The end of the year is a time for reflection. The past few months have also been extremely full of deliberations at the clinics and all aspects of the department. Some of these are local issues with UMA and NHS, etc. Other issues are part of a more global concern about family medicine and medicine in general. I am writing with a sincere question in mind. I want you to ask yourself to examine what you believe in about the department and clinic and family medicine.

This is what I believe.

Family Medicine is certainly the latest of the movements to help reform medical education: the process of making doctors for the US. It is the best hope of reforming medical education, but it seems to be socialized into some more typical roles. It has lost its zeal for reform and as it does so, it is not serving the missions that have kept funds flowing to support Family Medicine.

Continue success in Family Medicine is dependent on continuing to improve the quality of the doctors that emerge not only from Family Medicine residencies, but most medical schools.

Family Medicine continues to play a key role in medical education as well as medicine. The following areas are most important:

1. Doctor-patient communication, particularly visualizing the different perspectives of patients and translating the language and practice of medicine for our patients.
2. Whole person problem solving
3. Community level problem solving
4. Advocacy for patients
5. Demonstrating service by putting patient needs above the needs of ourselves and our other interests. This has always been at the head of the list of physician values and it is perhaps the most threatened value in the current age.

If we succeed in our efforts in Family Medicine, medical education will improve and medicine with it. If not, then medicine will continue to deteriorate, doctors will continue to lose respect, and medicine will be in ever increasing danger of replacement. Oh, and by the way, medical costs will continue to spiral out of reach and we will have yet another cycle of interference and regulation.

The national leadership in Family Medicine is not doing as good a job as it has in the past. It has two major areas to address. First it needs new vision. It must get back to becoming member-responsive. This is tougher with each passing year because corporate and other competing interests make deeper and deeper penetrations. The example of other associations, medical and otherwise, is to become more defensive and self-serving over time. Members are also more complacent. While not as lucrative as other disciplines, the living provided by family medicine is certainly more that comfortable and the work is satisfying and keeps you as busy as you want to be. This is not a generational thing. It is a function of personal choice and having possessions. The more you have, the more your possessions begin to possess you.

The individual responsibility is perhaps the most crucial. Family Medicine depends on the actions of its member family doctors. Past leaders did a good job of getting things going, but individual leaders can only go so far. Many have said that democracy cannot survive without an ethical and moral people and so it is true in Family Medicine. We must have certain values that we believe in and we must have a way to keep these values constant in the midst of a whirlwind of change. Most critical is that we continue to transmit those values to new students, residents, and practitioner. In particular family doctors that teach are a critical component of the success of family medicine.

I am proud to be a member of a department that continues to attempt to fulfill all that is possible in Family Medicine. In my rural area, I know of no other department that has successfully adapted training programs to the unique needs of the entire state, from inner city urban to remote rural. Our students can talk to patients and in the last few years, they even listen to them. Even more importantly, we are not satisfied with our efforts in these areas as we realize there is more to do. I see us continuing to strike out to improve medical training in this area. Our faculty and residents and staff demonstrate service. They support incredible efforts in the community. Our research focus is in areas that really matter. We research patient care and practices and practice management. Countless doctors and clinics and communities have benefited from our work.

In order to do so many things in so many areas, we have made some sacrifices. Some of these have enabled us to do spectacular things, but…

We have some work to do in two key areas:

One area seems more selfish, but it is critical for us. We need to toot our horn more than we currently do. This seems self-serving and it certainly can be, but our motives are more important than our actions. If we attempt to get recognition for service so that we can do more service, then it is important to do some self-promotion. Better minds than mine can work in this area and we need lots of assistance.

The second area is far more difficult. It is a very personal matter. It goes to the core of why you are and what you want to be. As I stated earlier, I want you to ask yourself to examine what you believe in about the department and clinic and family medicine. The difficult area is focusing on giving the best care possible to every patient that comes to you for care. For others in the department, are you doing what you can do to improve the care of patients through your efforts.

The solution is really quite simple. It has to do with doing what it takes to deliver that care. This is more than just increased hours. It is more than reform efforts. It is more than intellectual discussions with colleagues around the world. It is putting into action what you know to be the best for your patients, in the clinic, in the directions that you send patients, in all contacts that would improve their health. It involves changing the way you think, at age 40, 50, or whatever age and regardless how you have done things. It involves setting priorities and doing what it takes to accomplish these goals.

