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Family Medicine Today

Posted on: Saturday, 4 December 2004, 03:00 CST

We are very pleased to present this special issue of Medicine & Health/Rhode Island on Family Medicine, the first in several years. This issue provides vivid representation of some of the exciting directions that Family Medicine is taking and reflects on some its achievements. Family Medicine is currently the largest primary care specialty in Rhode Island, serving the population through research, education, advocacy and personal care throughout the lifespan.

The articles provide a glimpse into some of the primary care "hot spots": from maternal and child care, to homelessness, new concepts of research, primary care practitioners, smoking, and access to care. They all focus on the broad scope of healthcare; the need to consider the whole patient and practitioner in their physiological, psychological, familial, economic, and social context.

Family Medicine has a long and illustrious history in Rhode Island, beginning with the generations of country doctors and general practitioners who cared for the citizens of the State from its beginnings. One of these, Lucius FC. Garvin, MD, who became Governor at the turn of the last century, continued to make house calls on his way to and from the Capitol. He was an outspoken proponent of social legislation to further workers' rights, including reducing the length of the workweek, supporting women's right to vote, and encouraging educational reforms. (His tradition lives on in the annual family medicine Garvin Award to RI health and political leaders). After World War II, more technologically based medical specialties became emphasized, leading to a lack of primary care providers. To meet the needs for primary care in an increasingly complex environment, Family Medicine was begun in the late 1960s, with the origination of a three-year residency for newcomers and periodic reexamination for all.

The Rhode Island Academy of Family Physicians (RIAFP), formally known as the Rhode Island Chapter, American Academy of General Practices, was established on June 6, 1972, and is an affiliate of the American Academy of Family Physicians. The first five members of the organization were Alfred A. Arcand MD, John E. Murphy, MD, Jean Maynarcl, MD, Robert P. Sarni, MD, and Charles Millard, MD. These doctors formed RIAFP's new constitution, including the Academy's original mission statement: "to promote excellence in health care and the betterment of the health of the American people." Today, the RIAFP has an active membership of 175 family physicians, and over 100 medical students and residents. The active membership includes family physicians working in private practices, community- based health centers, hospitals, daycares, nursing homes, and school systems. The RIAFP has continued to serve this mission in promoting and maintaining high standards of primary care, as well as advocating for primary care among students and residents locally. This involves activities ranging from sponsoring continuing education of physicians to serving as a leading advocate for public polices to create a health care system that is personal, rational and just.

The Department of Family Medicine at Brown Medical School, the first in the Ivy League, originated through a fortuitous combination of events. Memorial Hospital of Rhode Island, a full-service community hospital that opened its doors in 1901, had a long-term commitment to general practice. In the early 1970s, the CEO, Mr. Frank Dietz, along with the Chief of Medicine, Dr. Mario Baldini, were urged by an internist and medical educator whom they had hired from Tufts, Dr. Robert McCoomb, to look into the fledging family medicine movement. Together they visited one of the first family medicine residencies in the US at Hunterdon Medical Center, in New Jersey, around 1972, and came back to Rhode Island convinced. The newly reconstituted Brown Medical School was simultaneously considering whether they should develop Family Medicine. When they decided in the affirmative, Memorial became the home of the experiment. Soon after, in 1974, Dr, David Greer, a leading community internist from Fall River, Massachusetts, was recruited to Brown as Associate Dean of the Medical School, and encouraged to lead the efforts in primary care and Family Medicine. He enthusiastically rose to the test, consulting with national leaders about the philosophy of the new discipline and the nuts and bolts of starting and running a residency. Dr. John Cunningham, a well-known Pawtucket General Practitioner, who had originally been hestitant about the new field, but became an avid supporter and enthusiastic leader, joined Dean Greer and a few part-time preceptors, to form the faculty of the new residency program in July 1975. The original eight residents were joined by twelve more the following year and the first graduation was held in 1978. Family Medicine remained a division of Community Health until 1978 when it became a full- fledged Department, under the leadership of its first Family Physician Chair, Dr Louis Hochheiser (1978 to 1984). After a hiatus, Dr. Vincent Hunt took over leadership of the Department, bringing it from its adolescence into adulthood over the fourteen years between 1986 and 2000. Dr. Charles Eaton, now the Director of the Center for Primary Care and Prevention, was the interim chair until August 2001, when Dr. Borkan was chosen.

