Family medicine (FM) is a medical specialty devoted to comprehensive health care for people of all ages. It is a division of primary care that provides continuing and comprehensive health care for the individual and family across all ages, sexes, diseases, and parts of the body. It is based on knowledge of the patient in the context of the family and the community, emphasizing disease prevention and health promotion. According to the World Organization of Family Doctors (Wonca), the aim of family medicine is to provide personal, comprehensive and continuing care for the individual in the context of the family and the community.
Scope of practice
Family physicians in the United States may hold either an M.D. or a D.O. degree. Physicians who specialize in family medicine must successfully complete an accredited three-year family medicine residency in the United States in addition to their medical degree. They are then eligible to sit for a board certification examination now required by most hospitals and health plans. The American Board of Family Medicine requires its Diplomates to maintain certification through an ongoing process of continuing medical education, medical knowledge review, patient care oversight through chart audits, practice-based learning through quality improvement projects and retaking the board certification examination every 7 to 10 years.
Doctors certified in family medicine in Canada are certified through the College of Family Physicians of Canada, after three years of additional education. Continuing education is also a requirement for continued certification.
The term “family medicine” is used in many European and Asian countries, instead of “general medicine” or “general practice“. In Sweden, certification in family medicine requires five years working with a tutor, after the medical degree. In India, those who want to specialize in family medicine must complete a three-year family medicine residency, after their medical degree (MBBS). They are awarded either a DNB or an MD in family medicine. Similar systems exist in other countries.
Family physicians deliver a range of acute, chronic and preventive medical care services. In addition to diagnosing and treating illness, they also provide preventive care, including routine checkups, health-risk assessments, immunization and screening tests, and personalized counseling on maintaining a healthy lifestyle. Family physicians also manage chronic illness, often coordinating care provided by other subspecialists. Many American family physicians deliver babies and provide prenatal care.
Family medicine and family physicians play a very important role in the healthcare system of a country. In U.S., for example, nearly one in four of all office visits are made to family physicians. That is 208 million office visits each year — nearly 83 million more than the next largest medical specialty. Today, family physicians provide more care for America’s underserved and rural populations than any other medical specialty.
Family medicine in USA
Following World War II, two events shaped the advent of family medicine. First, medical specialties and subspecialties increased in popularity, having an adverse effect on the number of physicians in general practice. At the same time, many medical advances were being made and there was concern within the “general practitioner” or “GP” population that four years of medical school plus a one-year internship was no longer adequate preparation for the breadth of medical knowledge required of the profession. Many of these doctors wanted to see a residency program added to their training; this would not only give them additional training, knowledge, and prestige, but would allow for board certification, which was increasingly required to gain hospital privileges. In 1969, family medicine (then known as family practice) was recognized as a distinct specialty in the U.S.
Family physicians complete undergraduate school, medical school, and three more years of specialized medical residency training in family medicine. Their residency training includes rotations in internal medicine, pediatrics, obstetrics-gynecology, psychiatry, and geriatrics. The specialty focuses on treating the whole person—acknowledging the effects of all outside influences—through all life stages. Family physicians will see anyone with any problem, but are experts in common problems. Many family physicians deliver babies in addition to taking care of patients of all ages.
In order to become board certified, family physicians must complete a residency in family medicine, possess a full and unrestricted medical license, and take a written cognitive examination. Between 2003 and 2009, the process for maintenance of board certification in family medicine is being changed (as well as all other American Specialty Boards) to a series of yearly tests on differing areas. The American Board of Family Medicine, as well as other specialty boards, are requiring additional participation in continuous learning and self-assessment to enhance clinical knowledge, expertise and skills. The Board has created a program called the “Maintenance of Certification Program for Family Physicians” (MC-FP) which will require family physicians to continuously demonstrate proficiency in four areas of clinical practice: professionalism, self assessment/lifelong learning, cognitive expertise, and performance in practice. Three hundred hours of continuing medical education within the prior six years is also required to be eligible to sit for the exam.
Family physicians may pursue fellowships in diverse topics including adolescent medicine, geriatric medicine, sports medicine, sleep medicine, and hospice and palliative medicine. The American Board of Family Medicine offersCertificates of Added Qualifications (CAQs) in each of these topics. Recently, new fellowships in International Family Medicine have emerged. These fellowships are designed to train family physicians working in resource poor environments.
While many sources cite a shortage of family physicians (and also other primary care providers, i.e. internists, pediatricians, and general practitioners), the per capita supply of primary care physicians has actually increased about 1 percent per year since 1998. Additionally, a recent decrease in the number of M.D. graduates pursuing a residency in primary care, has been offset by the number of D.O graduates and graduates of international medical schools (IMGs) who enter primary care residencies. Still, projections indicate that by 2020 the demand for family physicians will exceed their supply.
The number of students entering family medicine residency training has fallen from a high of 3,293 in 1998 to 1,172 in 2008, according to National Residency Matching Program data. Fifty-five family medicine residency programs have closed since 2000, while only 28 programs have opened.
In 2006, when the nation had 100,431 family physicians, a workforce report by the American Academy of Family Physicians indicated the United States would need 139,531 family physicians by 2020 to meet the need for primary medical care. To reach that figure 4,439 family physicians must complete their residencies each year, but currently the nation is attracting only half the number of future family physicians that we will need.
The waning interest in family medicine is likely due to several factors, including the lesser prestige associated with the specialty, the lesser pay, and the increasingly frustrating practice environment in the U.S. Salaries for family physicians in the United States are respectable but lower than average for physicians, with the average being $129,295 and ranging from $110,000 to $204,000, but when faced with debt from medical school, most medical students are opting for the higher paying specialties. Family physicians are trained to manage acute and chronic health issues for an individual simultaneously, yet their appointment slots may average only ten minutes. Physicians are increasingly forced to do more administrative work, and to shoulder higher malpractice premiums, thus forcing doctors to spend less and less time with patient care due to the current payor model stressing patient volume vs. quality of care. Things are starting to change as more insurance carriers consolidate. They are not stressing performance but more and more volume, thus increasing insurance company profit margins. Physicians are starting to shun insurance carriers to lessen the paperwork in order to focus more on patient care as they are originally trained to do.
Most family physicians in the US practice in solo or small-group private practices or as hospital employees in practices of similar sizes owned by hospitals. However, the specialty is broad and allows for a variety of career options including education, emergency medicine or urgent care, inpatient medicine, international or wilderness medicine, public health, sports medicine, and research. Others choose to practice as consultants to various medical institutions, including insurance companies.
There is a current trend among family physicians to adopt a practice model called the micro practice, or “Ideal Medical Practice“. These practices focus on reducing their overhead and increase their utilization of technology. Because the overhead is reduced, the need to see a high volume of patients to generate more revenue is diminished. This allows the doctor to spend more time with their patients, which results in higher satisfaction for the patient and the physician.