This issue contains an article that should make you a little uncomfortable: “Nurse Practitioners: Growing Competition for Family Physicians?” If it does, I hope your discomfort arises, not from a feeling that family practice risks losing some turf, but from far more defensible concerns. Any turf issue here is secondary, after all. If family practice can't demonstrate its value — that is, prove its cost-effectiveness and get the message out — turf may be the least of its worries. Besides, the practice that was the immediate impetus for the article, Columbia Advanced Practice Nurse Associates, is a solitary example of head-on competition from independent nurse practitioners. More, it's located in midtown Manhattan, which resembles most of the country about as much as the dark side of the moon.

No, let's forget turf for now and think about the other kinds of worry the article engenders:

• Concern that competition between family physicians and independent family nurse practitioners may threaten the enormously productive working relationships that family physicians and nurse practitioners enjoy in hundreds of practices across the country.

• Concern over what the marketing tactics adopted by proponents of independent nurse practice may say about family practice today.

The first point is self-explanatory, I think, but the second may need some unpacking. As the article points out, the way independent nurse practitioners are presenting themselves seems to echo in many respects the way family physicians have tended to present themselves — and to think about their specialty. For instance, “Nurse practitioners take a holistic approach to care. They do not function from the traditional medical model, focusing their attention strictly on diagnosing and treating an illness. Nurse practitioners look at the patient's whole environment.” (See “Does this sound familiar?”)

What does it mean for family practice that another set of providers can appropriate its rhetoric? That's a question worth thinking about. One answer is that nurse practitioners and family physicians are more in accord with one another about a number of philosophical issues than they are with other providers. Another is that family practice has been forced so far from its original ideals that those ideals are up for grabs.

If the first answer is reassuring, the second one can hardly be more discomforting. Goodness knows today's health care system has subjected family practice to more pressures than some fairly deep-lying parts of the earth's crust, and one has to wonder whether its underlying principles have been deformed as a result. What do you think? Is family practice still family practice? Are the ideals that first drew you to family practice residency still embodied in your practice? Is there any way we can ensure that all the pressure of circumstance will produce a diamond-hard, clear, bright vision of family practice? These are important questions, because for family practice, the product of the current competitive climate is likely to be fossils if it isn't diamonds.