Career Resources articles posted on NEJM CareerCenter are produced by freelance health care writers as an advertising service of the publishing division of the Massachusetts Medical Society and should not be construed as coming from the New England Journal of Medicine, nor do they represent the views of the New England Journal of Medicine or the Massachusetts Medical Society.
Both the age-old joys of an inherently varied practice and new types of practice opportunities are drawing physicians to the specialty.
Physicians who want to help reshape U.S. health care delivery, tap into emerging point-of-care health information technology, or embrace the challenge of caring for a newborn and a nonagenarian in a single afternoon can do all of that in family medicine today. Both the potential career paths and the range of practice settings for family physicians (FPs) are evolving and expanding well beyond the traditional clinic practice.
The primary care clinic and community health center are still mainstays in the field, but these days, family physicians are also likely to find themselves practicing as hospitalists, running urgent care centers, or directing accountable care organizations. Family medicine residents and practicing physicians are increasingly involved in, or at the helm of, patient-centered medical homes throughout the country. At the national level, family physicians are being tapped to assume key roles in two movements that are garnering considerable attention nationally: population health and value-based care.
“We’re seeing increasing public recognition of the importance of family practice, and of primary care generally as the foundation for health services, which is the way other industrialized countries have long approached care,” said Wanda Filer, MD, MBA, president of the American Academy of Family Physicians (AAFP). “This makes us [the academy] optimistic for both family medicine and the health of the nation.”
At the local and regional level, hospitals, health systems, and even policymakers also are looking to family physicians to help craft and direct initiatives to improve the health status of entire communities and, by extension, ultimately allocate limited resources more appropriately across larger patient pools.
“This is an exciting time for family physicians because people are starting to understand the power that primary care has to change health care in the community,” said Dr. Filer, who practices at First Family Health, a federally qualified health center in York, Pennsylvania. The restructuring of care delivery that is occurring, including the trend toward more sophisticated team-based care models, entails moving away from having specialty physicians drive services utilization, Dr. Filer noted. “This evolution will require that other specialties loop in with family medicine, instead of the other way around. Family physicians will have more power in directing referrals,” she said.
Emily Briggs, MD, MPH, a New Braunfels, Texas, family physician, exemplifies both the evolving nature of the specialty and its primary appeal: a broad scope of practice. She operates a small primary care practice that’s both traditional — she and her partner do full obstetrics — and “new fashioned.” Briggs Family Medicine is part of a San Antonio-based accountable care organization, UPSA ACO, LLC, whose membership includes only FPs and internists. The ACO’s objective is to improve care by sharing resources and data regionally, and preventing unnecessary testing or duplicative care, Dr. Briggs explains.
“If my patients need care outside my area, another family physician in our ACO sees them, and can access their data,” said Dr. Briggs, who has been in practice six years. “Family physicians are more likely to choose practice settings where they can be in ACOs, I think, because it’s an opportunity to be involved in quality improvement on a larger scale than private practice typically allows.”
The collegiality that ACOs and other collaborative-practice entities offer is also appealing to FPs who enjoy the small-practice environment but want to be connected through a larger venue for the purposes of pursuing quality improvement. Jennifer Brull, MD, is a solo family physician in Plainville, Kansas, who entered an organized health care arrangement (OHCA) with four other FPs to share patient information, in a HIPAA-sanctioned manner, for the benefit of the physicians’ collective patients and practices.
“The impetus for us was to be able to do more chronic care work because we were already, individually, doing a lot of ‘first-generation’ quality work, and in my practice we had been using an electronic health record for eight years,” said Dr. Brull. “What we’re moving toward now, in our OHCA, is identifying ways that we can prevent unnecessary ER visits and hospital admissions.” The practices share data, and staff and human resources functions, but are otherwise separate entities.
On a broader scale, Dr. Brull is a member and medical director of a recently formed ACO, Aledade Kansas, and spends one day each week in that administrative role. “This kind of work and collaboration gives family physicians an opportunity to demonstrate how primary care can affect patient outcomes and care utilization,” she said. “And it’s an important development, because we as a specialty are on the leading edge of an ‘inversion’ of U.S. health care — based on the recognition that we have too many specialists and not enough primary care physicians to achieve what we need to accomplish.”
