I never considered any specialty other than family medicine. I always saw the other specialties as necessary but supportive adjuncts. I always thought that the other specialties were all fascinating in their own way but saw them more as a part of a library that I could access when needed rather than ever feeling the need to delve deep into any specific subject. Specialists were the masters of the marvels of modern medicine and those rarely seen disorders. They could always be referenced when needed, though ideally not that often. Family medicine physicians were the librarians of this amazing library. The idea of being a generalist was intensely satisfying to me; I never wanted to “specialize” in anything in particular.

Then I started my family medicine residency, and I realized that I was specializing in something after all: relationships. What kind of relationships? All kinds. Between the organ system in the body. With time, from the cradle to the grave. A patient’s relationship with their social networks — i.e., friends and family with their community. And perhaps most importantly, with the health care system itself. Is the patient using the health care system too much or not enough? Do they go to the ER or urgent care when they should be going to the clinic or vice versa? Are they seeing too many specialists or too few? Too many medications or too few? Too many procedures or too few? Are they using the tools available to them, caregivers, nursing homes, assisted living, allied health professions, insurance/Medicaid/Medicare wisely or not? How do the other priorities in their life, education, financial, etc. intersect with their health? This expertise is something that I’ve discovered other specialists do not typically have.

That family medicine is the specialty of relationships may be indirectly implied in the name “family medicine,” but it’s not obvious … unless you look closely at its history. On the allopathic side, the family medicine specialty was started in 1969 in response to the feeling that medicine was becoming increasingly complex, and additional training was needed to do “general practice.” On the osteopathic side, the history is a bit more complex but also predicated on concerns about the increasing complexity of medicine and not losing the “generalist” approach. The general, broad-spectrum nature of family medicine tends to attract those who are more big-picture, continuity-oriented. I’m someone who likes puzzles and is good at puzzles, so perhaps it was not surprising that family medicine is where I ended up.

What does it mean to be a family medicine physician in practice? One family I treated during from residency stands out in particular for me. This family was initially assigned to another resident’s panel, and I saw one of the children first because there was room on my schedule.

Then I saw the other children one by one. Both the parents were present during my visits with the children. During the initial visit with one of the children, the parents raised the concern that the (pre-adolescent) child might have some kind of mental illness. Was there any history of mental illness at a young age in the family? No. Any history of mental illness at all in the family? No. Any social dysfunction in the family? No. During that visit, there was nothing to suggest the child might have any mental illness. The parents didn’t volunteer any specific behaviors to suggest mental illness. The child, by report, was functioning well in school. So I recommended monitoring and following up with any specific concerns or if the parents had any new history to report. After that, I had an initial visit with the mother and then finally the father. When I saw the father, he was alone, and he reported that he had a history of mental illness and described significant social dysfunction within the family … mental illness and social dysfunction that, as we know, can impact his children’s health, not to mention his and that of his wife’s, in multiple ways.

This highlights what I believe to be the true underlying cause of all the problems that we face as a health care community. No, it’s not EMRs. It’s not Medicare, Medicaid or the insurance companies. It’s not government regulations. The problem is that in the system we are trained in and most of us practice in, the functional unit of medicine is the patient encounter. It’s the exemplification of how fragmented our system really is. A patient encounter here and a patient encounter there, and we might feel like we’ve done our jobs. Metrics and billing would seem to support this. Residency competencies are based on this concept as well. Just like with procedures — so many adult outpatient, so many inpatient, so many pediatric and so on — are required to become board certified. But if we aren’t actually helping our patients heal, then what are we actually doing?

I believe that the functional unit of medicine should be the physician-patient relationship. I never saw this family again in my continuity clinic; they were lost to follow up. Another example of the fragmentation. But they taught me the folly of trying to practice medicine in this way. For this very reason, I will not see children unless their parents are also patients of mine in practice. It’s how I keep the relationship with my patients at the center.

We talk a lot about the problems that we face as a health care community and what to do about them. I would suggest that family medicine physicians have a great potential to help to solve them. We are most likely in the best position address patients who are lost to follow up, the “frequent flyers,” and the patients so lost in the complexities of the health care that they lose agency over their own health. We deal with all that messiness because that is medicine and no amount of medications or procedures is going to fix it.

Liz Hills is a family physician who blogs at Heal Thyself.

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