Introduction
As a specialty in the United States, family medicine outnumbers all other medical specialties for both physicians and physician assistant (PAs). Physicians practicing in family medicine make up the largest percentage of the total physician workforce and, as shown in Fig. 20.1 , family medicine PAs account for the largest percentage of the total PA workforce. Family medicine emerged from a generalist model of medical practice and, in 1969, was named the 20th medical specialty in the United States. The specialty of family medicine is commonly referred to as “birth-to-grave” medicine, and it overlaps pediatrics, general internal medicine, general gynecology, primary care geriatrics, and general psychiatry. Given this overlap, family medicine is known for its traditionally complex and large scope of practice and is acknowledged as a cornerstone of efficient and effective health care. In fact, comprehensive family medicine care results in fewer hospital admissions and emergency department visits, better health outcomes, and lower costs. ,
Along with general internal medicine and general pediatrics, family medicine is considered one of the primary care specialties. Moreover, given the scope of family medicine, it is often considered the specialty that best meets the definition of primary care: a practice that involves first contact with continuous follow-up for comprehensive services and the coordination of care for patients of all ages and genders for almost any disease or condition. , As reviewed and detailed by Epperly et al., the family medicine specialty incorporates seven shared principles that define primary care as:
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Person- and Family-Centered: Creating an empowered and mutually beneficial partnership between clinician, individuals, and families as equal members of the health care team. Person-centered is the preferred term over patient-centered because the latter may imply that individuals occupy a sick or dependent role rather than a collaborative one.
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Continuous: Ensuring an enduring, trusting, foundational relationship to best address acute, chronic, behavioral, and preventative health care needs.
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Comprehensive and Equitable: Providing care for individuals from all backgrounds and of all ages and genders for most of their health care problems and needs.
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Team-Based and Collaborative: Recognizing individuals, their families, and all staff and providers as critical members of the health care team.
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Coordinated and Integrated: Practicing with the goal of ensuring a seamless integration of health care data and records and “outside” providers to optimize outcomes.
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Accessible: Providing care that is consistently readily available and responsive to individuals seeking care and the needs of those individuals and their families.
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High Value: Recognizing the importance of trusting and enduring core relationships that promote the highest quality of care and patient safety, coupled with the lowest health care costs.
Approach to patient care
As discussed, the family medicine approach involves providing evaluation, treatment, and continuous care for patients across their lifespan. Accordingly, family medicine providers are among the only medical specialists who are distributed in the same geographic proportion as the U.S. population. Family medicine is further characterized by a focus on patient access to high-quality, evidence-based, and culturally sensitive care. Family medicine provides the unique opportunity to provide comprehensive, holistic care, with a singular dedication to treating the “whole person” in a long-term continuing relationship.
In their research and exploration of family medicine clinician identity, Carney et al. identified five core domains: (1) patient/family relationship; (2) patient advocacy; (3) career flexibility, such as options in building a practice and practice emphasis; (4) balancing the breadth and depth of care given the comprehensive expertise needed to evaluate, treat, and follow patients with a wide array of conditions and illnesses across their lifespan; and (5) the comprehensive nature of patient care and continuity of care. Interestingly, Carney et al. also found that many family medicine providers included the importance of supporting and pursuing social justice as a principal element of family medicine. Above all, many regard successfully establishing strong therapeutic relationships with both patients and families as a pillar of family medicine. Unique to family medicine, the provider-patient relationship extends beyond treatment or cure and includes the patient’s family members.
Understanding a person’s family is a fundamental concept in family medicine and is central to developing holistic and effective patient management strategies. Knowledge of family is an inherent aspect of the systems approach to primary health care, which is a hallmark of family medicine. Systems theory highlights the inter-relationship between natural and social sciences as a means to help family medicine providers best understand causes and effects related to patient presentations and outcomes. Biosciences and social sciences become intertwined into a contextual biopsychosocial framework in which knowledge of medical science, coupled with awareness of each patient’s individual characteristics and qualities, family, and community, informs the diagnosis, workup, treatment, and follow-up plan.
Family medicine providers are well prepared to collect and interpret a great amount of data and manage highly complex illnesses, diseases, and comorbidities. This ability, fueled by an extensive understanding of physical medicine, behavioral health, and general health care systems, results in the provision of effective, person-centered medical care at a low cost to the patient and health care system. Clinicians in family medicine are uniquely trained to offer preventative care, manage acute and chronic conditions across all organ systems and levels of severity, collaborate with other specialists, and perform a wide variety of office-based procedures. Given family medicine’s emphasis on comprehensive, continuous, and preventative care, providers in this specialty take a long-range approach when treating patients, focusing not just on the patient’s immediate and short-term issues, but also on issues that may arise 5, 10, or 20 years down the road.