Dr. Brull enjoys splitting her week among the various activities, and is particularly excited about the quality improvement work that she is facilitating on a regional basis. “My passion is around leadership in quality, and family medicine provides an excellent foundation for this kind of work,” she said.
Policy changes favor family medicine
That growing recognition of family medicine’s important position within the total care spectrum is driving changes in health policy, particularly physician payment reform, which will make the specialty more attractive from both a work-life balance and financial perspective. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) provides for a new payment methodology that provides more predictable and increasing payments for family physicians.
The MACRA legislation also established the Comprehensive Primary Care (CPC) initiative, whose aim is to strengthen primary care to support higher quality care, lower costs, and improved population health. Primary care practices that choose to participate in the CPC are eligible for population-based care management fees and shared savings opportunities.
This reimbursement change from a volume- to a value-based model better financially supports the kind of holistic care the FPs have historically sought to provide, Dr. Briggs observed. “With this value-based model, family physicians no longer need to see 50 patients a day to run their offices, but can instead provide the care their patients need. Our new family physicians will embrace this, I think, because we haven’t been in [the] quality world very long as a specialty,” she said. She added that she has witnessed considerable positive response to these developments among the younger physicians and residents she has encountered in her frequent speaking engagements on the topic.
Another relatively recent development, the emergence of the direct primary care (DPC) model, is gaining ground among FPs. The model is an alternative to fee-for-service insurance billing, in which patients (practice members) pay a monthly, quarterly, or annual fee that covers most services, including clinical, laboratory, consultative services, and care coordination and comprehensive care management. “We’re seeing increasing interest among AAFP members generally in the DPC model, and I think that this is an attractive potential career path for young FPs interested in collaborating to set up a large DPC practice, and avoiding the ‘treadmill mentality,'” Dr. Filer said, that now characterizes many struggling primary care practices.
That’s the vision of Qliance, a Seattle-based DPC organization that operates six care locations in the region. “This gives me the opportunity to change health care from the patient out — and from primary care up, because I think that’s the way we can build a healthy and functional health care system, and bring the soul back to medicine,” said family physician Erika Bliss, MD, Qliance’s CEO. The Qliance model is proving attractive to employers, too, she noted, as a cost-effective, convenient care option. Patients/members are given 30- to 60-minute appointments, can be seen 7 days a week, and can use email consultation for virtual visits involving non-urgent medical issues or concerns. “This kind of model also enables family physicians and patients to teach each other, and learn from each other,” Dr. Bliss said. “That’s the real benefit of this kind of model — the relationships. And personally, I now feel that I am doing what I wanted to do when I went into medicine.”
At the more traditional end of the spectrum, family medicine continues to offer an attractive combination of qualities to appeal to a wide range of physician interests. FPs can choose to practice in rural or urban settings, or to focus their practice in niche area such as global medicine, public health, emergency or urgent care, health care administration, or strictly inpatient or outpatient practice.
The inherent flexibility of the specialty is also a plus for physicians who seek to balance their professional and personal lives, noted Dr. Briggs, who counsels young FPs in her role with the AAFP New Physicians section. “Because of the broad scope of family medicine, you really can tailor your practice wherever and however you want. There are also many opportunities, too, to work part time if you want to do that, or to work in multiple settings simultaneously,” she said. “Our field is the most flexible, I think, in that regard, and because of the demand for our skills we know that we’ll always have a lot of practice options.”
For family physicians who actually choose the specialty because it offers opportunities to practice in far-flung places, the expanding reach of telemedicine and information technology generally are making for a an increasingly rich and gratifying practice life. John Cullen, MD, a family physician in Valdez, Alaska, experiences the joys of practicing full-scope family medicine in a small community — population 350 — and living the rugged lifestyle he always wanted, while having access to the technology resources he needs to deliver high-quality care. “I don’t know of many places you can practice where you have a glacier across the street, but you can have a CT scan read within the hour, or consult with an orthopedic surgeon, neurosurgeon, or radiologist in real time,” said Dr. Cullen, whose practice, Valdez Medical Clinic, trains residents and teaches medical students. “We’ve also got tele-ICU capabilities here, which makes us feel less isolated.”
