The value of family medicine

Family medicine physicians manage the highest complexity of conditions in their practices.¹ Family physicians must actively stay up to date on new advances and recent evidence; care for patients of all ages and throughout many stages of their lives; share patients’ struggles and triumphs; diagnose undifferentiated diseases; advocate for their patients at all levels of the health care system and coordinate complex treatment regimens; and help patients balance their care options with their values. They are also frequently carrying out these functions while running a full-time business. It is a career that can feel like an extraordinary blessing and a burden at the same time.

Unfortunately, many articles suggest primary care is suboptimal. Within a week of our starting to write this article, a study of patients with diabetes treated in Canadian primary care concluded that “target achievement … was suboptimal in all patient groups.”² Guidelines, frequently with little family medicine input,³ have piled on recommendations targeting primary care without reflection on the time burden or lost opportunity costs. It is estimated that to meet guideline recommendations for preventive care and chronic disease, primary care providers require more than 21 hours per day.⁴ Given the seemingly impossible nature of primary care, as defined by guidelines, many are calling for guidelines to consider competing priorities in primary care⁵ and to provide an estimated “time needed to treat” for each guideline recommendation.⁶

Despite the challenges, studies focusing on patient-oriented outcomes provide evidence that clearly underscores the value of comprehensive, primary care performed primarily by family physicians.

Family physicians provide most of the health care in Canada. About 70% of Canadian health care is provided by family physicians.⁷ In Alberta, for example, family physicians are the sole managers of most patients with common chronic conditions, including 86% of those with hypertension and 71% of those with diabetes.⁸

Family physicians provide care to complex patients. Family physicians see more patients with multiple comorbidities than specialists do⁹ and perform as well as specialists in managing diseases such as cardiovascular disease in older individuals, diabetes, and depression.^10-12 An analysis of 14 different medical specialties concluded that family medicine is the most complex of the medical disciplines.¹

Adding family physicians to a population improves health outcomes. Adding family physicians to a population yields more health benefits than adding any other physician group. For every additional 10 family physicians per 100,000 population, there are 15 fewer deaths, 40 fewer hospitalizations,¹³ and an average increase in life expectancy of 52 days.¹⁴

Family physician care also benefits patients with specific diseases. Studies, several from Canada, have reported on these benefits.

• Congestive heart failure: decreased readmissions and death at 1 year,¹⁵ with approximately 10% to 15% fewer deaths or readmissions compared with no follow-up visits, and 3% to 4% fewer compared with follow-up with an “unfamiliar” physician (eg, cardiologist).

• Asthma: decreased number of emergency visits (60% to 75% relative) and hospitalizations (about 25%).¹⁶

• Diabetes (in older patients): decreased hospitalization and death.¹⁷

• Dementia (community-dwelling patients): decreased emergency visits and hospitalizations.¹⁸

• Chronic kidney disease: decreased hospitalizations.¹⁹

• Opioid use disorder: greater treatment retention and patient satisfaction for those treated in primary care.²⁰

• Perinatal mortality and adverse maternal outcomes: similar for deliveries performed by family physicians or obstetricians.²¹

• Infant mortality: reduced with access to primary care.²²

Family physicians provide continuity of care. As continuity of care with a primary care provider increases, emergency department visits, hospital admissions or readmissions, and all-cause mortality fall, and health care costs decrease. In a systematic review of 22 cohort studies, 18 studies found that increased continuity of care in general (mainly provided by family physicians or mixed groups of physicians) decreased all-cause mortality.²³ Similar results were found when only primary care physician continuity was studied.²⁴ Using data from more than 6500 American primary care physicians (family physicians or general internists), the authors found that patients with the lowest continuity of care cost the system 14% more, or approximately $1000 per year more, compared with patients with high continuity.²⁵ An examination of data on the cost of government-funded health care services in British Columbia assessed continuity of primary care as the factor in health care provision with the strongest relationship to health care costs for 8 common chronic medical conditions, with high continuity associated with lower costs.²⁶

Patients benefit from longitudinal care provided by family physicians. The longer a patient’s relationship with a family physician, the greater the decrease in after-hours care, hospital admissions, and mortality. A recent nationwide Norwegian study found relatively linear relationships between the length of the patient-physician relationship and emergency care visits, hospital admissions, and overall mortality.²⁷ The researchers found that patients who had a regular general practitioner relationship for more than 15 years had reductions of approximately 30% in after-hours care or hospital admissions and approximately 25% in overall mortality compared with those who had a regular general practitioner for 1 year.²⁷ Canadian studies show that retention of family physicians in rural communities decreases hospitalization rates by approximately 6% to 20%, depending on the length of study and how retention was defined.^28,29 In Alberta, complex patients cared for by comprehensive family physicians are less likely to end up in the emergency department or admitted to hospital.³⁰

Comprehensive primary care led by a family physician improves patient outcomes. These include lowering of mortality, health care use (ie, decreased emergency department visits, hospitalizations, and readmissions), and health care costs. Paradoxically, while there has never been more evidence for the benefits of care delivered by family physician, never have we been so short of these providers. Primary care is in crisis, but this situation also implies opportunity. We are hopeful that solutions, with a focus on funding to empower primary care, are truly being considered and will soon be implemented. Let us help family physicians continue doing an impossible job, impossibly well.

Tools for Practice articles in CFP are adapted from peer-reviewed articles at http://www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome at toolsforpractice@cfpc.ca.