I frequently hear from colleagues that our health system is broken and that primary care is the only way to fix it. We (primary care providers) possess broad-spectrum training to prevent and treat illness; the idea seems to be that given the right number of family doctors, we could solve this country’s health issues.
I believe in the future of Family Medicine, but our specialty has a problem: Me. I am a family doctor who no longer practices full-spectrum care. My medical journey has taught me that individual circumstances shape physician practice. In the future, individual practices will prohibit an increase in family doctors and limit the “breadth” of services required to save healthcare. However, this problem is not a bad thing for doctors, or for the specialty.
Like many future family doctors, I liked everything in medical school! I met a wonderful mentor who showed me that Family Medicine was a specialty that would allow me to do all the things I loved. I matched at a full-spectrum Family Medicine program with the intention of doing every procedure. I would serve the underserved. I would develop community programs to improve population health. It was all in front of me: a good program, great faculty, and like-minded peers. I had every opportunity.
Then, as happens so often in life, my perspective changed. I was married and had children throughout training and the more engrossed I became in medicine, the more it affected my wife. One night, when I was on C-section call, the pager went off as I sat down to dinner. For the briefest of moments, a look of exasperation and hopelessness passed over her face, a look that said, “Again? Already? You just got home.” It left very quickly, but I never forgot it. We started to talk about our goals as a family.
I experienced the common traumas of residency. I ran to numerous codes, stillbirths, horrific emergency room scenes (all the while, thinking, “No human being should have to see this”). Sometimes, I excused myself to my car and screamed until I was hoarse. At the end of my first year, I spent almost two consecutive months on night float. I missed my wife and children. By the time I finally saw the sun, I was depressed. I couldn’t stand the hospital. I thought, “If this is Family Medicine, I’m not sure what I want any more.”
Then my perspective changed again. Early in my second year, I provided medical coverage for a local rodeo. As I shouldered my medical bag, I felt the crunch of gravel under my boots. I smelled horses, cattle, and sweat. A most improbable question arose in my mind: Could I be a doctor here? Outside, in the (not so) fresh air? That day, I bandaged and taped. I injected an elbow. I assessed a concussion. I counseled a barrel racer about laceration healing. This was Family Medicine as I had envisioned it!
When I went home, I was reborn. I had never considered Sports Medicine as a career but that night, it seemed like salvation. I participated in the residency’s Sports Medicine track, completed a Sports Medicine fellowship, and entered a Sports Medicine practice, where I take care of injured athletes and serve as a local team physician.
But this article is not about how wonderful Sports Medicine is as a subspecialty. Rather, it is about how Family Medicine always has, and always should, suffer from an identity problem. Who are we? Are we generalists, obstetricians, Preventive Medicine specialists, or surgeons? These questions must be answered by Family Medicine physicians individually, not as an academy. As I discovered important aspects of my medical personality, I altered my practice to include more of what I loved and to allow me to spend more time with my family. I still consider myself a family doctor. I treat multiple members of the same family. I look my patients in the eye. I counsel about tobacco cessation, weight loss, and osteoporosis. I find medical zebras while digging into abnormal radiographs. I treat mononucleosis and strep throat; I do cardiac workups and pulmonary function tests. And I stick a needle into whatever I can.
We often hear that family physicians are losing the opportunity to do full-spectrum care. The independent family doc is bought out by the hospital system and made to do narrow spectrum work. Others relegate themselves to closely-defined subspecialties and are thus “lost” as full-spectrum providers. Such is the narrative from our academy—and the narrative is painted as a tragedy.
Though there might be tragic elements, I wish to present another side of the narrative. I am not lost to Family Medicine. I practice primary care Sports Medicine because I choose to. It is the little corner of medicine that I enjoy most. It allows me to perform procedures I love and treat a patient population that inspires me. It lets me get home to my wife and children before midnight.
Family Medicine unites a diverse group of physicians and allows them to become who they want to be. This is a big tent specialty, and just as we advocate for our patients’ goals, we cannot be upset when colleagues follow their interests. In some cases, we willingly choose to narrow our scope of practice. But there will always be a place for full-spectrum family doctors. That said, had I persisted in becoming one, neither I nor my family would be happy. I unapologetically declare that I do not owe it to colleagues, faculty, or my community to persist in a path that does not bring happiness.
In the end, maybe there won’t be enough family physicians to go around. Maybe the whole system will have to be rebuilt from scratch. Maybe that new system will be better. But we must respect a person’s right to pursue happiness and fulfillment in his or her work; such respect is consistent with the values of our specialty. The preferences, aptitudes, and unavoidable perspective shifts of good physicians will keep Family Medicine the diverse and capable specialty it is, even if it fails to save the world in the process. If diversity and individual fulfillment is the problem with Family Medicine, then I am the problem.
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