Family Practice Clerkship

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Family Practice Clerkship College of Human
Medicine Michigan State University
Fundamentals of Family Medicine
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The History of Family Practice?

• Family practice is the 20th US medical specialty,
  formed in 1969.
• Family practice grew out of a combination of
  public and professional concerns.
• Family practice is intended to preserve a type of
  physician with a scope of clinical competence
  that would allow the patient, not the disease, to
  be the focus.

Family Practice in the United States, JAMA,
September 4, 2002 Vol 288, No 9. Ref 12,
13 Stephens GG. The Intellectual Basis of Family
Practice, Tucson, Ariz Winter Publishing
1982. Carmichael LP. The family in medicine,
process or entity? J Fam Pract. 19763562-563.
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The Nature of Primary Care

• Grounded in both biomedical and the social
  sciences.
• Clinical decision making differs from specialty
  care because it deals with undifferentiated
  problems
• Care based on sustained personal relationship
  between patient and clinician.
• Mental health is not considered separate from
  physical health.
• Promotion of health and prevention of disease are
  intrinsic.
• Information intensive.

Primary Care Americas Health in a New Era,
Institute of Medicine, National Academy Press,
1996.
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Family Practice

• Family practice is a major provider of primary
  care.
• Grounded in continuous comprehensive health care
  for the individual and the family.
• Integrates the biological, clinical and
  behavioral sciences.
• Encompasses all ages, both sexes, each organ
  system and every disease entity.

American Academy of Family Physicians, 1986, 1993
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The Modern Family Physician

• First Contact Care
• Comprehensive Care
• Continuing Coordination of Care
• Community
• Care in the Context of Family and Community.

Family Practice in the United States, JAMA,
September 4, 2002 Vol 288, No 9.
6
What Distinguishes Family Practice from all other
Specialties?
Doctor-Patient Relationship
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Other Distinctions

• Obstetrics and Gynecology
• Maternity Care
• Womens Health
• Procedures
• Sports Medicine
• Geriatrics
• Adolescent Medicine
• Health Maintenance
• Hospice
• Medical Administration
• Research

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The Quality of Primary Care

• First Contact Care
• Continuity of Care
• Comprehensiveness of Care
• Coordination of Care

Sources of Information Program Design, Claims
record audit, information systems, age/sex
registries.
Primary Care Balancing Health Needs, Services,
and Technology, Starfield, Barbara, Oxford
University Press, 1998.
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Quality of Care in Family Practice

• Studies show that family physicians, while
  caring for more patients with a wider variety of
  problems than other primary care providers, have
• Equal or better outcomes due to accessibility, at
  lower cost to patient.
• Higher rates of early detection of colon and
  breast cancer.
• Better patient satisfaction.

JAMA, September 4, 2002, Vol 288, No 9
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How much care do family physicians provide?

• Family physicians see substantially more patients
  daily than physicians of any other specialty.
• In 2000, family and general physicians were
  responsible for about 25 of all patient visits
  to physicians.
• General internists and pediatricians managed
  about half that many visits.

Family Practice in the United States, JAMA,
September 4, 2002 Vol 288, No 9.
11
Of 1000 adults at risk for illness and injury,
where does health care occur 1960-61?
Adult population at risk
1000
Adults reporting one or more Illnesses or
injuries per month
750
Adults consulting a physician One or more times
per month
250
Adult patients admitted to a Hospital per month
Adult patients referred to Another physician per
month
9
5
Adult patients referred to a University medical
center Per month
1
N Engl J Med, Vol. 344, No. 26 June 28, 2001
Data are for persons 16 years of age and older.
Reprinted from the 1961 report by White et. al. 1
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Of 1000 adults at risk for illness and injury,
where does health care occur - 2000? In an
average month
1000 people
800 have symptoms
327 consider seeking medical care
217 visit a physicians office 113 visit primary
care physicians office
65 visit CAM provider
21 visit a hospital outpatient clinic
14 receive home health care
13 visit an emergency department
8 are in a hospital
New Ecology of Medical Care - 2000
lt1 is in an academic health center hospital
N Engl J Med, Vol. 344, No. 26 June 28, 2001
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What would happen if family physicians did not
exist in the US?
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Most common reasons for visits to family
physicians

• General medical examination
• Upper respiratory conditions
• Medication treatment of hypertension and other
  conditions
• Chronic back pain
• Gastrointestinal symptoms
• Dermatologic conditions
• Chronic Disease, such as Diabetes and
  Cardiovascular Disease.

Data from US Department of Health and Human
Services, 2000. (27)
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Most common reasons for visits reported by
students

• General Medical Examination/Health Maintenance
• Musculoskeletal System/Connective Tissue
  
• Dermatology
• Infectious Diseases
• Circulatory System
• Respiratory System
• Endocrine, Nutritional, metabolic Immunity
• Mental Health
• Nervous System/Sense Organs
• Digestive System
• Genitourinary System
• Pregnancy, Childbirth, Pregnancy Related
• Other
• Injuries/poisoning
• High Cholesterol, other Lipid Abnormalities
• Blood and Blood-Forming Organs
• Neoplasms
• Congenital abnormalities/developmental
  disabilities

Diagnoses Reported by CHM Medical Students During
One Clerkship Fall I 2002
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Family physicians provide a key role in chronic
disease care.

• Anxiety/Depression 62
• Cancer 60
• Diabetes 67
• Heart Disease 56
• Hypertension 63

Family Practice in the United States, JAMA,
September 4, 2002 Vol 288, No 9.
17
Shared care between primary care physiciansand
specialists may produce the best outcomes.

• Patients in health maintenance organizations who
  had acute Myocardial Infarction and were cared
  for by generalists with cardiology consultation
  were more likely to receive guideline-directed
  care.

Annals of Internal Medicine, Vol 138, 3 257,
February 4, 2003
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Personal interaction is not unique to family
practice but a key element.

• There is a fragile moment when a person (the
  patient) passes a point of tolerance for his or
  her problems and reaches out toward the physician
  for help, and the physician extends the helping
  hand in return. It contains, among other things,
  the chance to make a real difference. A
  difference not only in the life of the patient
  that affects his or her health, but a difference
  in our own lives as well.

Essentials of Family Medicine, Fourth Edition,
Lou Barnett, M.D.
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Key Elements of Family Practice

• First Contact Care
• Entry to the health care system
• Comprehensive Care
• Prevention/Health Maintenance
• Continuing Coordination of Care
• Doctor-Patient Relationship
• Managing Referral
• Chronic Disease Care
• Shared Decision Making
• Community Concerns
• Acute Care Episodes
• Immunizations
• Sports Physicals
• Care in Context of Family and Community