Family medicine
Family medicine[note 1] is a medical specialty within primary care that provides continuing and comprehensive health care for the individual and family across all ages, genders, diseases, and parts of the body.[2][3] The specialist, who is usually a primary care physician, is named a family physician.[note 2] It is often referred to as general practice and a practitioner as a general practitioner. Historically, their role was once performed by any doctor with qualifications from a medical school and who works in the community. However, since the 1950s, family medicine / general practice has become a specialty in its own right, with specific training requirements tailored to each country.[4][5][6] The names of the specialty emphasize its holistic nature and/or its roots in the family. It is based on knowledge of the patient in the context of the family and the community, focusing on disease prevention and health promotion.[7] According to the World Organization of Family Doctors (WONCA), the aim of family medicine is "promoting personal, comprehensive and continuing care for the individual in the context of the family and the community".[8] The issues of values underlying this practice are usually known as primary care ethics.
For the journal, see Family Practice (journal).Focus
Family physician
Physician
Family doctor
- Doctor of Medicine (M.D.)
- Bachelor of Medicine, Bachelor of Surgery (M.B.B.S.)
- Bachelor of Medicine, Bachelor of Surgery (MBChB)
- Doctor of Osteopathic medicine (D.O.)
Scope of practice[edit]
Family physicians in the United States must hold either an M.D. or a D.O. degree. Physicians who specialize in family medicine must successfully complete an accredited three or four year long family medicine residency in the United States in addition to their medical degree. They are then eligible to sit for a board certification examination, which is now required by most hospitals and health plans.[9] 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. The American Osteopathic Board of Family Physicians requires its diplomates to maintain certification and undergo the process of recertification every 8 years.[10]
Physicians certified in family medicine in Canada are certified through the College of Family Physicians of Canada,[11] after two years of additional education. Continuing education is also a requirement for maintenance of certification.
The term "family medicine" or "family physician" is used in the United States, Mexico, South America, many European and Asian countries. 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 D.N.B. or an M.D. in family medicine. Similar systems exist in other countries.
General practice is the term used in many other nations, such as the United Kingdom, Australia, New Zealand, and South Africa. Such services are provided by general practitioners. The term primary care in the UK may also include services provided by community pharmacy, optometrist, dental surgery and community hearing care providers. The balance of care between primary care and secondary care - which usually refers to hospital-based services - varies from place to place, and with time. In many countries there are initiatives to move services out of hospitals into the community, in the expectation that this will save money and be more convenient.
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 counselling on maintaining a healthy lifestyle. Family physicians also manage chronic illness, often coordinating care provided by other sub-specialists.[12] Family doctors also practice safety-netting, which involves follow-up assessments for uncertain diagnoses associated with symptoms that could innocuous, but may also be a sign of serious illness.[13][14] Many American Family Physicians deliver babies and provide prenatal care.[15] In the U.S., family physicians treat more patients with back pain than any other physician sub-specialist, and about as many as orthopedists and neurosurgeons combined.[16]
Family medicine and family physicians play a vital role in the healthcare system of a country. In the 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.[17]
In Canada[edit]
Education and training[edit]
In Canada, aspiring family physicians are expected to complete a residency in family medicine from an accredited university after obtaining their Doctor of Medicine degree. Although the residency usually has a duration of two years, graduates may apply to complete a third year, leading to a certification from the College of Family Physicians of Canada in disciplines such as emergency medicine, palliative care, care of the elderly, sports and exercise medicine, and women's health, amongst others.
In some institutions, such as McGill University in Montreal, graduates from family medicine residency programs are eligible to complete a master's degree and a Doctor of Philosophy (Ph.D.) in family medicine, which predominantly consists of a research-oriented program.
