A New Face for Family Medicine
Jay Siwek (C’67, M’76), MD, is all for “rebranding” his profession – if that will save it. Siwek, the former Chairman of the Georgetown University Medical Center’s Department of Family Medicine, says the new push to establish what is being called the “patient-centered medical home” is an attempt to make primary care physicians the cornerstone of U.S. medical care – just as these doctors were decades ago.
“It can work – and it must,” says Siwek, who, as GUMC’s department chairman for 15 years, has seen a precipitous decline in both interest in family medicine among medical students and delivery of primary care in the United States.
“The patient-centered medical home was a term created by the American Academy of Pediatrics in the 1990s to make sure children with special needs obtained the care they need,” he says. “But it has evolved into a concept of personal physicians taking on the responsibility of coordinating all of the health needs, including preventive care, of an individual, a family.
“To me this is just a way of saying that this country needs good primary care, but if new packaging will make a difference, I am all for it,” says Siwek.
So far, all of the major American academies involved with primary care, including family medicine (American Academy of Family Physicians), general internal medicine (American College of Physicians), and pediatrics (American Academy of Pediatrics), have adopted the terminology and are pushing for its enactment. In addition, the Patient-Centered Primary Care Collaborative, a coalition said to include 330,000 physicians and employers of 50 million American workers, has been lobbying Congress on behalf of a patient-centered medical home, Siwek says.
“Family medicine is more of a calling. It has a social force at work behind it and now is the time for those forces to come back into play,” says Siwek. “It is not just being a doctor and taking care of people, but is a desire to meet the needs of health care in America. But it has been a struggle to work in a system that is broken in so many different ways, and to know the country’s health is worse off because of it.”
Siwek went into family medicine in order to treat both adults and children, figuring he could make the most sustained impact on the lives of families. He received his undergraduate and medical degrees at Georgetown, but completed his residency in Connecticut because GUMC did not, at the time, have a residency program in family medicine. When he returned to GUMC in 1979, it was to serve as a faculty member in a new residency program for family physicians. He has been in the Department of Family Medicine ever since, and in 2008 stepped down to become vice chair. He now spends much of his time as editor of American Family Physician, a medical journal.
During his almost 30 years on faculty, Siwek says he’s seen how family medicine has become somewhat marginalized, both within some of the country’s medical schools, and as a specialty choice among medical students. Both trends, at their core, have to do with finances, he says. “As unfortunate as it is, money talks, and the way that many physicians earn their money now is by reimbursement for procedures,” Siwek says. “And procedures offered by cardiologists and orthopedics, among others, pay much more than the services provided by family physicians.”
That means that while many students come into medicine to become family physicians, a substantial proportion of them change specialties because they worry about how to pay for their expensive education, given the relatively low salaries they expect to make nowadays as a family doctor, he says.
Studies back up what Siwek is saying. In 2007, the American Medical Group Association found that the annual median pay for family doctors was about $185,000, yet newly minted family physicians leave school with about the same level of debt (about $170,000) as physicians in higher-paying specialties. (To compare, orthopedic surgeons earn an average of $426,000 annually, and radiologists earn $414,000.)
Many medical schools have an official mission and curricula to support the choice of family medicine, and the program at GUMC is particularly strong, says Siwek. “We know how to teach family medicine. At Georgetown’s School of Medicine, we offer more courses than any other department, and require students to take these courses in all four years.”
Nevertheless, at GUMC and other medical schools, a substantial number of medical students who enter with a generalist’s mindset graduate seeking residencies in subspecialties, Siwek says. The reasons are complex, including the fact that medical training occurs in academic medical centers, where often the most complex medical cases are seen due to the cutting-edge treatments, and prominent experts in the field who practice also teach there. Students may not have as many opportunities to see family physicians at work, Siwek says.
“I think that medical students do come to Georgetown because of our commitment to the Jesuit concept of cura personalis, our community service requirement, and our school’s advocacy curriculum,” says Stephen Ray Mitchell, MD, dean of medical education at Georgetown University’s School of Medicine. These same factors, Mitchell says, led to the founding of the Hoya Clinic by the departments of community pediatrics and general internal medicine. The student-led clinic, the first in DC, offers comprehensive care to underserved and underinsured families. But Mitchell agrees that medical school debt plays a role in choice of specialties. “While 51 percent of the matriculates of the class of 2012 identify primary care as a principle reason they came here, debt may then cause them to leave those goals of conscience on the table,” Mitchell says.
The result is that nationwide fewer and fewer medical students are electing to take a residency in primary care. Even though family medicine has the second-highest number of residents enrolled, the decline in family medicine residency programs began in 1997, when 2,340 U.S. medical students chose family medicine. By 2009, this number had decreased to 1,083.
At the same time, the country’s need for primary care has been growing, Siwek says. Previously, the generalist/specialist ratio was about 50-50, but this has changed to 30-70 in recent years, Siwek says, adding, “Even so, there are still more family physicians in the United States than any other specialty. But the number of family physicians and other primary care physicians has decreased relative to their need for our growing population.”
Siwek says now that possible revamping of the country’s health care system is on the political agenda, the time is right to restore the role that family physicians play in offering high quality, effective, and relatively low cost health care. A so-called health czar could take steps to narrow the salary gap, help fund the training of more family physicians, and revamp insurance policies that currently favor costly procedures, rather than preventive care, he says. “It is appropriate for a neurosurgeon to make more than a family physician, but the difference is a lot greater in this country than in others,” he says. “Supporting family medicine as the backbone of American health care would narrow the prestige gap as well.”
“There was once a better time to be a primary care physician in America,” Siwek says. “Let’s hope that the patient centered medical home takes hold, and re-establishes the value of having good primary care in this country.”
By Renee Twombly, GUMC Communications
To read more about the shortage of physicians in the country and how it is potentially impacting health policy, read this story from the New York Times: