The rewards in family medicine come largely from knowing patients intimately over time and sharing their trust, respect, and friendship. The thrill is the close bond (friendship) that develops with patients. This bond is strengthened with each physical or emotional crisis in a person’s life, when he or she turns to the family physician for help. It is a pleasure going to the office every day and a privilege to work closely with people who value and respect our efforts.

The practice of family medicine involves the joy of greeting old friends in every examining room, and the variety of problems encountered keeps the physician professionally stimulated and perpetually challenged. In contrast, physicians practicing in narrow specialties often lose their enthusiasm for medicine after seeing the same problems every day. The variety in family practice sustains the excitement and precludes boredom. Our greatest days in practice are when we are fully focused on our patients, enjoying to the fullest the experience of working with others.

Patient Satisfaction

Attributes considered most important for patient satisfaction are listed in Table 1-1 (Stock Keister et al., 2004a). Overall, people want their primary care doctor to meet five basic criteria: “to be in their insurance plan, to be in a location that is convenient, to be able to schedule an appointment within a reasonable period of time, to have good communication skills, and to have a reasonable amount of experience in practice.” They especially want “a physician who listens to them, who takes the time to explain things to them, and who is able to effectively integrate their care” (Stock Keister et al., 2004b, p. 2312).

Table 1-1 What Patients Want in a Physician

Modified from Stock Keister MC, Green LA, Kahn NB, et al. What people want from their family physician. Am Fam Physician 2004;69:2310.

Patient satisfaction correlates strongly with physician satisfaction, and physicians satisfied with their careers are more likely to provide better health care than dissatisfied physicians. If physicians do not enjoy their jobs, their patients are not likely to be happy with these physicians’ job performance.

Physician Satisfaction

Physician satisfaction is associated with quality of care, particularly as measured by patient satisfaction. The strongest factors associated with physician satisfaction are not personal income, but rather the ability to provide high-quality care to patients. Physicians are most satisfied with their practice when they can have an ongoing relationship with their patients, the freedom to make clinical decisions without financial conflicts of interest, adequate time with patients, and sufficient communication with specialists (DeVoe et al., 2002). Landon and colleagues (2003) found that rather than declining income, the strongest predictor of decreasing satisfaction in practice is loss of clinical autonomy. This includes the inability to obtain services for their patients, control their time with patients, and the freedom to provide high-quality care.

In an analysis of 33 specialties, Leigh and associates (2002) found that physicians in high-income “procedural” specialties, such as obstetrics-gynecology, otolaryngology, ophthalmology, and orthopedics, were the most dissatisfied. Physicians in these specialties and those in internal medicine were more likely than family physicians to be dissatisfied with their careers. Among the specialty areas most satisfying was geriatrics. Because the population older than 65 years in the United States has doubled since 1960 and will double again by 2030, it is important that we have sufficient primary care physicians to care for them. The need for and the rewards of this type of practice must be communicated to students before they decide how to spend the rest of their professional lives. Overall, 70% of U.S. physicians are satisfied with their career, with 40% being very satisfied and only 20% dissatisfied (Leigh et al., 2002).

Development of the Specialty

As long ago as 1923, Francis Peabody commented that the swing of the pendulum toward specialization had reached its apex, and that modern medicine had fragmented the health care delivery system too greatly. He called for a rapid return of the generalist physician who would give comprehensive, personalized care.

Dr. Peabody’s declaration proved to be premature; neither the medical establishment nor society was ready for such a proclamation. The trend toward specialization gained momentum through the 1950s, and fewer physicians entered general practice. In the early 1960s, leaders in the field of general practice began advocating a seemingly paradoxical solution to reverse the trend and correct the scarcity of general practitioners—the creation of still another specialty. These physicians envisioned a specialty that embodied the knowledge, skills, and ideals they knew as primary care. In 1966 the concept of a new specialty in primary care received official recognition in two separate reports published 1 month apart. The first was the report of the Citizens’ Commission on Medical Education of the American Medical Association, also known as the Millis Commission Report. The second report came from the Ad Hoc Committee on Education for Family Practice of the Council of Medical Education of the American Medical Association, also called the Willard Committee (1966). Three years later, in 1969, the American Board of Family Practice (ABFP) became the 20th medical specialty board. The name of the specialty board was changed in 2004 to the American Board of Family Medicine (ABFM).