Every office visit provides an opportunity to practice preventative care and increase patient well-being in the present as well as the distant future. In addition, person-centered care requires the provider to “meet patients where they are” and recognize and address issues of health literacy, which refers to an individual’s capacity to retrieve, receive, process, and understand basic health care information to make appropriate decisions regarding their care. Promoting health literacy helps family medicine providers ensure that patients understand their current and potential future medical issues and understand how to prevent and preempt disease complications and progression.
Perhaps one of the best ways to describe the family medicine–specific approach to patients is through the commonly adopted Patient-Centered Medical Home (PCMH) model. The PCMH model has existed since the 1960s; however, in 2002 the American Academy of Pediatrics (AAP) expanded the PCMH definition to incorporate access to care; continuity of care; comprehensive care; and family-centered, compassionate, and culturally sensitive medical care for patients. In 2007 the American Academy of Family Physicians, the AAP, the American College of Physicians, and the American Osteopathic Association developed the Joint Principles of the Patient-Centered Medical Home, outlining standards for the current PCMH model ( Box 20.1 ). The family medicine approach to the PCMH involves creating partnerships between individual patients and families and their personal primary care providers, and facilitates the comprehensive primary care of children, adolescents, and adults. At the heart of the model are the principles of quality and safety. Consequently, primary care clinicians and PCMH practices serve as strong advocates for the well-being of their patients and—through strong, compassionate partnerships between the patient, clinician, and practice—aim to achieve optimal, person-centered outcomes.
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Develop strong relationships with patients.
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Provide first contact and continuity of care.
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Incorporate a clinician-led, team-based approach at the practice level, assuming responsibility for the continuous care of patients.
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Adopt a whole-person orientation in which the clinician provides for his or her patient’s health care needs, including but not limited to appropriate referrals and follow-up, throughout the lifespan and for acute, chronic, preventive, and end-of-life care.
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Ensure coordination and oversight of care throughout complex health care systems, using such tools as electronic health records to assist in identifying health care services.
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Provide enhanced access to care by incorporating expanded hours, open scheduling, and various forms of communication (e.g., phone, web-based, remote communication, and face-to-face interactions).
Scope of daily practice
Nearly 40% of family medicine physicians report working collaboratively in a team model of practice with PAs and/or nurse practitioners. This team model results in increased patient panel sizes, a broadened scope of practice, and lower per-visit labor costs. In such practices, PAs generally perform more substitutive rather than supplemental responsibilities; thus the family medicine PA should expect to have a scope of practice mirroring that of the family medicine physician. Nevertheless, scope of family medicine practice is highly variable and practice-specific. In response to a recent survey, 90% of family medicine physicians reported caring for teenagers and adults over age 65, but only a third reported caring for patients in a hospital; 8% reported performing deliveries; and just 7% reported providing emergency care.
Perhaps one of the most significant influences on scope of practice is the ruralness of the setting. Rural practice presents unique challenges to the family medicine PA on multiple levels. Rural family medicine providers may receive lower reimbursement than their nonrural counterparts and may be required to work at a higher and more comprehensive scope of practice. Given that residents in rural communities are more likely to suffer exacerbated and more complicated health issues, these individuals often require a higher level of full-spectrum, comprehensive care from family medicine providers.
All family medicine providers practice a very broad breadth of care, while maintaining a continuing relationship with patients and patients’ families, bridging the boundaries between well-being and illness. Family medicine primarily involves outpatient, in-office care but, depending on the practice, may include house calls, palliative care, after-hours care, and minor surgery. In addition to improved access to care and a strong focus on preventative care and early management of illness and disease processes, the family medicine approach also emphasizes the reduction of unnecessary referrals for specialty services and the educating of patients on how to care for themselves whenever feasible.
As previously discussed, family medicine recognizes the great importance of having knowledge of the whole patient to set the stage for building a strong relationship between patient and clinician. Such knowledge includes awareness of a patient’s social and financial circumstances, as well as past medical and psychiatric histories. Family medicine providers often gain more utility from a medical history than from “fishing for labs.” Therefore one characteristic of the family medicine approach is the emphasis placed on garnering a comprehensive and accurate patient history. Furthermore, to protect patients and reduce cost, family medicine centers around rapid access to care, evidence-based care, preventative care strategies, and limiting unnecessary diagnostic tests and specialty referrals. Delivering cost-effective care, not only to benefit individual patients but also to benefit the larger health care system, is a common theme among family medicine providers.
Prevention of and screening for disease, including appropriately managing patients to prevent chronic disease exacerbations that result in emergency room visits and hospitalizations, is another common theme in family medicine. The importance of such an approach cannot be overemphasized. Research reveals that regions with more primary care providers have: improved population health with lower health care costs; lower death rates from illnesses such as heart disease, cancer, and strokes; and lower infant mortality rates. A sign of the value of family medicine specifically is that improved health, better treatment outcomes, and lower costs are most strongly associated with care provided by family medicine providers. , Additionally, evidence shows that family medicine outpatient encounters are equally or more complex than nonprimary care specialty encounters.
