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Thursday Mar 22, 2012

Shrinking Scope of Practice Raises Questions About Future of Family Medicine Training

During the past two years, all 12 of the residents who completed the family medicine program at the University of Nevada School of Medicine started their careers as employed physicians. They're not alone.

According to AAFP data, more than 60 percent of AAFP members are employed physicians, and more than 80 percent of new physicians -- those who completed residency within the past seven years -- are employed. Thirty years ago, employed physicians were a minority in family medicine, but a slow shift to the employed model during the past two decades has eroded our collective scope of practice.

That erosion has occurred because some employers dictate scope of practice. Many family physicians have taken jobs with hospital groups who need primary care physicians to coordinate outpatient medicine. They don't necessarily need FPs to provide obstetric or pediatric care.

A recent AAFP member survey indicates that fewer than 20 percent of AAFP members have hospital privileges for routine obstetric delivery, and fewer than 60 percent have privileges for newborn care. Those numbers are down from 25.7 percent and 64.7 percent, respectively, in 1995. According to the American Board of Family Medicine (ABFM), fewer than 10 percent of family docs are providing maternity care, and fewer than 42 percent perform in-office procedures.

These numbers likely will continue to decline as more of us take employed positions.

One of the factors that typically draws students to family medicine is the broad scope of practice. Traditionally, family medicine has offered us opportunities to do a bit of everything. We have treated and cared for entire families -- from cradle to grave. But many new physicians are finding that they can't do that.

Employers are just one factor contributing to the problem. Restrictions on duty hours have reduced residency training and experience, leaving new physicians feeling less prepared for practice than in previous generations.

Although many small towns and rural areas continue to need primary care physicians who can provide a wide range of services, the percentage of family physicians taking those kinds of jobs is small. Fewer than 20 percent of AAFP members practice in rural areas, down from 31.7 percent in 1994.

And even rural areas aren't immune to these changes. According to the ABFM, more than 70 percent of family physicians -- regardless of whether they practiced in urban areas, rural areas or areas with health care professional shortages -- were "attending to the specialized needs of women" in 2003. By 2010, the percentage of physicians in all three categories who offered those serviced had dropped to less than 50 percent.

These are troubling trends. We have advocated against expanding the scope of independent practice for nurse practitioners (NPs), but if family physicians aren't providing pediatric care or maternity care or doing procedures or inpatient care, how do we differentiate ourselves from NPs or any other health care professionals?

As more residents are becoming outpatient docs, we have to ask ourselves:

  • Where are we going with training?
  • What needs to be done with curriculum design?

I recently attended the Association of Departments of Family Medicine (ADFM) winter meeting. Half of a day of the four-day event was dedicated to scope-of-practice issues. The Council of Academic Family Medicine, which includes the ADFM, is in the process of evaluating training and curriculum. Meanwhile, the ABFM is surveying test takers about what skills are truly needed by family physicians.

The aforementioned reduction in training time coincides with an ever increasing amount of complexity in the specialty. Patients are living longer while coping with more chronic conditions. Meanwhile, physicians are expected to be more tech savvy, implementing electronic health records and transforming practices to the patient-centered medical home model. How do we teach everything in a condensed time frame?

One potential solution is expanding residency programs to four years. The extra year would make up for time lost to work restrictions and give residents a chance to develop an area of concentration. The Accreditation Council for Graduate Medical Education has announced a pilot to examine length of training, and a call for proposals was released March 16. Up to 25 residency programs will be selected for a pilot scheduled to begin in July 2013.

The AAFP needs to be involved in these important discussions, and the Academy needs to know what members think. So I pose these questions to you:

  • Is it important to you that your Academy advocate for full scope of practice?
  • Should we instead move forward, focusing education and training on outpatient adult medicine and population management issues?

The AAFP Board of Directors is expected to discuss this issue at its May meeting. Your input here could help inform that discussion.

Daniel Spogen, M.D.of Reno, Nev., is a first-year member of the AAFP Board of Directors. He is a professor and chairman of the Department of Family and Community Medicine and director of medical education at the University of Nevada School of Medicine.