Much of the impetus for the Millis and Willard reports came from the American Academy of General Practice, which was renamed the American Academy of Family Physicians (AAFP) in 1971. The name change reflected a desire to increase emphasis on family-oriented health care and to gain academic acceptance for the new specialty of family practice.

Specialty Certification

The ABFM has distinguished itself by being the first specialty board to require recertification, now called maintenance of certification, every 7 years, to ensure the ongoing competence of its members.

In the basic requirements for certification and recertification, the ABFM has included continuing education (CE), the foundation on which the American Academy of General Practice had been built when organized in 1947. A diplomate of the ABFM must complete 300 hours of acceptable CE activity every 6 years and one self-assessment module per year over the Internet to be eligible for recertification. Once eligible, a candidate’s competence is examined by cognitive testing and a performance in practice evaluation. The ABFM’s emphasis on quality of education, knowledge, and performance has facilitated the rapid increase in prestige for the family physician in the U.S. health care system.

The logic of the ABFM’s emphasis on continuing education to maintain required knowledge and skills has been adopted by other specialties and state medical societies. All specialty boards are now committed to the concept of recertification to ensure that their diplomates remain current with advances in medicine.

The four components of “maintenance of certification” by the ABFM are professional standing, lifelong learning and self-assessment, cognitive expertise, and practice performance assessment. The ABFM also offers subspecialty certificates called certificates of added qualifications in five areas: adolescent medicine, geriatric medicine, hospice and palliative medicine, sleep medicine, and sports medicine. Combined residency programs are available at some institutions combining family medicine and emergency medicine or psychiatry. The combined residency makes candidates available for certification by both specialty boards with 1 year less of training than that required for two separate residencies, through appropriate overlap of training requirements.

Definitions

Family Medicine

Family medicine is the medical specialty that provides continuing and comprehensive health care for the individual and the family. It is the specialty in breadth that integrates the biologic, clinical, and behavioral sciences. The scope of family medicine encompasses all ages, both genders, each organ system, and every disease entity (AAFP, 2009).

In many countries, the term general practice is synonymous with family medicine. The Royal New Zealand College of General Practitioners emphasizes that a general practitioner provides care that is “anticipatory as well as responsive and is not limited by the age, sex, race, religion, or social circumstances of patients, nor by their physical or mental states.” The general practitioner must be the patient’s advocate; must be competent, caring, and compassionate; must be able to live with uncertainty; and must be willing to recognize limitations and refer when necessary (Richards, 1997).

Family Physician

The family physician is a physician who is educated and trained in the discipline of family medicine. Family physicians possess distinct attitudes, skills, and knowledge that qualify them to provide continuing and comprehensive medical care, health maintenance, and preventive services to each member of a family regardless of gender, age, or type of problem (i.e., biologic, behavioral, or social). These specialists, because of their background and interactions with the family, are best qualified to serve as each patient’s advocate in all health-related matters, including the appropriate use of consultants, health services, and community resources (AAFP, 2009).

The World Organization of Family Doctors (World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians [WONCA]) defines the “family doctor” in part as the physician who is primarily responsible for providing comprehensive health care to every individual seeking medical care, arranging for other health personnel to provide services when necessary. The family physician functions as a generalist who accepts everyone seeking care, whereas other health providers limit access to their services on the basis of age, gender, or diagnosis (WONCA, 1991, p. 2).

Primary Care

Primary care is health care that is accessible, comprehensive, coordinated, and continuing. It is provided by physicians specifically trained for and skilled in comprehensive first-contact and continuing care for ill persons or those with an undiagnosed sign, symptom, or health concern (i.e., the “undifferentiated” patient) and is not limited by problem origin (i.e., biologic, behavioral, or social), organ system, or gender.

