Electronic health records. Smart phones. Near-universal broad-band Internet access. Asynchronous communication. Electronic visits. Telemedicine. Patient-centered primary care homes (medical homes). Team-based care. A wide range of practice models. Hospitalists. Value-based purchasing. Accountable care. In the 13 years since the Keystone III conference that set the stage for the Future of Family Medicine (1.0) initiative, which attempted to renew and transform the discipline of family medicine, these innovations have all become commonplace, resulting in one of the most substantial transformations of primary care practice in the past century. The 10 members of the Generation III (youngest generation) group at the conference have been closely involved with many of these changes through practice, policy, research, and medical education; in many ways these changes represent a microcosm of the diversity among family physicians today.
As our original article makes clear, the definition of the “ideal” family physician was a recurrent theme during the Keystone conference. Those of us in Generation III, some late baby boomers and some early Gen Xers (those born 1964–1985), undoubtedly had expectations of work-life balance, the scope of our practices, and how we might structure our practices and careers that were different from those held by Generations I and II. Over the intervening years, it has become evident that one might best describe the ideal family physician as a pluripotent stem cell; our generalist inclination, diverse training, and range of meta-skills (listening, systems thinking, team-building, advocacy, etc) allow family physicians to pursue a wide range of careers both in and out of medicine, and even change careers within family medicine. Nationally, family physicians lead government programs, serve as medical directors for corporations and insurance companies, invent new technologies, develop and franchise new models of practice, and enter additional professions, such as politics, information technology (IT), law, and business. Even among the 10 of us, we have 3 department chairs, an associate dean, a mayor, a state senator, a medical director of Planned Parenthood, a state Medicaid director, a research director for a nonprofit IT collaborative, and a chief executive officer of a direct primary care organization. Each of us has chosen to interpret our mission as a family physician differently and believes that each is serving as a family physician every day, regardless of whether we see a patient that day in a traditional family medicine clinic.
The historical article presented in this issue, written by our group immediately after the Keystone III conference, reflects well the overall tenor of the conversation around family medicine at the beginning of the century. We were, in many ways, playing defense, frustrated by the increasing industrialization of medicine, with terms such as relative value units and productivity permeating our daily practice. This industrialization only accelerated in the decade after Keystone III, becoming almost an arms race between the various segments of the health care system; clinicians were trying to maximize revenue by any means possible, and payers were instituting complex mechanisms to control costs. The economic boom that allowed medical costs to balloon without consequence, pushing high-tech rather than high-touch as the best form of health care, even as health outcomes worsened, further exacerbated industrialization. Family physicians were dragged further and further away from our core: whole-person, whole-family, and whole–community-centered care. We responded and continue to respond through various strategies to preserve that core.
In response to the unsustainable trajectory of health care costs seen by politicians, employers, insurers, and providers of health care of all types, the family of family medicine ultimately has chosen a more proactive course. We have engaged increasingly in advocacy, and many family physicians have taken on new roles in leadership, both in medicine and beyond. We have reframed the conversation and educated the public and decision makers about the value of prevention rather than cure, as well as the necessity of empowering and partnering with patients to improve their health care experience and health outcomes. In many ways, family physicians have had a substantial influence on the Affordable Care Act, which will have lasting implications on the future of health care in the United States.
Furthermore, family medicine has been a leader in developing the evidence for and implementation of practice redesign and payment reform. Family medicine appears to be adapting more rapidly than most specialties to practice-based research and the technologic changes in care delivery. Many family physicians understand that direct, one-on-one, face-to-face contact may not always represent the best, most patient-centered care. For example, many use asynchronous communication by means of the electronic health record to help patients with diabetes adjust their insulin dosing, rather than rely on frequent office visits. Paradoxically, many in our generation have found that the ability to be always on call using modern technology has decreased our anxiety about work-life balance (eg, we can go home directly after office hours are done, have dinner with our families, and finish charting later from home) and allowed us to focus on one of the aspects of family medicine—true engagement with our patients—that drew us to the specialty in the first place. Those of us in regular contact with students and residents find the same to be true of later Generation III and early Generation IV members (roughly speaking, those entering practice after 2004, when electronic health records became more common place).
Our work with learners has also changed dramatically as a result of technology and practice models. We have learned, and now must teach, electronic health record data extraction and analysis, asynchronous communication with patients, population health management, and systems thinking. The national move toward patient-centered primary care homes has required us to move toward a more interprofessional model of training, which will only increase in years to come. Our tradition of understanding the importance of aligning primary care, mental health, and public health enables us to teach learners about how improvements in our patients’ mental well-being and social determinants of health might be more important to their health than the care provided in the academic health center hospital.
Ultimately, our group of 10 Generation III members believes that family medicine represents the professional expression of evolution. Particularly during the past decade, our specialty has demonstrated the ability to not only adapt to a rapidly changing health care ecosystem, but to thrive in it, and to shape it to advance what we’ve always known—true primary care can and should be delivered in a wide range of settings and modalities, and when practiced in ways that promote patient-centeredness and physician well-being, we deliver health care that improves health, lowers cost, and enhances the patient experience.