The questions raised in this excellent essay are deeply concerning: family medicine, in my opinion, will be compromised and redefined out of existence if we stop being "comprehensivists" able to provide competent care for 90% of the health problems we encounter. Several pressures in the American culture and health care system are probably contributing to these trends. Medical students with heavy debt want to go into high-paying specialties, they want professions that they perceive to have "low-demand" lifestyles, and they are inculcated during training with the myth that generalists cannot possibly do everything as well as a dozen specialists (when, in fact, we can--and for much lower cost). I have suggested before (J Rural Health, Summer 2009) that rural medicine may be its own specialty--the body of knowledge and skill that can provide quality care in limited-resource areas, for lower cost, to 90% of those who need it. Family medicine used to be the comprehensive specialty that filled this role, but I fear that it will no longer be so, should these trends continue. Family physicians and our representatives in the AAFP should aggressively advocate for our specialty to regain its identity as comprehensivists and to assert our proven ability to provide excellent clinical, obstetric and procedural care in many settings.

Posted by Paul D. Simmons, MD, FAAFP on March 22, 2012 at 07:13 PM CDT #

Nurse Practitioners will replace FPs because they can do the job for less cost. Individual and small group practices won't be able to compete unless they are part of an ACO. To be part of an ACO, they must be a Recognized PCMH. The process for becoming a Recognized PCMH is very costly and time consuming. So small practice is going away in favor of hospital-run, government micro-managed multi-linked offices. Residents are smart enough to see what is happening and gravitate toward well defined, salaried positions. If family medicine training requires an additional year, then for the same reasoning should internal medicine and pediatrics. And that is very unlikely to happen. From what I have observed, the graduates of my residency program are well prepared to enter the independent practice of medicine upon graduation.

Posted by George Miller MD on March 24, 2012 at 05:56 PM CDT #

you could do a 2 year basic training and then elective blocks and get a special diploma with exams to show competence 9Obstetrics should really be optional but takes a lot of training time away )for 6month extra training in areas of special interest eg peds or ENT or a medical subspecialty like cardiology with less technical scope -thats the UK model which is primary care based you could have a nice rural group practice with each partner some extra special certified expertise

Posted by Matthias von Reusner MD,MRCGP,UK on March 25, 2012 at 08:35 PM CDT #

Family medicine is at a critical moment. The reasons why are many and beyond the scope of my response. I do not believe we can continue to live in the past any longer and must deal with the reality that the days of the "all inclusive care" family physician are dwindling. Why are we training residents to perform colonoscopies, exercise tolerance tests, and many other procedures when they are not "allowed" to perform them once they enter the corporate world and are told that only the gastroenterologist or the cardiologist have those privileges? It would seem the time and money could be better spent elsewhere unless the AAFP, the ABFM, and other influential leaders stop "advocating" and start actually "doing". Talk is cheap and we've heard plenty of rhetoric over the past 2 decades promising to return family medicine to its former prominent place in American medicine. Having practiced for 39 years, I can assure you that this isn't the kind of prominence I'd been hoping for. I can understand the argument for increasing the primary care role of nurse practitioners and other allied health personnel. Most of the NP's I've encountered are highly professional and establish fast rapport with their patients. Most also have significant gaps in their knowledge or practice base. But, if motivated to consult appropriately, this is not a major detriment. I can't understand how we can look our residency graduates in the eye when we know that most all of them are going to be relegated to a corporate "office practice" and that it will only be a few years until those hard-learned skills begin to erode. The residents haven't failed. Our faculties haven't failed. Our practicing physicians laboring to preserve their livelihood and scope of practice from being reduced on all sides by insurance companies, large corporations, and the government haven't failed. Plain and simple: our leadership has and it's been doing it for a long, long time while most of the AAFP membership has had its collective eye on survival. Actions speak louder than words and right now, positive actions are needed to save our speciality.

Posted by Greg Darrow on March 26, 2012 at 03:29 PM CDT #

This is indeed a troubling trend. For a variety of reasons including debt, lack of practice management training, desire for a 9-5 lifestyle and increasingly burdensome regulations, the solo, full spectrum family practice is an endangered species. I think it is quite clear that the government wants to control the direction of healthcare and physicians. As it is notoriously hard to herd cats, the increasingly burdensome regulations serve to effecticely eliminate solo and small group practices. As a soon to be dodo bird I feel 2 options are available. One is to do what the government wishes and join larger institutions as an employee and lose autonomy. This course will lead to the end of Family Practice as we know it and hasten the replacement of us with NPs. The other path is to drop out of Medicare and commercial insurance programs, thereby refusing to embrace the unproven and dubiously beneficial EHRs, electronic prescriptions, ICD-10 and ACOs. This course will allow us to function utilizing the full breadth and knowledge of our training. The extreme reduction in overhead costs make this much more feasible than most think. The office visit charge can be reduced to less than what most patients spend a month on their cell phone bill. As for me, I will follow the advice of Patrick Henry.