In addition to diagnosis and treatment of acute and chronic illnesses, primary care includes health promotion, disease prevention, health maintenance, counseling, and patient education in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care). Primary care is performed and managed by a personal physician, using other health professionals for consultation or referral as appropriate.

Primary care is the backbone of the health care system and encompasses the following functions:

1. It is first-contact care, serving as a point of entry for the patient into the health care system.

2. It includes continuity by virtue of caring for patients in sickness and in health over some period.

3. It is comprehensive care, drawing from all the traditional major disciplines for its functional content.

4. It serves a coordinative function for all the health care needs of the patient.

5. It assumes continuing responsibility for individual patient follow-up and community health problems.

6. It is a highly personalized type of care.

In a 2008 report, Primary Health Care—Now More than Ever, the World Health Organization (WHO) emphasizes that primary care is the best way of coping with the illnesses of the 21st century, and that better use of existing preventive measures could reduce the global burden of disease by as much as 70%. Rather than drifting from one short-term priority to another, countries should make prevention equally important as cure and focus on the rise in chronic diseases that require long-term care and strong community support. Furthermore, at the 62nd World Health Assembly in 2009, WHO strongly reaffirmed the values and principles of primary health care as the basis for strengthening health care systems worldwide.

Primary Care Physician

A primary care physician is a generalist physician who provides definitive care to the undifferentiated patient at the point of first contact and takes continuing responsibility for providing the patient’s care. Primary care physicians devote most of their practice to providing primary care services to a defined population of patients. The style of primary care practice is such that the personal primary care physician serves as the entry point for substantially all the patient’s medical and health care needs. Primary care physicians are advocates for the patient in coordinating the use of the entire health care system to benefit the patient (AAFP, 2009).

Patients want a physician who is attentive to their needs and skilled at addressing them, and with whom they can establish a lifelong relationship. They want a physician who can guide them through the evolving, complex U.S. health care system.

The ABFM and the American Board of Internal Medicine have agreed on a definition of the generalist physician, and they believe that “providing optimal generalist care requires broad and comprehensive training that cannot be gained in brief and uncoordinated educational experiences” (Kimball and Young, 1994, p. 316).

The Council on Graduate Medical Education (COGME) and the Association of American Medical Colleges (AAMC) define generalist physicians as those who have completed 3-year training programs in family medicine, internal medicine, or pediatrics and who do not subspecialize. COGME emphasizes that this definition should be “based on an objective analysis of training requirements in disciplines that provide graduates with broad capabilities for primary care practice.”

Unfortunately, the number of students entering primary care continues to decline. “In 2009, for the 12th straight year, the number of graduating U.S. medical students choosing primary care residencies reached dismally low levels” (Bodenheimer et al., 2009).

Physicians who provide primary care should be trained specifically to manage the problems encountered in a primary care practice. Rivo and associates (1994) identified the common conditions and diagnoses that generalist physicians should be competent to manage in a primary care practice and compared these with the training of the various “generalist” specialties. They recommended that the training of generalist physicians include at least 90% of the key diagnoses. By comparing the content of residency programs, they found that this goal was met by family practice (95%), internal medicine (91%), and pediatrics (91%), but that obstetrics-gynecology (47%) and emergency medicine (42%) fell far short of this goal.

Personalized Care

It is much more important to know what sort of patient has a disease than what sort of disease a patient has.

Sir William Osler (1904)

In the 12th century, Maimonides said, “May I never see in the patient anything but a fellow creature in pain. May I never consider him merely a vessel of disease” (Friedenwald, 1917). If an intimate relationship with patients remains the primary concern of physicians, high-quality medical care will persist, regardless of the way it is organized and financed. For this reason, family medicine emphasizes consideration of the individual patient in the full context of her or his life, rather than the episodic care of a presenting complaint.

