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Ranit Mishori, M.D., MHS Headshot

Time for Total Medicine -- Get Family Medicine Out of the Shadows

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With input from Laurence Bauer

It happened again the other night. At dinner with friends and a few people I didn't know, I was asked the routine Washington, D.C. question: "So what do you do?" Even as I answered, I knew what would come next.

Me: "I'm a family physician."
Woman: "Oh, you're an internist."
Me: "No, not really. I am a family doc. I also see children."
Another woman: "So, you are a pediatrician"?
Me: "No, I am a family physician. I also deliver babies."
First Woman: "Ah, so you are an Ob-Gyn!"

Clearly family medicine, the specialty I chose when I earned my M.D., has a public relations problem. For too long, we family medicine doctors have explained what we are by explaining what we are not. And it's true: We are not pediatricians, orthopedists, internists, cardiologists, gastroenterologists, ophthalmologists, OB-gynecologists, endocrinologists, dermatologists, rheumatologist, neurologists, psychiatrists, or surgeons.

Yet, every day we do treat children, mend bones, manage chronic diseases, deal with hypertension, diagnose intestinal conditions, carry out eye exams, deliver babies, help control diabetes, take skin biopsies, inject aching joints, evaluate stroke victims, monitor depression and in some cases perform minor surgeries. And yes, this range of skills, while broad, does constitute a genuine and focused medical specialty -- the specialty of knowing your patient inside out and over years. We are meant to be experts as much in the person who comes to see as we are in the medical procedures we employ, to build a shared trust with our patients, to be partners with them toward the lifelong goal of staying healthy -- enough, by the way, to avoid too often the need for one those other specialists, whose practices often depend on people being very sick in the first place.

There is an odd logic that diminishes the status of family doctors. It is also faulty logic. People think that the more a physician knows about a specific medical problem or body part and the higher that physician's salary, the better care they will receive. Leaving aside whether that's actually true, it sets up a phony reverse corollary -- the belief that a doctor whose knowledge is more generalized, and whose pay scale is lower, is therefore providing inferior care. This is just wrong.

As generalists, we believe the ability to see the patient's big picture; knowing "enough" about most problems and understanding the preferences, past medical history and the resources of the person seeking care is far more important in most situations than narrow expertise.

In fact, give me a magic wand, and I would change the name family medicine to something that better captures what we do. "Total" medicine -- is that too bold? Or would it get the attention of the current health care marketplace where -- let's face it -- we total docs (okay, okay... it's still family docs) don't swing nearly the weight we should, given our numbers -- 100,000 nationally.

Some indicators:

• Only two cents out of every 10 dollars of NIH research money goes to research carried out by family medicine specialists.

• Family doctors literally don't have a seat at the table at the national medical committee that ranks the economic value to various physician services.

• Medical students who consider family medicine as a career report being discouraged away from the field by advisors, who say: "Family medicine? But why? You are such a smart/intelligent student."

Does this matter to anyone but those of us in the field? We believe it does. Because in a time of crisis both for quality of medical care, and its cost, the medicine we practice is a significant part of the answer.

Research shows that when patients access family medicine the result is high scores on the patient experience and lower costs overall. In fact, countries with higher proportions of generalists experience better health outcomes, at a lower price.

Why might be this be? Consider what the family doctor of today is actually doing:

The family doctor of today is a specialist trained to handle diagnostic complexity. According to one study, "care during family physician visits is more complex per hour than the care during visits to cardiologists or psychiatrists."

The family doctor of today is a forward-thinking researcher. Our research lab is reality: the exam room, the community. Our studies focus on what really happens between doctors and patients, between patients and their environments.

The family doctor of today is tech savvy and often a trailblazer. In many studies, family doctors lead in implementation of electronic medical records, and discovering new efficiencies in their use.

And yet, family medicine fails to attract the next generation because it is not as prestigious and lucrative. This won't change unless there is a fundamental upgrade our status, with more research funds into primary-care field, and improved incentives to med students -- like loan repayment assistance -- to join the field. Because at current pay rates, it can take 10 years to get clear.

And on the question of pay: It is time to declare that we family doctors possess an economically-undervalued skill set. Consider what we bring to the practice of medicine: detailed and individual counseling of patients, a coordinating role among specialists, the providing of preventive care, knowing our patients in the context of their communities. These skills are as unique to what we do, and as well-honed, as are the scalpel techniques of our most successful heart surgeons.

But look at how doctors get paid -- and how it works against us. Heart surgeons get paid per operation, dermatologists per mole removed, radiologists per x-ray analyzed. That's called payment by procedure. We family doctors, however, are in the business of helping patients avoid procedures. Paradoxically, we lag in compensation because we're at what we do. This needs to change.

Some of this needed change requires those of us in the field to step up. Maybe we've bought into our own misconstrued image, as the crunchy granola docs, and don't like to rock the boat. Enough. Total docs, let's rock. Let's demand a place at the table of decision makers. It is fine to be the "sensitive" M.D.s -- we believe in that value -- but we need to wise up when it comes to getting our message out.

Dr. Ranit Mishori is a family physician and a faculty member at the Georgetown University School of Medicine, in Washington, D.C.

Lawrence Bauer is the founder and executive director of the Family Medicine Education Consortium (FMER), a not-for-profit corporation based in Dayton, Ohio, which supports the educational and scholarly needs of family physicians

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