Beginning of a New Century As the new century began, there was a strong sense that medical practices were far behind those of European countries, particularly England and Germany There was a wide gap between scientific growth and medical education Many saw the need to reform medical education and establish standards. Harvard and J Hopkins medical schools were the pioneers in this task

By 1900, the AMA’s objectives were to Purify the profession from quackery Establish standards for medical education based on scientific principles Promote standards for public health (sanitation, food and drugs)

Medical Education Reform In 1904 the AMA established a Council on Medical Education The AMA invited the Carnegie Foundation for the Advancement of Teaching to investigate all schools and report its findings. Heading this task was an educator, Abraham Flexner The Flexner Report, in 1910, was the first critical event to influence the development of medical education in the US

The Flexner Report, 1910 Pre-medical requirements were established with a strong basis in science Medical curriculum was standardized Full-time faculty were dedicated to teaching and research The medical schools were attached to universities

The Flexner Report, 1910 Biomedical research was promoted and supported The development of specific areas within medicine led to the growth of specialization and the creation of the American Medical Boards

The American Boards: The Road to Specialization The Boards’ responsibility was to prepare and administer professional certifying examinations for individuals in their fields Specialties flourished, and the AMA prospered and gained professional and academic control of specialization through the American Boards

The Growth of Specialization Ophthalmology 1917 ENT 1924 Obstetrics and Gynecol 1930 Pediatrics 1933 Radiology 1934 Colon-rectal surgery 1934 Orthopedics 1934 Urology 1934 Internal Medicine 1936 Anesthesiology 1937 Thoracic Surgery 1948 Family Practice 1969 Emergency Medicine 1979 Adapted from Geyman J, MD Foundation of Changing Health Care

The Growth of Specialization The cost of medical education increased Medicine became a profession of the upper class Specialization was emphasized and highly valued while GPs became lower in rank, fewer in number and were aging GP continued to lose ground In 1946 the Section on General Practice was created in an effort to organize and lobby on behalf of generalists

Trends in Specialists and Generalists 1931 to 1967 GP 40:

The Organization of US Medicine As US medicine organized, medical bureaucracy evolved toward specialization and institutionalization BUT NOT toward nationalization of medicine

Four areas of control were established The universities control the MD degree The state controls the license to practice medicine The AMA controls graduate medical education through the Council of Medical Education and the Residency Review Committees The American Boards control certification of specialists

By 1935 major changes have occurred Standardization of pre-doctoral medical education awarding all physicians the same medical degree Specialization based on extended graduate education = Residency The specialists gained control of the location and use of technology Hospitals became the major place where medicine and technology reside and are developed

Science and Technology In the 1940s, and particularly after WW II, the US recognized the superiority of Germany and England in regard to technological advances The war led to an intense push toward scientific and technological advances in all fields The federal government invested large amounts of resources into the development of science America fell in love with science and technology

Research and Technology Enrico Fermi demonstrated the atomic reaction The Germans had the knowledge and likely the capability to develop an atomic bomb The National Science Foundation was established in 1950 The Soviets demonstrated their technological superiority by putting the first satellite in orbit, Sputnik in 1957 NASA was founded in 1958 and only eleven years later, Apollo XI landed on the moon

The Sixties: A time of increased Social Awareness In spite of all these changes, from 1920 to 1960 medical schools did not grow significantly, while the population continued to increase Eventually this created a shortage of physicians, particularly of generalists In the 1960s the public began to express their dissatisfaction with the state of medicine

Public Outcry The shortage of physicians and maldistribution of doctors The inaccessibility of health care in rural areas and inner cities The high cost of medical care The increased depersonalization of medicine The fragmentation of care

In Response to Social Concerns The federal government increased and extended direct support to medical schools and funded Area Health Education Centers Ten years later, in 1976, US Congress passed the Health Profession Education Assistance Act, increasing support for primary care The AMA sponsored an independent study on primary care needs. This was taken by the Citizen’s Commission on Graduate Medical Education resulting in the Millis Report

Landmark Reports The simultaneous release of three reports on Primary Care reflected the social winds –The Millis report –The Willard report –The Folsom report

