The appeal and possibilities of family medicine

I remember the moment I chose family medicine as my specialty. My medical school class had just experienced a tragedy: the sudden and accidental death of a beloved classmate. In the context of this grief, I was on an internal medicine rotation at a Veterans Affairs hospital and was frustrated by how transactional the care seemed. Our patients would come in acutely ill, our team would set them up, send them away, and a month later they would come back unable to support themselves outside of the hospital structure. I asked if anything in medicine could feel fulfilling as a career. During this rotation, I spent a day at a local hospice learning about end-of-life care with another classmate. The other day we were confronted with the collective grief of our class and I had a flash of insight into understanding health in the context of mortality. The hospice director was a family physician who had a deep understanding of the beauty of a life well lived, from birth to death. By the end of the day, I felt that the family medicine philosophy was the only way to practice as holistically as I wanted to.

Dr. Timothy Hoff does a remarkable job of collecting such stories in his book Search for a family doctor, and contextualizes them within the historical development of family medicine as a specialty, while outlining the cognitive dissonance of practicing family medicine in a broken health care system. He spends many chapters profiling medical students and doctors at various points in their careers, painting a picture of the tension between mission-driven altruism and the pragmatism of financial stability. He relates this tension to why today’s family physicians struggle to embody the grand vision of well-trained physicians who provide diagnostic and therapeutic measures to all ages, serve as the primary decision-maker for illness in and out of the hospital, and take on a community role attorney and specialist liaison.

As an outsider looking at the specialty, Hoff offers his own insight in the final chapter: The Top Ten Family Physician Rescue List. In it, he includes a number of fascinating thoughts and suggestions, some of which should probably be considered by the profession. One suggestion is to consider renaming the specialty to reflect the full range of care family physicians are capable of—rebranding, if you will. Hoff notes that he wasn’t sure where the name “family medicine” came from, so I took this opportunity to see if I could learn on my own.

I happened to be directed to a quote from Dr. Dan Ransom, a behavioral psychiatrist and early influencer of family medicine as a specialty. In his 1981 essay, “The Rise of Family Medicine,” he wrote, “it is not the family as an entity or institution that is of central importance, but the ‘family’ as a metaphorical designation for primary, largely self-regulating human systems. Thus, family medicine deals with any group that significantly changes the lives of its members. More important… is a “family mindset” among providers as health problems are conceptualized, defined and addressed in relation to their specific context. In this way, family medicine deals with both the formal and the concrete and personal aspects of human health and relationships.’

Compared to internal medicine residency programs, for example, family medicine is unique in its requirement to incorporate behavioral health into clinical care, with an emphasis on the biopsychosocial model of health. This emphasis is only compared to pediatric studies, where understanding child health requires knowledge of family systems. However, family medicine is the only specialty in which an understanding of both family and community is explicitly encoded in the training requirements of the Accreditation Council for Graduate Medical Education, outside of the core template.

This understanding of family medicine was exemplified for me during the third year of my residency program. My mentor for the day, Dr. Mary Jo Fink, runs the Friday colposcopy clinic. Colposcopy is how cervical biopsies are obtained after an abnormal Pap smear. One Friday we had a young patient, Linda, about 20 years old, who was distraught throughout the procedure. No amount of reassurance or expectation could comfort her.

After the visit, Dr. Fink and I wondered what Linda’s emotional reaction was to this procedure. We later found out that about 15 years ago, Dr. Fink diagnosed Linda’s mother with cervical cancer, from which her mother eventually died.

A week later we saw Linda again to discuss the results of her biopsy, which were normal. Dr. Fink was able to connect with Linda about her family history, an insight that Linda would not have shared otherwise.

In this case, knowing the immediate family member was instrumental in getting to the root cause of Linda’s tension. Such long-term relationships are rarely the norm anymore, with primary care physician relationships being severed based on employment status, insurance changes, and changes in employer income. Re-prioritizing relationships and longevity and creating sustainable practices for physicians are key to building and improving the primary care infrastructure in the United States.

In today’s health care system, we also talk about family medicine as if it were synonymous with primary care. But family medicine is not just about whether cancer screenings are completed or whether HEDIS scores are measured. It’s about understanding the patient in the context of their community and family system and getting them the care they need, whether it’s a blood pressure check or a biopsy, and balancing that perspective in the context of the health care system.

Can this only happen if family doctors, as Hoff claims, treat families? Family medicine-trained physicians who choose to be hospitalists or emergency physicians do so out of financial pragmatism, according to Hoff. However, if we consider family systems as the foundation of family medicine, “family” medicine can still be practiced without significant continuity. It is a philosophical approach that involves understanding the patient’s social structure in order to develop innovative solutions for their individual care.

In this way, family physicians are equipped not only to ensure that screenings are performed, but also to address the behavioral aspect of addiction, stress, and other epigenetic factors that influence the expression of disease states. In understanding the “family” in family medicine, I have a better idea of ​​what I actually do, how I present myself to my patients, and perhaps even how to change the health care system.

Author’s note

Lalita Abhyankar, PhD MHS is employed by Carbon Health. Shees is an area director and board member of the California Academy of Family Physicians and a board member of the California Academy of Family Physicians Foundation.

By Timothy J. Hof

Baltimore (MD): Johns Hopkins University Press, 2022

288 pp., $39.95

Editor’s note

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