Posted by Keith Dinklage on March 27, 2012 at 09:20 AM CDT #

Other than full-time faculty members of FP residency programs or rural family doctors who lack access to specialist support, no family physician in 2012 can realistically plan to provide ‘full service’ primary care in the traditional sense of our discipline. Moreover, I see no meaningful purpose in advocating that we should do so. Here’s why: 1. It is far too expensive on both the training end and on the reimbursement end in a society of 313 million persons. 2. No rational formulation of a ‘national health care policy’ could or would support it. 3. We would be far better off with a more regionalized ‘cluster approach’ within which family physicians become quintessential outpatient specialists, handling the most challenging cases while supervising NP’s and PA’s who provide most outpatient services. 4. Hospitalists who acquire proper training develop far more definitive skills for the in-patient setting than virtually any typical family physician. 5. Whenever a family physician performs an intervention that a board-certified specialist in another field can perform ‘better’, we set ourselves up for malpractice charges if we violate the specialist-level ‘standard of care’ and something goes awry. In my humble opinion, we should market ourselves as quintessential outpatient specialists and tailor our training to fit that role. If not, I anticipate that the 'old time family doctor' will go the way of the dodo bird. Everyone needs a good family doctor, but no one needs an improperly oriented or inappropriately trained one. Mark Gary Blumenthal, MD, MPH Knoxville, TN

Posted by Mark Gary Blumenthal, MD, MPH on March 29, 2012 at 04:25 AM CDT #

Why are we not having more post residency training option. For instance lets have community health, rural health, Native American health, care of elderly, EM [1 year ], Anesthesia [1 year] and so many more, we can attach. they all dont need to be 1 year long, they could be 3-6 month long. Please lets do this, I believe it will make a huge impact the future of patient care and academics of our profession.

