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Family Medicine in the United States: history, education

and the practice.

J III MD

John J. Frey III MD


Madison, Wisconsin

?
What happened to general practice?
1950

Increased specialization in the 1950s led to decrease

number of generalists

Specialists had extra training

Loss of prestige for G.Ps

()

Loss of income (surgery, procedures)


Loss of role as center of health system

1960
Medical education changed in the 1960s

The hospital dominated education

Emphasis on technology

New areas of research

Pressure
to expand number of students but no requirement to create the right mix of specialties

No academic departments of general practice

?
Why family medicine?
(

) Communities demanded doctors (rural and urban)


() Patients
lost the entry point to care (the primary physician)


Specialism caused fragmented care

Political
pressure from elected officials toward medical schools to respond to community
needs


Essential organizational components

The American Academy of Family Physicians

A trade union for general practice

A system of organized education

The Association of Residency

Directors

()

A certifying body (accreditation)


The American Board of Family Medicine

An organization of academics

The Society of Teachers of Family Medicine

VS

General practice

vs.

family medicine

No organized training

3 years post graduate

Hospital based

Community based

No training in behavioral sciences

Training in family and


individual systems

Curative only
No

six years

requirements for continuing education

Emphasis on individual

Includes preventive
6 Certification every

Emphasis on family and social


systems


Family Medicine was successful
2700

2700 graduates from residency training each


year.

1132

113

University Departments and 2 Divisions.

85,000

85,000 family doctors

nationwide.

3
3rd Largest Physician Professional Organization.

2009
Practicing US Family Physicians 2009

36%47 36% women, mean age is 47


83%7%
83% direct patient care, 7% teaching

22%70%

22% in small town/rural,

70% metropolitan

25% 25% solo or two person practice


23%43% 23% own their practice,
43% employed

64%

50%

64% on some salary arrangement


<50% do hospital work

2008


2008

?
Where do family doctors work?

1:
Where do family doctors see patients each week:

:
Patients seen in the office

8.1

Patients seen in the hospital

:
Patients seen in nursing home

:
House calls

0.6

2.4

84.9


Profile of activities of family doctors


Family doctors and obstetrics


Most common diagnostic groups

Top 25
Top 25 diagnoses


Procedures done in office

21
In the 21st Century

50
The factors that created family medicine 50 years ago still persist

Fragmentation of care, need for a guide in
the labyrinth of modern medicine, a personal physician who is trustworthy

The responsibility of family doctors for chronic disease management and


prevention is greater

The cost of care has risen dramatically while the quality of care has not

1
Number of positions filled with US
graduates

:
Challenges: education

Cost of medical

school is rising

Patient

care is in community, education is in the hospitals


Students more interested in technology than people

Medical students dont

learn team care

()
The ubiquitous society (everyone is linked all the time)

:
Challenges: patient care
(

) Specialty care is not


necessarily the best care (more expensive without increase in quality)

Patients need a guide and a coach through the system.


Access to information (the Internet) can improve care or create unnecessary


problems

:
Challenges: society

What value is placed on generalism?


No
responsibility for uninsured

US population is aging


Disparities based on race, socioeconomic status and location

Cost of health care

continues to rise

Employers are not offering health insurance the old


model is disappearing


Causes for optimism :

The rest of the world understands the need for well trained
family doctors.


Governments have to live within their budgets

Students still have a strong belief in


community service

After a point, more money does not produce better care, just more costs.