Calls to declare family physicians the “backbone of health care” are emotionally appealing, but they do not withstand scrutiny. When we examine training pathways, cost structures, insurer incentives, and real-world performance, a different picture emerges, one in which many other clinicians are better trained for the populations they serve and, critically for insurers, far cheaper. This is not an attack on family physicians. It is a call for accuracy in describing a system that is already strained, fragmented, and financially unsustainable.
Training: the foundation that cannot be ignored
Family medicine residencies provide two to three months of pediatrics. Pediatric nurse practitioners receive far more pediatric training, including pediatric-specific coursework and hundreds of supervised clinical hours. Pediatricians complete three full years of pediatric residency. Developmental-behavioral pediatricians complete three additional years of subspecialty training focused on neurodevelopment, disability, systems navigation, and family functioning. Yet family physicians routinely position themselves as primary providers for infants, children, and adolescents, populations for whom they receive the least training of any clinician in the system. Families notice. Insurers notice. Outcomes reflect it.
Economics: the backbone of insurer decision-making
If insurers truly believed family physicians were the “backbone,” reimbursement would reflect that belief. It does not. Instead, insurers increasingly rely on:
- Pediatric nurse practitioners for child health
- OB/GYNs for maternity care
- Hospitalists for inpatient care
- Urgent care and retail clinics for low-acuity adult care
Why? Because these clinicians are better trained for their specific populations and cost less. The financial argument becomes even more strained when extended to obstetrics. No hospital CFO, and no insurer with basic actuarial sense, wants a clinician with only family medicine training delivering babies while carrying OB malpractice premiums that rival small business budgets. The math simply does not work.
Minot: a case study in what families actually choose
During my time in Minot, North Dakota, the gap between rhetoric and reality was impossible to ignore. The Air Force base population included many families enrolled in EFMP, the Exceptional Family Member Program, which identifies dependents with medical, developmental, or educational needs requiring specialized care. These families were discerning. They understood complexity. They recognized training differences immediately. While the family medicine department struggled to empanel patients, a failure reflecting both training limitations and leadership gaps, I had consistent success empaneling EFMP families. Not because of marketing or personality, but because the training matched the need. Families with children facing developmental, behavioral, or medical complexity gravitated toward clinicians who could actually meet those needs.
This reality became even clearer when the Air Force sought to build a true pediatric medical home. Contrary to the narrative that family medicine is the “backbone,” the USAF pediatric medical home was not created by family physicians at all. It was built on a design I developed, grounded in developmental-behavioral principles, interdisciplinary coordination, and systems-level care. Kelly, a surgeon with strong systems instincts, recognized the validity of that design and implemented it. The model succeeded because it was pediatric-centered, evidence-based, and aligned with the needs of EFMP families, not because it emerged from family medicine. The fact that the Air Force adopted a pediatric-designed model, rather than an FP model, speaks volumes about where true backbone functions reside.
The backbone of health care is not a single specialty
The backbone of health care is fit-for-purpose training, not a romanticized generalist identity:
- Pediatrics is the backbone of child health.
- OB/GYN is the backbone of maternity care.
- Internal medicine is the backbone of adult chronic disease.
- Developmental-behavioral pediatrics is the backbone of neurodevelopmental care.
Family medicine plays a role, an important one, but it is not the structural support beam the rhetoric suggests.
A more honest narrative
Instead of elevating one specialty as the “backbone,” we should acknowledge what families, insurers, and outcomes data already show. Health care works best when clinicians practice at the level of their training, and when that training matches the population they serve. That is not an insult. It is a commitment to safety, fiscal responsibility, and dignity for the families who depend on us. Health care systems don’t need slogans. They need structure. And structure begins with training, accountability, and alignment between clinician expertise and patient need. The backbone of care is not declared; it is built. I’ve built it. And I’ve seen what happens when families are given clarity, competence, and dignity. They stay. They thrive. And they know the difference.
Ronald L. Lindsay is a developmental-behavioral pediatrician.