The Millis Commission: The Citizens Commission on Graduate Medical Education “A physician who focuses not upon individual organs and systems but upon the whole man, who lives in a complex setting… knows that diagnosis or treatment of a part often overlooks major causative factors and therapeutic opportunities”

The Folsom Report: The National Commission of Community Health Services established by the American Public Health Association and the National Health Council “ Every individual should have a personal physician who is the central point for integration and continuity of all medical services to his patient. Such physician will emphasize the practice of preventive medicine… He will be aware of the many and varied social, emotional and environmental factors that influence the health of his patient and his family… His concern will be for the patient as a whole, and his relationship with the patient must be a continuity one”

The Willard Committee: an Ad Hoc Committee on Education for Family Practice “The American public does want and need large numbers of qualified Family Physicians”

Indeed the 60s brought a sense of Social Responsibility The Civil Rights Movement, the Vietnam War Protests, the Peace Movement, etc In fact many people see Family Medicine as the result of the “Counterculture movement” and perhaps as a child of the sixties

The Birth of Family Medicine In 1969 the American Boards approved Family Practice as a new Specialty In 1970 the ABFP offered the first certification exam and mandated re- certification every 7 years In 1971 the AAGP became the AAFP

Growth of Family Medicine Family Medicine grew and flourished through the 70s, 80s and mid-90s Residencies grew and diplomates increased The Society of Teachers of Family Medicine was established in 1968 to promote the specialty The ABFP is now the second largest board The specialty has the largest delegation to the American Medical Association

Who is a Family Physician? Family physicians possess unique attitudes, skills, and knowledge which qualify them to provide continuing and comprehensive medical care, health maintenance and preventive services to each member of the family regardless of sex, age or type of problem, be it biological, behavioral, or social

What is the Impact of Family Medicine in the Delivery of Health Care?

ECOLOGY The study of relationships between organisms and their environment Medical ecology = relationships between people and the environments in which medical care is rendered

The 1961 Ecology 1, adult pop at risk those reporting illness/injury per mo those consulting a physician 1 Referred to University Med Ctr 5 referred to another physician 9 admitted to hospital NEJM Vol.265, 1961

It Is 40 Years Later Much has changed, for example: –Medicare, Medicaid –Physician Assistants, Nurse Practitioners invented –General Practice resurrected as Family Medicine –Managed Care –Transplantation; Genetics; ‘oscopies Galore; Maturation of Social Sciences...

1000 people 800 have symptoms 327 consider seeking medical care 217 visit a physician’s office 113 visit primary care physician’s office 65 visit CAM provider 21 visit a hospital outpatient clinic 14 receive home health care 13 visit an emergency department 8 are in a hospital <1 is in an academic health center hospital New Ecology of Medical Care In an average month:

Another Cut Through the Ecology Model: What is the effect of having health insurance and a usual source of care?

+Health Insurance No Usual Source of Care 1000 people 119 visit a physician’s office 11 hospital outpatient clinic 10 emergency8 home health care 8 hospital

NO Health Insurance +Usual Source of Care 1000 people 149 visit a physician’s office 15 emergency14 hospital outpatient clinic 3 home health care 3 hospital

NO Health Insurance NO Usual Source of Care 1000 people 62 visit a physician’s office 10 emergency5 hospital outpatient clinic 2 home health care 2 hospital

CONCLUSIONS A large portion of the population has a health problem each month The bulk of the medical care enterprise is in the community, in physicians’ offices The ecology model reveals opportunities that would be missed by limiting education, research and health service enhancements to hospital settings The stability of the estimates over 40 years and the expansion of the model to include other settings indicates that the ecology model provides a useful framework for thinking about health care

What is the Contribution of Family Practice According to National Data Sets? FP contribution from different perspectives: 1.Annual number of visits to Family Physicians 2.Proportion of visits to FP/GP for selected problems 3.Number of visits to Family Physicians for the top eight Priority Health Conditions 4.Distribution of Family Physicians in rural areas 5.Contribution of FP across the nation as a function of Primary Care Health Personnel Shortage Areas