As of last year, the Brown/Memorial Family Medicine Residency has graduated over 300 Family Physicians during its nearly three decades, including about two-thirds of the currently practicing Rhode Island Family Physicians. This remarkable statistic is even more notable given that, in comparison to residency programs around the nation, this has been achieved with almost no State support. Graduates are not only active clinicians, but most continue to teach the next generation of students and residents. Graduates also include many leaders around the country in research, academics, and advocacy.

Family Medicine has spread in Rhode Island and has had increased organizational and institutional strength and recognition. There are long-standing clinical Departments at Newport Hospital and Fatima/ St.Josephs, joined in the last three years by Departments at Rhode Island Hospital, and in the past year at Miriam, Roger Williams, and South County Hospitals.

As described in the article about the state of primary care, Family Medicine, along with its brethren, is at a crossroads, initiated by an internal generation change, external forces, and shifting social values. The first generation of founders, those who entered from associated fields or upgraded from general practice, is now almost entirely retired or passed on. They were almost all males, who dedicated themselves to practice and teaching. They created the field of Family Medicine, and trained the second generation, which has now assumed most of the senior clinical roles and leadership posts, locally and nationally. This second generation, in its forties and fifties, has achieved some of the academic and political landmarks that eluded their elders and have branched from clinical work, into teaching, research, and advocacy. The influence of the third generation, those entering practice in the past ten years, is now being felt. Almost evenly split between males and females, many are pursuing more focused professional careers, and many have chosen more "balanced" professional and personal lives. This generation has broadened the myriad of new family practice options-from pure outpatient to pure hospitalist practice; from health policy to genetics research; from continuing medical educational directors to undergraduate deans; from community health center directors to health insurance administrators.

Generations of Family Medicine

Even with our successes, challenges abound. Family Medicine is in the process of renewing the discipline to meet, first and foremost, the needs of our communities and patients. We must also be attractive to medical students and practitioners, addressing compensation issues and identity issues, and create a strong scholarly base. Research is not an end in itself-we must answer the questions that arise in practice. Many of us remember when there was no literature on common problems in family medicine, such as back pain or ear infections, from a primary care perspective. We often mistakenly treated these conditions based on insights from specialty and tertiary- care centers that were a mismatch with our own patient populations. This has been partially remedied, but more work is required. It also appears that we must be active in the larger social and political arena if we want to advocate for our patients or even ensure our continued financial existence.

There have been notable strides forward in defining the directions we must take. One of the most significant is the Future of Family Medicine project (1) in which seven leading national family medicine organizations have labored over the past two years to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. This ambitious project has identified core values of Family Medicine, proposed a new practice model, and a process for development, research, education, partnership, and change that aims to transform the ability of the discipline to improve the healthcare and health of the population. The new practice model hasthe following characteristics: "a patient-centered team approach; elimination of barriers to access; advanced information systems, including an electronic health record; redesigned, more functional offices; a focus on quality and outcomes; and enhanced practice finance."

The project concluded:

"Ultimately, system wide changes will be needed to ensure high- quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home, promoting the use and reporting of quality measures to improve performance and service, advocating that every American have health care coverage for basic services and protection against extraordinary health care costs, advancing research that supports the clinical decision making of family physicians and other primary care clinicians, and developing reimbursement models to sustain family medicine and primary care practices."

To achieve such sweeping changes, we must work together with our colleagues and our patients from throughout the state and the nation.

ACKNOWLEDGEMENT

Thanks to my co-editors, Dr. Alicia Monroe and Mrs. Laura Lavallee, whose efforts have been instrumental in bringing this issue forward. Also thanks to Mr. Frank Dietz and Dr. David Greer for their historical accounts, and to the RIAFP and to Dr. Michael Fine for background material.

REFERENCES

1. Future of Family Medicine Project Leadership Committee The Future of Family Medicine: A Collaborative Project of the Family Medicine Community Ann Fam Med 2004 2: S3-S32.

2. Keystone III: the Role of Family Practice in a Changing Health Care Environment: A Dialogue. Robert Graham Center, Washington DC, 2001.

3. Showstack J, Rothman AA, Hassmiller SB (eds). The Future of Primary Care. Jossey-Bass. San Francisco. 2004.

JEFFREY MICHAEL BORKAN, MD, PHD

Jeffrey Michael Borkan, MD, PhD, is Professor and Chair, Department of Family Medicine, Brown Medical School.

Copyright Rhode Island Medical Society Nov 2004

Source: Medicine and Health Rhode Island

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