When I ask some doctors what they see in the future for medical practice, their answers tend to be negative: limited options, burdensome contracts, transient relationships with patients, hassles with managed care. What it boils down to is a sense of doctors' continuing loss of control over their work. That is no psychosomatic complaint. Physicians' ability to shape their future without outside interference is a thing of the past.

But that doesn't mean that we have no control. We have different control and, in the rapidly evolving health care system, new opportunities to improve our value to our patients and the public. For example, with computers and information systems, we now have the opportunity like never before to measure as well as improve the outcomes of the health care we provide.

Exercising this different kind of control begins with adopting a proactive mind-set. As we think about how to make ourselves and our practices succeed in the years to come, we have a choice of following the counsel of one of two sports philosophers: former New York Yankee Yogi Berra or hockey star Wayne Gretzky. Berra advised, “When you come to a fork in the road, take it.” Unfortunately, this has been the approach of too many physicians in recent years who have found themselves constantly reacting to sudden changes in the new health care environment with precious little time to think and plan. We would be better served to follow Gretzky's advice: “Always skate to where the puck is going to be.” Granted, it's a tall order. But as advocates for the interests of our patients as well as ourselves, we must strive to carry out this proactive approach.

So where does it appear that the puck of health care is headed? What will health care look like in the new century? How will family physicians fit into it? And what skills will we need?

Health care in the 21st century

While many health care trends quickly come and go, health care in the new millennium may be shaped by these following characteristics. First, patients will be seeking care as “educated consumers,” more aware of both what they think they want and whom they want it from. Their information may come from the most recent drug ad on television, a new health Web site or anywhere in between, but more and more patients will be coming to us well-versed in the most current therapies for their conditions or curious about recent research. They'll also be more choosy about the doctors to whom they bring their questions. For example, members of our health plan can go to the AvMed Web site and pick a doctor with the characteristics they're looking for. Just by clicking on certain criteria, a member can find a list of female Hispanic family physicians in a specific ZIP code who admit at a certain hospital. And that's not all. In addition to getting the doctors' name, phone number and office hours, the member sees the physicians' pictures, personal statements about what it means to be a family doctor, where they were trained, and their latest patient-satisfaction survey scores.

As physicians, all this may seem threatening. But it means that patients are taking a more active role in their health care decisions and looking for a family physician to help them do their part to keep themselves healthy and obtain the right care.

Another change we'll continue to see is increasing competition among physician groups and health systems on the basis of health outcomes and consumer satisfaction. Patients, employers and the government are asking their health systems — and, therefore, us — to document the quality of the product they're purchasing: health care. Today, if you look on the Web for information about a health plan or a large medical group, you'll be likely to find data about its immunization rates, mammography rates and percentage of patients taking beta-blockers after heart attacks. You may see data that show which health plans or groups have the highest patient satisfaction and what percentage of members would recommend that group to someone else.

Again, all this may seem threatening; professionals tend not to like those outside their profession to evaluate their work. But we have to keep in mind that if health systems and physician practices are competing on the basis of health outcomes and consumer satisfaction, the behaviors being rewarded include those that typically keep people healthy.

As far as care delivery is concerned, we will be responsible with other health professionals for the entire care of a specific population of patients. In the new century, we will find ourselves accountable not just for the care we deliver but also for the care we don't deliver. We will be responsible for our entire panel of patients, not simply those who self-select to come into our offices. For example, to be effective, we will need to be proactive in identifying and following up with hypertensive patients who haven't been in for an appointment recently, children who haven't received their scheduled immunizations and patients with asthma, diabetes, heart failure and other chronic conditions who will wind up in the emergency department if they do not adhere to our treatment plan.

With this kind of new responsibility to practice population-based care, patient communication and coordination of care outside the office becomes nearly as important as clinical skill in the exam room, and a team-based approach is key to making it work. Increasingly, office-based family physicians will be working with nurses, hospitalists, mental health providers, home health nurses, social workers and other physicians as we strive to proactively identify those people we care for and keep them healthy.

The push to make care more cost-effective certainly will continue in the new century. We'll have to keep looking at the drugs we're prescribing to ensure that we haven't overlooked a less costly but equally effective option. We'll have to keep watching the diagnostic studies we order to ensure that we really need them — and that someone else didn't already order them last week. We might share after-hours phone and e-mail “call” to ensure our patients don't unnecessarily utilize more expensive emergency department care. We'll enroll our patients in special “disease management” programs to proactively treat them and avoid hospitalization.