Family physicians assess the illnesses and complaints presented to them, dealing personally with most and arranging special assistance for a few. The family physician serves as the patients’ advocate, explaining the causes and implications of illness to patients and families, and serves as an advisor and confidant to the family. The family physician receives great intellectual satisfaction from this practice, but the greatest reward arises from the depth of human understanding and personal satisfaction inherent in family practice.

Patients have adjusted somewhat to a more impersonal form of health care delivery and frequently look to institutions rather than to individuals for their health care; however, their need for personalized concern and compassion remains. Tumulty (1970) found that patients believe a good physician is one who shows genuine interest in them; who thoroughly evaluates their problem; who demonstrates compassion, understanding, and warmth; and who provides clear insight into what is wrong and what must be done to correct it.

Ludmerer (1999a) focused on the problems facing medical education in this environment:

Some managed care organizations have even urged that physicians be taught to act in part as advocates of the insurance payer rather than the patients for whom they care (p. 881)…. Medical educators would do well to ponder the potential long-term consequences of educating the nation’s physicians in today’s commercial atmosphere in which the good visit is a short visit, patients are “consumers,” and institutional officials speak more often of the financial balance sheet than of service and the relief of patients’ suffering (p. 882).

Cranshaw and colleagues (1995) discussed the ethics of the medical profession:

Our first obligation must be to serve the good of those persons who seek our help and trust us to provide it. Physicians, as physicians, are not, and must never be, commercial entrepreneurs, gate closers, or agents of fiscal policy that runs counter to our trust. Any defection from primacy of the patient’s well-being places the patient at risk by treatment that may compromise quality of or access to medical care…. Only by caring and advocating for the patient can the integrity of our profession be affirmed (p. 1553).

Caring

Caring without science is well-intentioned kindness, but not medicine. On the other hand, science without caring empties medicine of healing and negates the great potential of an ancient profession. The two complement and are essential to the art of doctoring.

(Lown, 1996, p. 223)

Family physicians do not just treat patients; they care for people. This caring function of family medicine emphasizes the personalized approach to understanding the patient as a person, respecting the person as an individual, and showing compassion for his or her discomfort. The best illustration of a caring and compassionate physician is “The Doctor” by Sir Luke Fildes (Figure 1-1). The painting shows a physician at the bedside of an ill child in the preantibiotic era. The physician in the painting is Dr. Murray, who cared for Sir Luke Fildes’s son, who died Christmas morning 1877. The painting has become the symbol for medicine as a caring profession.

Compassion

The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal.

Francis Peabody (1930)

Compassion means co-suffering and reflects the physician’s willingness somehow to share the patient’s anguish and understand what the sickness means to that person. Compassion is an attempt to feel along with the patient. Pellegrino (1979, p. 161) said, “We can never feel with another person when we pass judgment as a superior, only when we see our own frailties as well as his.” A compassionate authority figure is effective only when others can receive the “orders” without being humiliated. The physician must not “put down” the patients, but must be ever ready, in Galileo’s words, “to pronounce that wise, ingenuous, and modest statement—‘I don’t know.’” Compassion, practiced in these terms in each patient encounter, obtunds the inherent dehumanizing tendencies of the current highly institutionalized and technologically oriented patterns of patient care.

The family physician’s relationship with each patient should reflect compassion, understanding, and patience, combined with a high degree of intellectual honesty. The physician must be thorough in approaching problems but also possess a sense of humor. He or she must be capable of encouraging in each patient the optimism, courage, insight, and the self-discipline necessary for recovery.

Bulger (1998) addressed the threats to scientific compassionate care in the managed-care environment:

With health care time inordinately rationed today in the interest of economy, Americans could organize themselves right out of compassion…. It would be a tragedy, just when we have so many scientific therapies at hand, for scientists to negotiate away the element of compassion, leaving this crucial dimension of healing to nonscientific healers.

Time for patient care is becoming increasingly threatened. Bulger (1998, p. 106) described a study involving a “good Samaritan” principle, showing that the decision of whether or not to stop and care for a person in distress is predominantly a function of having the time to do so. Even those with the best intentions require time to be of help to a suffering person.