Family medicine cannot be simply defined by practice location, condition severity, organ system, or even patient age or gender. Rather, the specialty may be better characterized by the provider-patient relationship, as well as relationships with patients’ families and communities. In their research on core themes in family medicine, Bradner et al. identified five core attributes embraced in family medicine that are consistent with the discussion of family medicine presented in this chapter: (1) a deep understanding of whole person dynamics; (2) the fostering of personal growth in patients, including practices to promote behavioral change leading to improved quality of life; (3) humanizing patient experiences within the health care setting; (4) enhanced availability for and open communication with patients; and (5) a natural command of complexity.
The family medicine clinical rotation
Throughout the family medicine clinical rotation, students should recall that family medicine is unique among the clinical disciplines in that family medicine PAs provide continuity of care for both acute and chronic conditions for patients of all ages and genders. Patients frequently present with complex comorbidities or multimorbidities and ill-defined problems. Many family medicine patients present multiple times each year, often with multiple concerns at each visit. Coordination and integration of care for complex medical problems and comorbidities, as well as the expertise to manage a wide range of acute, subacute, and chronic conditions in a variety of practice settings, is required of family medicine providers. Additionally, each patient visit, regardless of reason and setting, provides an opportunity for health promotion and disease prevention for both the patient and the patient’s family. It is the provider’s responsibility to prioritize and balance the management of medical problems in conjunction with the delivery of preventative care, orchestrating the visit to ensure that patient needs are met; the student shares in all of these responsibilities.
Students on family medicine clinical rotations should be knowledgeable about the acute and chronic presentations of diagnoses seen in family medicine practices. Given the breadth and comprehensiveness of family medicine, these presentations cover a wide variety of conditions and levels of urgency. The U.S. Centers for Disease Control and Prevention collects medical care utilization data regarding diagnoses made in ambulatory settings such as family medicine practices. After these data have been collected, they are presented in national health statistics reports ( http://www.cdc.gov/nchs/products/nhsr.htm ), which are often used to inform medical educators on expected student competencies. For example, the Society of Teachers of Family Medicine (STFM) used such reports to develop the STFM’s Family Medicine Clerkship Curriculum, which outlines both the common and serious causes of acute and chronic conditions ( Box 20.2 ), and includes essential topics for health promotion ( Box 20.3 ). The curriculum is geared toward the entry-level clerkship student and serves as a valuable resource in preparing for the family medicine rotation.
Acute disease presentations
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General: evaluation of fever
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Cardiovascular conditions: chest pain, shortness of breath, wheezing, leg swelling
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Dermatologic conditions: common skin rashes and lesions
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Gastroenterologic conditions: abdominal pain
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Gynecologic conditions: abnormal vaginal bleeding, vaginal discharge, initial presentation of pregnancy
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Musculoskeletal conditions: joint injury and pain, low back pain
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Neurologic conditions: headache, dementia, dizziness
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Psychiatric conditions: initial presentation of depression
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Pulmonary conditions: upper respiratory symptoms, cough, shortness of breath, wheezing
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Urinary conditions (male and female): dysuria, symptoms of prostatic disease
Chronic disease presentations
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Cardiovascular and peripheral vascular conditions: chronic artery disease, heart failure, hypertension, hyperlipidemia
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Endocrine conditions: diabetes, obesity
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Pulmonary conditions: asthma, obstructive pulmonary disease
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Musculoskeletal and rheumatologic conditions: arthritis, chronic back pain, osteopenia, osteoporosis
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Psychiatric conditions: anxiety, depression, substance use, dependence, and abuse
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Comorbidities: presentation and management of patients presenting with more than one chronic illness
Health promotion conditions for adults
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Cardiovascular conditions: coronary artery disease
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Endocrine conditions: diabetes mellitus, obesity
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Infectious disease: sexually transmitted infections, hepatitis, human immunodeficiency virus (HIV), tuberculosis
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Musculoskeletal and rheumatoid conditions: osteoporosis
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Oncologic conditions: breast cancer, cervical cancer, colon cancer, lung cancer, oral cancer, prostate cancer
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Psychiatric conditions: depression, substance use and abuse
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Injury and violence: fall risk (for elderly patients), intimate partner violence, family violence
Health promotion conditions for children and adolescents
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Accidental and nonaccidental injury, abuse, and neglect
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Lifestyle: diet, exercise, nutritional deficiency
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Family and social support
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Growth and development
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Hearing, vision
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Immunizations
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Lead exposure
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Sexual activity and sexually transmitted infections
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Psychiatric conditions: depression, substance use
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Infectious disease: hepatitis, HIV, tuberculosis
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