All these changes in health care delivery depend on an underlying and fundamental megatrend: the growing reliance on computers, electronic communication and comprehensive information systems. Increasingly, patients will be contacting physician office Web sites to confirm their office appointment, leave their last week's blood glucose or pressure readings or ask the family doctor a health-related question. Interdependent practice requires computerized patient records, prescriptions and patient education materials that are accessible to members of the care team in different locations. Choosing the right drug or preventing a duplicative test demands that you have the information you need at your fingertips. Competing on the basis of quality, affordability and patient satisfaction requires the practice or health system to collect and analyze outcomes data that we can use to improve our practice effectiveness.

By the same token, a good information system and some sophistication in data analysis enables you to play defense when you have to. If health systems or insurers make comparisons that cast your group in a negative light, you may need to be able to question the methodology of the comparison: Are the data adjusted for sex and age? Are the patient populations comparable by diagnosis? Is your population so small that a very few ill patients are causing your utilization rates to appear high? And you may need to be able to present better, more complete data from your own information system.

Of course, you'll only be able to do that if your data show you really are doing better. Quality improvement (QI) is another trend we'll see continuing in the new century because it's a manageable approach to meeting a seemingly overwhelming goal: always doing better. Simply put, QI is a systematic way of continually examining and improving the care we provide. To the extent we embrace QI and implement it in our practices, we'll position ourselves to compete on the basis of health outcomes, provide a higher-value “product,” keep our patients satisfied — and help people stay healthier.

New skills for family physicians

What kinds of knowledge and skills will we need to skate to where this health care “puck” is going in the new century? I believe they fall into 10 categories. (Not coincidentally, these are also the 10 major topics in the Family Practice Management curriculum. We of FPM believe strongly that the publication you're reading should be one of your primary tools for gaining the knowledge and skills you need. For recent articles related to each of the topics below, see “Where to turn in FPM for help.”)

1. Measuring and improving clinical care. It's becoming the conventional wisdom in family practice that we won't make real improvements in our care or our office operations without going about the improvement process very intentionally. The sooner we embrace QI and put it to use in our offices, the sooner we will start seeing everything from outcomes to incomes improve.

2. Maximizing patient satisfaction. We need to ensure that we take the time to see our patient relations from the other side of the reception desk and examining table. Does the receptionist greet patients with a smile? How long do they have to wait? Do we effectively utilize their wait time to obtain relevant health information or to complete a patient satisfaction survey? How much time do we spend listening to patients before we interrupt them? We have to find out what patients think of us and our care and then act based on the feedback they give us. Otherwise, they'll find someone who will listen and treat them better.

3. Using computers and information systems. What the stethoscope was to the family doctor in the 1960s, computers and information systems will be in the early 2000s. So learning about (and struggling with) computers and becoming comfortable using them to maintain medical records, print out patient education materials, search the Web for clinical guidelines and communicate via e-mail with patients and fellow physicians will make us more effective and efficient family doctors in the years to come.

4. Running an effective practice. Effective practice management may once have consisted of hiring a good office manager and hoping for the best, but not anymore. An important part of riding the other trends we'll see in the new century is making sure your entire office works better than it ever has before — and then improving on it.

5. Maximizing reimbursement. Family doctors don't need to become accountants, but we do need to become reimbursement-savvy. This means learning how to negotiate good contracts with insurers and recognize bad ones, how to use the coding and documentation rules to our best advantage, and how to take on risk contracts as safely as possible. Finally, our contracts should include bonuses, not just on productivity or utilization, but also if we demonstrate our patients are healthier and highly satisfied with our care.

6. Practicing ethically and legally. The need for this isn't new, but the environment in which we're asked to do it certainly is. Just think about the dubious incentives that risk contracts can dangle before physicians, the labyrinth of bureaucracy, the threat of Medicare fraud-and-abuse investigations and the temptation to practice defensive medicine as a risk-management tool. We will need to continue to keep the patient's interest first while we recognize our responsibilities to communicate the limits of both health care and their insurance coverage.

7. Monitoring health care trends. Until relatively recently, monitoring health care trends meant staying abreast of the clinical literature. We still must do that, of course, but now we have to keep an ear to the ground of that nebulous “health care environment” in which we all work. Why? Sometimes freight trains come so fast you don't have time to get out of the way if you don't first hear them in the distance.

8. Forming and operating groups and integrated systems. Not all the health care gurus agree that integration is the key to higher quality, more cost-effective practice, but enough do that we should become familiar with what makes successful groups work and how we might benefit from the lessons they've learned. We also should learn the skills that the leaders of large groups and integrated systems need so that we continue seeing family doctors taking leadership roles in health care.

