My journey in the specialty of family medicine started in 2004 during my third year family medicine clerkship. I was assigned to an office located in the southwestern town of Yauco, Puerto Rico. The practice had two providers who saw patients of all ages. My family medicine attendings made me appreciate the way our specialty approaches patient care. We treat our patients taking into account their psychosocial framework and partner with them to accomplish the best possible outcomes. These same principles were also engrained upon me throughout my residency training in inner city New York.
The Annals of Family Medicine recently published “The Future Role of the Family Physician in the United States: A Rigorous Exercise in Definition.” The role definition highlighted our specialty’s unique position to address the health of communities and be ideal leaders for health care and public health systems. The article presented this as a new role for family medicine. It is not new. It is the foundation of our specialty. It is the same role I was taught during my medical school and residency training, and that which I teach my residents in a community residency program in Georgia. Furthermore, I argue our specialty should be engaged in identifying and combating the challenges of our health care systems rather than focusing on redefining ourselves.
In 2004, the Future of Family Medicine Project Leadership Committee presented ten recommendations that aimed to transform and renew the discipline of family medicine. Two of these recommendations were embracing the concept of the personal medical home and implementing patient access to electronic medical records for better physician-patient relationships. These recommendations sound appealing, positive and revolutionary. However, are they practical in our current health care environment? Do these initiatives actually benefit the health of our patients, or do they simply serve as a way to again redefine our specialty and its role in our health care system?
The personal medical home and the introduction of electronic medical records initiatives advocate for more patient autonomy, and repel the traditional physician paternalistic role in patient care. Offering a medical home supposes to provide patients with comprehensive care and open access to their medical information. Our residency program follows the patient medical home model. Our biggest challenges are getting patients to attend their appointments and adhere to their medical care. Many of our patients do not have access to proper housing, food or education. Most of the visits consist of trying to find ways to overcome these deficits. Patients without basic resources have a difficult time maintaining and improving their health. This experience is not unique to our practice, but it is the reality of many family physicians in the United States. The implementation of the medical home and patient access to electronic medical records does not address these patient challenges.
A few weeks ago I was rounding with residents in the hospital, and we evaluated a patient with acute coronary syndrome. The patient was scheduled for a cardiac catheterization the next morning. While rounding, we found the patient eating fried chicken, french fries, and a regular soda. I had a discussion with the patient about the health consequences of this diet. The patient’s reply was, “I know, I know.” The patient left the hospital with a couple more coronary stents and more medications to control cholesterol and blood pressure; but with no clear desire to modify behavior.
This patient experience made me reflect about the nature of the physician-patient relationship. The health care industry has turned the practice of medicine into a business. The physician-patient relationship has moved away from a partnership into a contractual agreement between two parties. This shift in the physician-patient relationship has made many patients have the expectation to receive a “health care product” of wellness and satisfaction. Surveys constantly ask patients if they are satisfied with the services they receive from their providers, without taking into account whether or not the services are evidence-based or beneficial to their health.
The concept of contracting services affects the trust that has always characterized the relationship between family physicians and their patients. Many patients no longer come to their office visits to discuss their health or how to improve it. Rather, they present with a predetermined agenda. They will report a poor costumer service experience if they feel that their agendas are not fulfilled. Our current system has created a culture of patient entitlement. It makes health care services look like a commodity with no responsibilities attached to it.
Family physicians’ skills are essential in our health care system. We should try to implement initiatives that address the underlying challenges of our patients and strengthen the physician-patient relationship. We have a lot of work to do, and our energy should not be diverted into trying to redefine our specialty. We already know our role.
Jose M. Villalon-Gomez is a clinical assistant professor, department of family medicine, Mercer University School of Medicine, Macon, GA.