In the United States[edit]
History of medical family practice[edit]
Concern for family health and medicine in the United States existed as far back as the early 1930s and 40s. The American public health advocate Bailey Barton Burritt was labeled "the father of the family health movement" by The New York Times in 1944.[18]
Following World War II, two main concerns 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.[19] 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.[19] In February 1969, family medicine (then known as family practice) was recognized as a distinct specialty in the U.S. It was the twentieth specialty to be recognized.[19]
Education and training[edit]
Family physicians complete an undergraduate degree, medical school, and three more years of specialized medical residency training in family medicine.[20] Their residency training includes rotations in internal medicine, pediatrics,[21] obstetrics-gynecology, psychiatry, surgery, emergency medicine, and geriatrics, in addition to electives in a wide range of other disciplines. Residents also must provide care for a panel of continuity patients in an outpatient "model practice" for the entire period of residency.[22] The specialty focuses on treating the whole person, acknowledging the effects of all outside influences, through all stages of life.[23] 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.[24] 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.[25]
Family physicians may pursue fellowships in several fields, including adolescent medicine, geriatric medicine, sports medicine, sleep medicine, hospital medicine and hospice and palliative medicine.[26] The American Board of Family Medicine and the American Osteopathic Board of Family Medicine both offer Certificates of Added Qualifications (CAQs) in each of these topics.[27]
Shortage of family physicians[edit]
Many sources cite a shortage of family physicians (and also other primary care providers, i.e. internists, pediatricians, and general practitioners).[28] The per capita supply of primary care physicians has increased about 1 percent per year since 1998.[29] 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.[29] Still, projections indicate that by 2020 the demand for family physicians will exceed their supply.[29]
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.[30]
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 will be needed.[31]
To address this shortage, leading family medicine organizations launched an initiative in 2018 to ensure that by 2030, 25% of combined US allopathic and osteopathic medical school seniors select family medicine as their specialty.[32][33] The initiative is termed the "25 x 2030 Student Choice Collaborative", and the following eight family medicine organizations have committed resources to reaching this goal:
United Kingdom[edit]
History of general practice services[edit]
The pattern of services in the UK was largely established by the National Insurance Act 1911 which established the list system which came from the friendly societies across the country. Every patient was entitled to be on the list, or panel of a general practitioner. In 1911 that only applied to those who paid National insurance contributions. In 1938, 43% of the adult population was covered by a panel doctor.[39] When the National Health Service was established in 1948 this extended to the whole population. The practice would be responsible for the patient record which was kept in a "Lloyd George envelope"[40] and would be transferred if necessary to another practice if the patient changed practice. In the UK, unlike many other countries, patients do not normally have direct access to hospital consultants and the GP controls access to secondary care.[41]
Australia[edit]
General Practice services in Australia are funded under the Medicare Benefits Scheme (MBS) which is a public health insurance scheme. Australians need a referral from the GP to be able to access specialist care. Most general practitioners work in a general practitioner practice (GPP) with other GPs supported by practice nurses and administrative staff. There is a move to incorporate other health professionals such as pharmacists in to general practice to provide an integrated multidisciplinary healthcare team to deliver primary care.[74]
Japan[edit]
Family medicine was first recognized as specialty in 2015 and currently has approximately 500 certified family doctors.[87] The Japanese government has made a commitment to increase the number of family doctors in an effort to improve the cost-effectiveness and quality of primary care in light of increasing health care costs.[88] The Japan Primary Care Association (JPCA) is currently the largest academic association of family doctors in Japan.[89] The JPCA family medicine training scheme consists of a three-year programme following the two-year internship.[87] The Japanese Medical Specialty Board define the standard of the specialty training programme for board-certified family doctors. Japan has a free access healthcare system meaning patients can bypass primary care services. In addition to family medicine specialists Japan also has ~100,000 organ-specialist primary care clinics.[88] The doctors working in these clinics do not typically have formal training in family medicine. In 2012, the mean consultation length in a family medicine clinic was 10.2 minutes.[90] A review literature has recently been published detailing the context, structure, process, and outcome of family medicine in Japan.[91]