Searching for the Family Doctor

The family doctor is dying, but is not dead, argues author Timothy Hoff in Searching for the Family Doctor: Primary Care on the Brink. This is not news to many patients or providers, with low fill rates for family practice residencies and high attrition from the specialty. National family medicine organizations estimate that the growing need for primary care will require that 25% of all graduating medical students enter family medicine by 2030.¹ Current trends do not bode well for reaching this goal, with only 8.5% of all graduating MD seniors and 23.3% of DO students entering family practice in 2020.^1,2 In addition, burnout, which continues to plague medicine in general, was reported for 49.7% of family medicine physicians in 2020.³ The value of this book is that Hoff’s amalgamation of testimonial vignettes helps us to understand the how, the why, and the so what of the rise and the subsequent perturbations experienced by the specialty of family practice and of family doctors.

Idealism drove the creation of this specialty. Note however that this term, “the specialty of family practice,” is seen by some as an oxymoron, in that generalism and broad thinking are core to family practice, rather than a narrow, “specialist” focus. Cultural icons of the late 1960’s and 1970’s, such as Marcus Welby MD’s embodiment of the ideal physician, modeled relational, and cross-generational medicine, as opposed to procedural, “quick hit” medicine. Even today this still resonates with the experiences of many of us, beginning with the early physician role-models from our formative years. In the case of one of us (UKS), for example, these models included both our family doctor in small-town Michigan, and “the doctor-uncle” who rode atop commercial rigs as he travelled to tend to his patients across a swath of villages in western India.

Family medicine in the United States started with the goal of being inclusive of all ages, and all disorders, by focusing on communication with patients and other specialties. This was not a part-time job. Doctors were incorporated into the private and community lives of their patients, and the workday was measured not by a clock, but by their patients’ sometimes incessant needs. Not surprisingly, this model was increasingly untenable due to paperwork demands, insurance regulations, poor reimbursement patterns, and corporate dictates such as restrictive hospital privileges. The limited training through hospital-based systems rather than community-centered sites made for poor preparation for an often-grueling career.

The family doctor then had to be a superman or superwoman: idealistic and tireless. While the initial cohort of family doctors evinced idealistic motives, this idealism was a recipe for disillusionment and burn-out. Today’s younger physicians tend to prioritize work-life balance more than their older counterparts. They are more likely to entertain “shift-work” jobs as hospitalists or urgent-care physicians—roles that do not promote continuity of care or support strong relationships with patients, which are at the heart of family medicine. In addition, the “perfect storm” of growing corporatization, and specialization, as well as changes in healthcare reimbursements, the strictures of the Resource Based Relative Value Scale (RBRVS), and narrower scopes of work for family medicine, all have led those who survive in family practice to adjust by either diversifying or, conversely, by limiting their clinical practices.

Through patients’ letters and interviews with doctors, the promise, and the tragedy, of a “paradise lost” become palpable. Their truths allow us to understand how we got here and lay the foundation for how Hoff proposes that we help family practice out of this rut. Hoff offers a ten-point plan for rescuing this much needed component of our health care delivery system here in the United States, listed here as in the text in descending order:

What does this mean for our world of medical regulation? We need to be attuned to the winds of social, political, and cultural changes, for example in conversations on Diversity, Equity, and Inclusion (DEI) initiatives in medicine.⁴ Additionally, we must be flexible when initially constructing and subsequently adjusting specialties, with the understanding that community and provider needs will change over time. Scopes of practice and training requirements for providers must be able to “flex” as medicine and society evolve. Most importantly, something we all would do well to heed is the clarion call of family practice: to keep the patient at the center of our medical systems.