Posted by hamed azimi on March 29, 2012 at 07:10 AM CDT #

I wrote this editorial for FPM in 2006. The handwriting was already on the wall, even then. Reinventing Family Medicine Redefinition is the first step toward reinvigoration. Sanford J. Brown, MD Fam Pract Manag. 2006 Apr;13(4):17-20. Our specialty is ailing. The dissatisfaction and unhappiness of our physicians is mirrored in years of declining Match numbers and the consequent decline in the number of training programs. The old model of adding two or three years to the postgraduate education of general practitioners to give them more clinical training no longer works in today’s medical marketplace. In the 1970s, when the American Academy of General Practice became the AAFP specialists were less common and midlevel providers rare. Today midlevels and specialists abound. The former claim to do what we do, and the latter claim to do it better. Our clinical expertise, both cognitive and procedural, is being assailed. Many family physicians have long felt that our specialty needs redesign. The Future of Family Medicine project1 is one institutional manifestation of that need. But reinvention requires that we first be clear what makes us different from other medical specialties. Is it that we value interpersonal interactions leading to lasting quality relationships more than other specialties, as William J. Hueston, MD, suggests in his editorial “Rekindling the Fire of Family Medicine”?2 Perhaps, but that’s hard to achieve when some of us have to see a patient every 15 minutes all day long. Besides, what gives us bragging rights over other primary care physicians? Don’t internists, pediatricians and ob/gyns value their long-standing patient relationships as well? The old GPs worked solo, did almost everything and truly did care for families. Today’s FPs work in large multispecialty groups, are mostly employed and tend to subspecialize. Today’s FPs can be hospitalists, emergency medicine physicians or holistic health practitioners; they can concentrate on dermatology, women’s health or pretty much anything else they choose. What exactly is a family physician today? What is our core identity? We need a new paradigm for a new time. The old models are obsolete. If we are going to be a specialty unto ourselves, then we need new areas of expertise. These have to be taught and nurtured in our residency programs. Here are a few suggestions for skill sets that will help redefine us in the new millennium: 1. Practice management. Our new initiates need to know how to run an independent practice, because only working for ourselves gives us absolute control of our time and enables us to deliver the highest quality care. Practice management should be taught as a core competency in our residency programs. Physicians tend to shun it, but it really is not that difficult to master. It is certainly a lot easier than getting into medical school. Our forebears ran their own offices and, with computers, it’s even easier to do today. 2. Wellness medicine. This is territory that needs mapping. We should be leaders in keeping our patients well and out of the hospital. That requires special expertise in nutrition, exercise and stress management. We need to train our patients to come in annually for a health maintenance exam that tells them how healthy they are and what they need to do to remain well. We shouldn’t be competing with our colleagues in treating diseases; we should be at the forefront in preventing them. 3. Information technology. No, not the electronic medical record but learning how to use available technologies to access up-to-date medical information, patient education materials and sources of referrals. This could involve something as simple as phoning up the junior author on a paper that speaks to a patient’s problem or as complex as researching a database for cutting-edge therapies. We need to learn to use statistical tools to evaluate the evidence. Since we have always been a source of referrals, we need to develop contemporary expertise in that realm and not just rely on anecdotal experience. Perhaps we need to implement evidence-based systems for referring our patients to other specialists to assure our patients the best possible care. 4. Home visits. House calls are a rarity in medical practice today, but what better way to get to know our patients than to see them at home in the presence of their families? We need to reclaim the house call as our province and have sophisticated systems for caring for our patients in their homes. Now that so many Americans have no health insurance, this could be an economical way of providing health care and avoiding the high costs of hospitalization. 5. Family dynamics.Do we truly take care of families? In fact, if we had to restrict our practices to families we would not survive. Our patients are family members, but for the most part we don’t care for whole families. Nor can we claim special expertise in dealing with families, since meaningful education in family dynamics is conspicuously absent from our training programs. If we claim to specialize in taking care of families, then we have to master the social and psychological skills needed to better understand and help our patients. Knowing how to listen and respond in a therapeutic way to our patients’ concerns and health problems will separate us from the herd. 6. Community medicine.. We need to be leaders in our communities not just in preventing disease and disability but in preventing violence, accidents and obesity – not to mention health care disparities and the diseases they cause. We also need to be able to recognize the community as a patient and create programs to take care of our communities’ needs. These skills can be learned from our colleagues in preventive medicine and from organizations working in prevention. Family physicians need to think more globally and become leaders in these efforts. The fight for privileges to do procedures saps our energies and is one that we will eventually lose, not only because specialists are better trained to do them, but because in this day of consumer-driven health care, our patients will select the doctors with the most experience and best track records to do their colonoscopies, colposcopies, cardiac stress tests, C-sections, hernia repairs and critical care. Perhaps no other specialty trains its residents to do so many things they will never use in practice, while spending so little time training them to do what most of them will wind up doing – clinic medicine. To maintain the dynamism of our specialty, we must define ourselves by what we can do better than everyone else, not by what everyone else is doing. The skills inventory I have outlined above is compatible with an office-based practice. It is a listing for our time. It should excite medical students considering family medicine and residents already in family medicine by showing them ways to actualize the core values of the “New Model” of family medicine (“continuing, comprehensive, compassionate and personal care”3) while maintaining patient loyalty, getting adequate remuneration, developing independence and building the profound interpersonal relationships that will afford them immense satisfaction in practicing their healing art.

Posted by Sandy Brown on March 29, 2012 at 08:38 AM CDT #

I guess, I will be defined as a new physician being out of residency at my 7th year now. I am afraid that extending the FM training to 4 years will repel more students from pursuing this residency. For one, the average medical student is graduating with a $140,000 debt; And I know the first thing on my mind was to get rid of my debt when I graduated from residency. Secondly, going solo is risky for a new graduate simply from the business standpoint. I think, we should keep the current business trends and needs of the new graduates in mind while discussing the future of Family Medicine. Let's admit, with all the talks aside, the competition is tough in the medical arena. A career in Family Medicine has allowed me to practice a wide array of medicine. I believe everyone has a right to pursue his/her dream. I just wish for even more options through various fellowship programs (ER, hospitalists, etc.) to become available to a family physician. Let's not forget that family medicine is not just about practing OB and newborn care, but it also allows one to become a more comprehensive "FAMILY doctor" (i.e. developing strong bonds with people) and the patients appreciate that. I think, I can continue to practice this skill no matter where I end up.

Posted by Tariq Vora on March 29, 2012 at 08:53 AM CDT #

Dr. Simmons and Dr. Darrow have summarized well the main needs and challenges. We must take action to address both the needs and the challenges. Coming from a rural background and having worked over the last 27 years in several rural and urban underserved communities, as well as with underserved populations globally, the breadth and depth of broad scope family medicine practice is what is needed and what will improve health outcomes in an effective cost efficient manner (there is also some evidence on this). NPs and PAs are important members of our health care team, however by nature of their training and its purpose they lack breath and depth -- family physicians provide this. I propose two types of family medicine residencies: one type prepares those who chose to practice with a more limited scope (3 years), the other prepares those who chose to practice with breadth and depth serving those with great needs especially the poor/disenfranchised (4 years). We must take action and stop being wishy-washy, indecisive and confused.

