Have family physicians abandoned acute care?

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Not long ago, I had a conversation with a colleague—a residency director and family physician—about the unique contributions family doctors make to health care. He believes FPs are best trained to provide chronic disease care and address prevention. And he’s proud that his program trains residents in motivational interviewing to guide patients to healthy behaviors and adherence to medications and recommended screening tests.

I agree that these health-coaching skills are important for FPs and that we should strive to nudge our patients toward healthier lifestyles. But is that the heart of family medicine? I don’t think so.

I was dismayed by the fact that my colleague did not mention caring for people who are sick: those who have aches and pains and those who just don’t feel well and need careful evaluations that could lead to a diagnosis of cancer—or to the realization that the symptoms are related to psychological distress.

At times I fear that all the focus on prevention and chronic disease management, necessary as these are, distracts us from our most important work: meeting the immediate needs and concerns of our patients. The agenda of the office visit used to be exclusively the patients’. Now a visit—and our attention—is often split between their agenda and ours, which includes screening for this and that and exhorting patients to a healthier lifestyle whether they want it or not. I had one irate patient tell me, “Don’t put me on that scale again! I know I’m fat and if I want your help, I’ll ask for it.”

Overemphasis on prevention and chronic disease management, I fear, has caused many physicians to undervalue diagnosis and acute care. The sad result? In some practices, the schedule is so full of routine follow-ups that patients must go to an urgent care center or the ED for complaints that could be easily managed in a doctor’s office.

I did not go to medical school to be a health psychologist, even though my college major was psychology. I wanted to be a doctor, and I still do. I want to diagnose illness or wellness accurately and efficiently and help patients feel better—to offer reassurance to the worried well and the right treatments to those who are sick. The “number needed to treat” to listen carefully and provide reassurance and proper treatment to a patient with an acute complaint is one!

My beliefs about family medicine are reflected in the contents of JFP. We publish articles about chronic illness, prevention, and acute care in a balanced fashion. Family physicians need to be triple threats, not health psychologists.

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