These are hard words. For some, it may mean other pathways. Others may need to work together to provide this kind of care as other priorities may prevent the full effort needed.

This effort is most important in the local clinics and department, but it is also a national need. Family L is the list serve for Family Medicine Educators who deal with residency education. One of the longest running discussions on the list serve had to do with the relationship between physicians and the pharmaceutical industry. During this busy time on the list serve, some comments were posted about open scheduling and same day appointments. I decided to respond, noting that we had tried this, but the root cause would not be addressed by changes in scheduling.

There were hundreds of responses to the pharmaceutical ethics issues, but only a few regarding this post that attempted to get to the heart of the patient care issue. Granted that the lack of response is not, in itself, proof that the real difficulty is the lack of a patient care priority in Family Medicine. But the type of responses, where these responses are coming from (faculty development experts, respected chairs of family medicine), and the inability of family medicine to deal with this area give weight to my concerns.

The post is repeated for reflection. Again, remember that this is my view as seen through multiple departments and residencies that I have worked in and with over 20 years:

"We need to be doctors first and make this and our clinical activities our top priority. Anything less will not survive. If the clinics do not survive, then we will not be able to teach, research, serve the underserved, etc. Good quality clinics will continue to be able to teach, but mediocre clinics are just not good teaching sites. I suspect that we are doing our residents and their patients a great disservice in this area.

We are attempting to make patient care our top priority, again and again. We seem to discover this every few months, but fail to make headway in this area. One of our faculty who is mostly practitioner is doing her MBA now. Regarding recent "Jerry Maguire" type memo episodes from myself and others and resultant clinic meetings, she notes that these are temporarily helpful for feeling better, but not much help in the long run without some implementation. Everyone from top to bottom has to have this commitment to quality for it to work. We have far too much to do in our clinics to continue to put the overload on nurses, a few clinic faculty, or key staff that tire and leave (in various ways, transfer, quit, or impairment).

This is really the only strategy that works if you plan to care for patients at all. Seems simple, but we have missed the point too long. Our patients deserve the best, our learners deserve the best, and family medicine must have the best in order to survive these turbulent times and come out ahead and influential in the decades to come."

Robert C. Bowman, M.D.

A response: "I also echo Dr. Bowman's comments on adjusting priorities and "putting patients first." Interestingly, when we've tried to address this issue in faculty development (both inside and outside the institution), it's been a very difficult concept for many in family medicine education to accept."

Viki Kaprielian Duke Family Medicine

Will we be like many of our physician leaders who are focusing on dollars and control and position or will we continue to embrace patient care advocacy and teaching values to learners?

I think what we can all agree upon is that reflection, re-evaluation and change is necessary. Barbara Starfield, as well as many other knowledgeable leaders, has documented that primary care is not delivering on its promise. Our founders are crying out for a new paradigm.

Another post for your reflection:

"Respected leaders in Family Medicine such as McWhinney, Carmichael, White, those at Keystone, et al. are proposing and airing their ideas. To me, they are not attempting to write in stone, but are raising the bar on future negotiations for a change process. We must consider their words.

Times are changing, there are many warning signs, and the public is growing restless. In my opinion, the concepts presented by these leaders can be a beginning point for a new and necessary revolution in family medicine philosophy.

We need to:

1. Rewrite our goals (professional resonance) and look at progressive and unique ways of educating our students to better prepare them for this New World medicine. (ethics bias communication health caresystems)
2. Agree on our battles (Universal health care? Renumeration? Funding? Training? Improvement of quality of care? Relationship with specialists?).
3. Decide how we will join forces with our brothers and sisters (nurse practitioners, physician associates, primary care internists, etc.).
4. Develop a rapid system which constantly provides and updates recommendations on new technology usage and offers unbiased information (especially on medication utilization). In this area, we need a critical look at how we relate to the pharmaceutical industry. We must pursue behaviors which reduce the cost of medications.
5. Emphasizes patients stories and takes a broader look at "biosemiotic thinking (the interpretation of signals and the assignment of meaning to them) and salutogenesis (production and maintenance of health)".
6. Re-energized our mission, our vision and our message.
7. Reach out and connect with our practicing brethren and sistren.
8. We need careful and thoughtful action. We rely on our academic leaders to institute change.

Lead and the warriors will follow.

Lawrence Silverberg

Thanks for reading. May the new year find you with greater vision, greater hearing, and greater focus on what really matters.

Robert C. Bowman, M.D.