Posted by Inis Jane Bardella, MD, FAAFP on March 29, 2012 at 08:56 AM CDT #

I tend to agree with the opinion expressed by Dr. Blumenthal. Once we emerge from our idealistic protected cocoon of medical education and residency clinical training, it becomes obvious that the reality in the evolution of our discipline and specifically, family medicine, has not been driven by us (as physicians) in as much as shaped by the environment in which we work - market forces/area needs (employers), government forces (regulations) and insurance company forces (payments). Therefore, we have developed, generally, to become the experts in oupatient primary care - from cradle to grave, which is awesome. We learn how to and should continue to take care of families in one venue; evaluating, treating and helping to prevent a majority of the routine and complex chronic and acute medical problems occurring in those families. This is our uniqueness and value. It is a majority of what we do and what we do well. Our specialty training should reflect this. I do not think our "full scope" is becoming extinct, it has adapted and changed. I do not believe the need or value for well trained primary care outpatient based Family Medicine physicians who are experts at clinical evaluation, treatment, education, ensuring quality and leading an entire team of staff (MA's, LPN's, PA's, NP's, etc...) in the care of individuals, families and populations in the communities in which we work will go away. It can't - "nature finds a way."

Posted by George Rankin MD, MS, CAQSM on March 29, 2012 at 09:22 AM CDT #

As a medical student intending to practice rural family medicine in a community 100 miles from the nearest hospital or specialist, I find this trend really disturbing. I understand the need to churn out more FPs to meet the growing need, but cutting our training short or making it more of a 'specialty' is not the right answer, in my opinion. With practices hiring more PAs and FNPs, I feel we need our traditional full set of skills to distinguish ourselves from these physician-extenders, and to have the knowledge base to oversee them well. What distinguishes a FP MD from all others is that we're consummate generalists: we have the ability to take care of any patient from cradle to grave in the outpatient setting. Yes, hospital privileges are important, and I actually hope to do general surgery as well as see patients of all ages in my clinic, but we are not hospitalists. So I'd prefer if residencies remain focused on preparing us for the full breadth of services traditionally provided by private practice FPs. Then if we choose to be employed by a hospital or group, we can use a smaller set of our skills. But we're not diluting or limiting our skill set. On the other hand I have to say, that even though I pay in-state tuition, my debt of well over $250K at the end of these 4 years (twice that if I have to do the extended payment plan) would make it hard for me to consider a 4-year residency. We no longer get our loan interest deferred, so it started accruing on day 1 of year 1 and that's a burden that affects choices about how long to remain a student. So I'd like to see changes made at the med school level. I currently precept with a PCP just 4 hours a week. We have plenty of slack and pointless fluff in our curriculum that could be replaced with more hands-on mentored training. That would decrease the need for residencies to be longer, despite the shortened duty hours. And it would benefit all med students by having them hit 3rd year, sub-I's and residencies with a better foundation in basic doctoring. I hope that, by the time I get there, FP residency will still prepare me to be an old-fashioned country doctor able to care for all the day-to-day medical needs of a community and not just run a multi-doc practice and make referrals.

Posted by Lisa Hamilton, MS1 on March 29, 2012 at 09:27 AM CDT #

I agree with Ms Hamilton. The broad scope of our training strengthens us and differentiates us from other specialties, not to mention that - I believe - the generalist skill set will become far more valuable relative to other skill sets as the early baby boomers retire. As I've rotated through various specialties I'm always pleasantly surprised by how quickly one can adopt the fundamentals of a subspecialty into one's practice, and how superior this base of knowledge is to that of the focused sub specialist when seeing a varied population. We are the answer to the inflated cost of medicine in America! Residents are choosing to go to hospital based practices because of their debt load and the complexity our medical system, but this does not mean that they are locked in to that model of practice. Our current broad scope of training and the decreasing pool of rural FPs will continue to draw those with an independent nature toward the ideal of a generalist practice.