Visits to US Office-based Physicians (in millions) (draft) Total GIM Gen Peds OBG FP/GP

Proportions of Visits to FP/GPs for Selected Problems (NAMCS)

Proportion of Visits to FP/GPs for Selected Problems (NAMCS)

Priority Health Conditions: Heart disease Stroke Hypertension Diabetes Cancer Emphysema and Chronic Bronchitis Asthma Anxiety/Depression

Primary Care or Subspecialists? NAMCS 1996

Family Medicine and Rural Settings In 1997, the proportion of non-Federal, allopathic, primary care practicing in non-MSA, rural setting was: Family Practice 21% General Internists8% General Pediatricians 7% Robert Graham Center

Primary Care and US PCHPSA’s PCHPSA=Primary Care Health Personnel Shortage Area A key criterion=Ratio of less than 1 primary care physician to 3500 people living in the area Robert Graham Center

At the End of the 20th Century MAPS!

Primary Care Health Personnel Shortage Areas By County in 1999 Robert Graham Center

Robert Graham Center

Robert Graham Center

Robert Graham Center

Robert Graham Center

Conclusions The bulk of care occurs in the community, in physicians’ offices FPs see more patients than any other primary care specialty We care for a large proportion of patients suffering from serious medical conditions This is a good position to occupy and fill well

Family Medicine In the New Millennium

Family Practice 1969 versus 2000 Hopes in 1969 Reality in FM would become the main PC discipline - FM is one of the four disciplines. IM the largest - FP will increase in proportion to all MDs - FP represents only 12% of all MDs, (18% in 1969) - FP will have a central role in med schools - FM’s role is rarely central and often marginal - FM residencies would represent 25% of all US positions - FM residency positions are < 15% of all US positions - FP would integrate the biopsychosocial approach into practice - Mixed record J. Geyman The Keystone Papers. Vol. 33 No 4 April 2000

Family Medicine Patient-Doctor Relationship Continuity, generalist Economic Forces Social Changes Financing Medical Education Structure of Med Ed Managed Care & Medicare Demographics, Family, Ethnic Diversity, Women’s Role etc Knowledge& Information Lack of Health Care Infrastructure The Complexity of Social and Economic Forces

Keystone III Keystone was convened to discuss the state of Family Medicine and to look at the challenges that the specialty faces Three generations of Family Physicians were present as well as representatives from AAFP, AAFP-F, ABFP, STFM, AFPRD and NAPCRG

Highlights from Keystone The Challenges Faced The lack of insurance coverage The value of continuity The eroding boundaries of the specialty The feasibility of maintaining competency The demographic changes of society The price of isolation The economic pressures of a market economy: –The effects on health care delivery, medical education and the mission of academic institutions

Lack of Insurance ~ 40 million Americans have no medical insurance, another large % underinsured –One in five are children The US lacks the infrastructure to deliver health care to all its people These shortcomings have hindered Family Medicine’s ability to play a larger role in the care of all people, despite being uniquely suited to do so

The Doctor-Patient Relationship is being constantly eroded Family Medicine is based on its ability to create long term relationships of trust and partnership between doctors and patients Continuity is based on time commitment

The Challenge of Continuity How can relationships be built in a system where health care is sold to the cheapest bidder almost on a yearly basis? Continuity of care is also affected by the increasing mobility of both patients and doctors

The Boundaries of the Specialty Eroding Away? The Scope of Family Medicine is Shrinking –Internal Pressures Issues of Competency –External Pressures: Economic forces Mandatory Hospitalists Unfavorable reimbursement for procedures performed by Family Physicians

Demographics, Ethnic Diversity and the Evolving Family The aging population The changing face of America The evolving concept of family The changing role of women in society and in medicine

The Price of Isolation The birth and growth of FM has been an uphill road and many struggles have kept us isolated “The three primary care specialties remain distinct tribes on parallel but separate courses” J. Geyman Turf battles are still a source of conflict Major disparities in reimbursement maintain a wall between primary care and specialists

The Effects of the Economic Forces: Managed Care and Primary Care Managed Care emerged as an attempt to control health care cost In the early days, it appeared that it would establish primary care as the foundation of American medicine

