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FAMILY MEDICINE: WHAT ARE WE GRADUATING?

As the family of family medicine begins the process of revising the Residency Guidelines for Family Medicine, it may be time to look back over our progress to date in order to steer our efforts in the best direction in the future. What is the difference in our present product versus our ideals as our “founding fathers” delineated them in our “constitution” of 1968? 
 
The original guidelines from family medicine covered a mere 3 pages laying out the length of training, and general content, as well as proposed categories of programs that reflected and embraced the wide variation of locations where family medicine physicians lived and worked.1 Our founding document also defined the family medicine physician in 4 domains. First, the family medicine physician was to serve as the physician of first contact with the patient who provided an entry for the patient into the health care system. Second, the family physician was tasked to evaluate the patient’s total health care needs and to provide personal medical care and referral management. Third, our graduates were to provide continuous and comprehensive care as well as the coordination of care. Lastly, the vision asserted that family medicine physicians were to provide care for the patient within the context of the patient’s family and social milieu. 
 
Current guidelines include these attributes; future decisions in new guidelines will need to address the appropriateness of these parameters in the 21st century. Our current question is whether or not we and our graduates hold firm to this definition, or whether a majority tailor their practice to a narrower spectrum of care. Clearly, residents enter traditional family medicine practices, but they also opt for fellowships in geriatrics, obstetrics, and sports medicine and practices that embrace hospital medicine; they work in emergency departments, health departments, and Veterans’ hospitals. Also, clearly, these graduates consider themselves family medicine physicians, although their career paths may not adhere to the strict definition as outlined in our founding documents. 
 
There is no national database that answers the question, “where are our graduates, and what exactly are they doing?” Logically, we also cannot answer with complete confidence the question as to whether or not our residency programs prepared them for the world at large. The AMA collects physician data from specialty boards, state medical boards, and societies and publishes data on physician specialty and distribution, but does not drill down to the detail of practice profiles of family physicians.2 Several states also track physician resources, but still leave crucial questions unanswered that address the need for feedback on our residency programs. Although we are required to survey our residents following graduation, we use no consistent instrument across all programs, nor do we know if a single instrument could be designed to embrace all variations of family medicine residency programs to help us answer these questions. Several publications deal with regional outcome data, and at least 1 P4 project attempted to grapple with the concept of a common post graduate survey instrument.3 
 
It follows that we may need to ask ourselves, is it time for a universal survey that would help the discipline answer the thorny questions of our role and worth in the healthcare system. Do we need to expand the definition of the family physician to include alternate types of practice? And, lastly are our values antiquated, are our visions of ourselves valid, or should we change?