Posted by Chris Killer pgy3 on March 29, 2012 at 10:46 AM CDT #

What Family Medicine is able to hang it's hat on is the fact that we are able to care for all types of patients. What an individual doctor chooses to do with that training is a personal choice. I agree that the new model tends to be the employed physician, as I am now, but that does not always have to be a limiting factor. I am in a rural area but the hospital no longer does OB so I am not delivering or taking care of nursery patients. However, I am seeing infants after discharge from the nursery and need those skills I learned during residency even though I am not actually seeing them in the nursery. I see patients of all ages, I do scopes at the local hospital, I round on my patients in the hospital, and I see patients in the nursing home. To cut out any exposure to this type of training in residency would not only do the resident a disservice but also his furture patients. Granted, mine is a rural practice and the situation is different for Family Physicians in more urban settings. Again, location is a personal choice that comes with a compromise on practice style. The physicians that choose to do a more rural practice are doing more procedures and seeing a wider variety of patients out of necessity. We need physicians trained to handle a vast variety of medical conditions to best serve the needs of any patient wherever that might be. To say that something is no longer important train on in Family Medicine is to say that the particular skill or knowledge is no longer of use and I don't see that. All knowledge is usefull even if not used everyday. I had an attending in residency that said medicine is an " experince related science" and through a large variety of experience is one able to care for each individual patient.

Posted by Jonathan Maddux, M.D. on March 29, 2012 at 10:53 AM CDT #

We have done ourselves a disservice by calling ourselves "primary care" physicians. That implies triage and refer as a basic mode of practice. I consider myself a "comprehensive care" physician because I have not only the breadth, but also the depth, of knowledge to manage patients with multiple complex problems (social and psychological as well as physiologic) as well as, if not better than specialists. This is because I can integrate these problems into a "whole" which is greater than the sum of its parts (specialties). In my 20 years in private solo practice it was not unheard of that I needed to instruct a specialist in the appropriate care of a problem in his/her area that he/she mismanaged. Those that say a single physician is no longer capable of managing all the complex problems of a patient appear to be projecting their personal discomfort and inadequacies on others. This appears potentially related to teaching faculty who have never been in private practice and start teaching directly out of residency. If we want graduates who know how to practice, we need faculty who have done it. Unfortunately, these types of faculty may not be able to to much more than triage and refer resulting in graduates who do the same. If that is true, then we are no different from mid level providers. I closed my private practice because of the economics. I agree that the only way out is to return to a free market model by not accepting direct payment from 3rd party payors.

Posted by David Weldy on March 29, 2012 at 12:14 PM CDT #

Excellent essay, and stimulating discussion in these comments. I largely echo the sentiments of Drs. Simmons, Bardella, Killer, and Ms. Hamilton, and I agree that scope of practice is a major challenge for our specialty today. Based on the data from the ABFM regarding current scope of practice, the trend towards "office-only" is clear. Now in my first year of practice, having attended a rurally-focused residency and now working (as an employed physician) in a rural practice (which includes clinic, hospital, procedures, OB, surgical OB, ER), I recongize I am in the minority of AAFP members. However, whether we call it the comprehensivist model, or the rural model, or the OB/procedural/surgical/EM/hospital model, when I interviewed FM residency applicants this year, this full-spectrum training is what they were seeking. So, while I acknowledge the trend in our specialty, I hope we (and the AAFP) continue to emphasize the importance of full-spectrum training and practice. If that means creating different distinctions within family medicine (and possibly training tracks), so be it. However, I fear that if we call a subset of our specialty "rural family medicine" (or something similar), we may be weakening, inadvertently, the credentials of our non-"rural" colleagues, and potentially creating factions within the specialty, thereby undermining efforts (by the AAFP and others) for family medicine physicians to remain the foundation of primary care in this country.

Posted by Matt Horning on March 30, 2012 at 11:53 AM CDT #

I agree that adding a 4th year will help reduce interest. I would encourage optional fellow ships for those going to rural practice with exposure to OB- Csxn fellowships which already exist, and perhaps a trauma track for 6 months additional training- of which there are a couple programs. If we want more people to be FP's- then pay off their debts- it's unthinkable for a student with $250,000 in debt to even consider FP. I did solo rural practice and I quite- long hours, and the real kicker is I had to struggle every day to get paid from big insurance companies. Until you fix the payment issue- solo practice are dying.

Posted by Marcus Higi on April 02, 2012 at 06:26 PM CDT #

The real challenge for traditional family practice today is of survival. Will those belonging to the endangered species of practicing full spectrum of family medicine be able to survive? Darwin's theory of the survival of the fittest makes it important for us to realize the need to adapt to the changing world at the cost of losing the original persona of the family doc and making peace with it. Residents will graduate to face the realities of the new status of family medicine and why not prepare them for the changed face of family medicine? I would vote for new curricula to train future family docs.

Posted by Sushama Kotmire on April 20, 2012 at 09:59 AM CDT #

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