Managed Care: adverse effects It forced medical organization into the profit- oriented health care market Should Health Care be treated as a commodity? The introduction of the Primary Care Physician as a gatekeeper was often negatively perceived as –Limiting access to specialists –Rationing care –Increasing rules and regulations in medical practice –Increasing demands for documentation

Medicare and Medical Education In 1965 the Medicare Program was enacted and the federal government began to subsidize academic centers –Paying customary charges which also covered teaching overhead –Providing teaching hospitals grants for direct and indirect costs of medical education –Providing extra payments to hospitals with a disproportionate share of high cost cases (DISH)

Medicare Growth: Need for Cost Containment In order to control costs, in 1983 Medicare shifted its payment from an open-ended to a prospective payment system. This resulted in: –Fundamental changes in philosophy, including shorter hospital stays and fewer interventions –In academic centers, faculty are pressured to bring in clinical revenue to subsidize their institutions

According to the AAMC Faculty Practice as a source of revenue has increased from 5% in 1960 to 50% in accounted for 5% – 1980 accounted for 30% – 1995 accounted for 47% – 2000 accounted for ~ 50% NEJM Sept, 1999

The Balanced Budget Act In 1997 the BBA substantially decreased the support to teaching centers by – payments to all hospitals for patient care and capital – support for hospitals with DISH – subsidies for teaching BBA was to reduce payments by $ 5.6 billion over a five year period

Erosion of the Social Mission of Academic Institutions Role of Academic Centers: –To generate knowledge: Research –To transmit knowledge: Teaching –To serve the community: Clinical Service These missions are equally important and benefit society at large

Effects on the Teaching Mission Increased pressure to cut cost See more patients in less time Decreased time available to spend with medical students and residents Students and residents have less time to observe the course of a disease and its treatment Increased amount of paper work: documentation, rules and regulations, etc

Medical Education and Society Education is a very costly endeavor, such that it requires societal financial support Similarly, medical education is a very expensive enterprise which cannot possibly earn a profit on its own terms, and therefore its cost must be borne collectively Society benefits from the education and training of physicians

AMERICAN ACADEMY OF FAMILY PHYSICIANS FUTURE OF FAMILY MEDICINE PROJECT

Goal of the Project To develop a strategy to transform and renew the specialty of Family Practice to meet the needs of people and society in a changing environment

FOFM Project Launched in Jan 2002 and expected to present its findings and recommendations to the WP and AFMO in August 2003 Project Leadership Committee includes two representatives from each FM organization and 5 Task Force Chairs Participants (AAFP, AAFP-F, ABFP, STFM, ADFM, AFPRD and NAPCRG)

Task Forces: Questions to answer TF #1 What are the core attributes of family practice, how can FP best meet consumer expectations, and what systems of care should be delivered by family practice? TF #2 What are the training needs for family physicians to deliver the core attributes and services expected by consumers and the health delivery system?

Task Forces: Questions to answer TF #3 How can we ensure that family physicians continue to deliver the core attributes of family practice and the services the system expects throughout their careers TF #4 What strategies should be employed to communicate the role of family physicians within medicine and health care, as well as to purchasers and consumers TF #5 What is family practice’s leadership role in shaping the future health care delivery system

FOFM Project Continue Consulting firm, Siegelgale of New York will do quantitative and qualitative research to answer the question: What do people want and expect from health care professionals in the health care delivery system and what is the role that family physicians should play?

Siegelgale will survey People who get their care from FP People who get their care from other MDs Consumer advocate groups FP in academia, FP in practice and other physicians Non-physician heath care providers Employers, other payers, government Residents and medical students

In Summary: The United States depends on Family Physicians for health care We bear considerable responsibility for how well the country is doing when it comes to health care With this position comes responsibility, opportunity, and challenges

In Summary: We must work at developing better ways to deliver care to all people We need to break barriers and work with other PC specialties as well as specialists toward this common goal We need to work at ensuring that medical education is protected from the forces of the for- profit economy We must work to make fundamental changes in medical education at all levels of training, promoting Family Medicine as a fundamental pillar in the U.S. health care delivery system

THANK YOU!