In addition, remote settings such as Alaska give FPs numerous opportunities to add to their skill sets by learning new procedures to augment their practice scope. “That’s part of the appeal of family medicine — that we can learn new procedures and actually use them in practice. I always remind residents that they don’t have to learn every procedure they’re interested in during training,” Dr. Cullen said. “One of the benefits of our field is that we have many opportunities over the years to learn new procedures.”
Training adapts to support changing environment
In tandem with the market- and policy-driven changes occurring in family medicine, training programs are adapting their curriculum to better prepare family medicine residents for the changing practice models such as the patient-centered medical home, as well as the new kinds of challenges that family medicine physicians will encounter.
“As we move toward value-based payment in health care, residency programs are emphasizing the concepts of rapid-cycle quality improvement and inter-professional team-based care, and helping trainees develop leadership skills,” said Stan Kozakowski, MD, director of the Division of Medical Education for AAFP and a former president of the Association of Family Medicine Residency Directors. “What we’ve heard is that residents want to be part of the solution for improving care outcomes.”
To that end, he explained, programs are introducing residents to resources such as risk stratification tools to understand ways that care might be delivered more strategically. Programs are also training family medicine residents in broad-based team models involving, for example, pharmacists, social workers and nutrition professionals, and more sophisticated practice structures that have the potential to not only improve overall care but also to relieve FPs of some of the responsibilities that don’t require physician skills.
“What we’re discovering is that effective use of care teams frees up the family physician to actually provide the care and focus more on the patient relationship,” Dr. Kozakowski said. This approach also helps FPs identify and focus their efforts and practice resources on the patients who are at relatively higher risk for poor outcomes compared to those who can be managed or cared for less intensively.
These developments, collectively, as well as the improving reimbursement picture, position family physicians for engaging careers in the specialty, in Dr. Kozakowski’s view. “I can’t think of a better time to be entering the field. We’re moving out of the period of administrative hassle, toward a new time where we have more control over how we deliver care and how we leverage resources,” he said. “We’re also seeing an unprecedented level of interest in placing family medicine physicians in leadership roles — in health systems, multispecialty organizations, and ACOs, for example — because of the nature of our training.”
Dr. Filer concurs with Dr. Kozakowski, and urges young physicians to consider the specialty as an ideal launching point for a satisfying career regardless of the direction they ultimately choose. Physicians who have somehow gotten the idea that family practice as a specialty is inherently limited clinically or less intellectually rigorous or demanding than other specialties should leave that notion behind, Dr. Filer maintains. “Family medicine is not a back-up plan. It’s an exciting field that’s going to become even more exciting moving forward as the leadership opportunities continue to expand,” she said. “The health care system is looking for systems thinkers who understand the continuum of care, and family medicine equips you for that.”
In Dr. Bliss’s view, physicians who choose family medicine are coming in to the field at an ideal time. “In the last five years, the country has started to understand the importance of primary care, and to value our work,” she said. “There’s also an awareness now, I think, that family medicine holds the key to bringing down the cost of health care.”
Family medicine MATCH rates, compensation on the rise
Perhaps as evidence of family medicine’s increasing importance on the national front as health reform continues to reshape care delivery, family physicians are seeing their compensation increase commensurately.
The annual Medical Group Management Association physician compensation survey found increases in median family medicine compensation of 4.7 percent and 6.9 percent in 2013 and 2014, respectively, with a median income of $221,419 last year. The Medscape 2015 Physician Compensation Report found that family physicians’ average compensation increase 10 percent over 2014.
MATCH rates for the specialty are on the rise as well. This year, 3,060 of the 3,216 family medicine training positions offered were filled, compared to a spread of 2,782 to 2,292 in 2005.