9. 9. Enjoying salaried practice. As the environment becomes more demanding, we're likely to continue seeing more and more family physicians opting out of the traditional doctor-as-business-person role. People in salaried practice may have fewer concerns about running effective practices, merging with groups or negotiating with health plans, but they have their own issues to consider: How do you find a good salaried position? How do you negotiate with your boss? How do you work effectively within a large system? What leadership opportunities are available? Even if you have no plans to turn to salaried practice now, you probably should be familiar with its advantages and disadvantages. You never know when that option might start looking more attractive.

10. 10. Maintaining life balance. The most important issue for many family physicians is maintaining balance in our own lives. Given the demands of practice, both clinical and nonclinical, how can we make time for our families, our friends and ourselves? How do we recognize the signs and symptoms of burnout, and what can we do about it? How can we rediscover what is most meaningful to us about being family doctors?

How to skate to where the puck is going

Admittedly, this list of knowledge and skills is a little overwhelming. But don't think you need to master it all at once. It will take us a while to reach the top of this learning curve. Here are several steps you might take to begin your journey.

• Educate yourself about the future. Actually, by reading this journal, you're already taking this step. If you're interested in FPM, you realize that family practice is, and will continue to be, more than simply practicing good medicine with each patient you see. Keep seeking opportunities to learn more about effective practice. If you have some idea what's coming tomorrow, you'll know better what you need to learn about today.

• Teach your office staff to consider patients as customers. We may like the implicit message in patient — that the people we serve will be patient with us and grateful for the time, attention, knowledge and expertise we share with them. Now that perspective is shifting; patients expect us to be grateful to them for choosing us as their doctors. And we should be. Understanding some of the skills and strategies for making patients' experiences as positive as possible can do wonders to maximize their satisfaction with us and the value they see in us as family doctors.

• Measure patient satisfaction and quality of care, and then improve them. Implementing QI may sound daunting, but it's really a manageable process that begins with simply knowing how you're doing on variables that matter. For example, before you can compare your effectiveness in diabetes care with that of other physicians, you need to know what percentage of your patients with diabetes are in good control. So bite the bullet and do the chart audits to record your patients' Hb A_1c levels. Convene a small group to consider how you might improve the average, implement an improvement plan and measure again in a few months. In a nutshell, there's a QI project.

• Improve your computer system and your computer skills. If you don't have a computer, then consider buying one. If you have one but are not yet comfortable using the Internet, then take a class … or have your friends or your children show you. If you already use the Web to record your CME with the AAFP, search MEDLINE for key articles, print out personalized patient education materials, use electronic medical records, communicate with your patients via e-mail, scan in and analyze your own patient satisfaction surveys, review Microsoft Excel spreadsheets of your patients with chronic diseases, and have your own Web site, then you can teach others!

• Provide care cost-effectively. Largely, this is a matter of adopting a mind-set of good stewardship. Here again, the key is self-education —staying up-to-date on less costly diagnostic and therapeutic interventions that work just as well and use the hospital only when unavoidable.

• Carefully consider your scope of practice. We come out of residency with a broad training, and then we have choices: Do we want to do obstetrics? Hospital care? Skilled nursing care? Perform sigmoidoscopies? Biopsy skin lesions? It's important to think about the implications of these choices. Family doctors who maintain a broad scope of practice may find themselves better positioned to demonstrate their relative value in the new century and justify higher incomes as the health care system continues to change. If you limit your scope, do so for explicit personal reasons.

• Make an effort to care for all your patients. If your health plan asks all members to choose a primary care physician, then you may be held accountable for the cost and quality of care your population of patients receives even if they don't regularly see you for their care. On the other hand, some of your patients' health plans probably no longer require you to act as the “gatekeeper” to the rest of the health care system. That may be wonderful as far as patient convenience is concerned, and it probably eases your paperwork burden and expenses, at least to some extent under capitation. But the move to open-access care models means that family physicians may well not know about all the care their patients are seeking — or not seeking.

  For your patients who are at higher risk and need ongoing care, call to remind them of their next visit and demand that consultants always follow up with you by phone or dictated letter. You may consider sending your patients birthday cards or your practice's office hours, phone and e-mail address just to let them know you're there. If patients choose us as their family doctors, shouldn't we make some effort to be their family doctors, even if the health plans don't require it?

• Communicate effectively with your health care team. As we are increasingly coordinating care of our patients with consultant physicians, home health nurses, pharmacists, hospitalists and health plans, good listening and communication skills are a valuable part of a family doctor's black bag.

• Find the right balance in your life. To help us keep from burning out in the face of so many duties and opportunities, we need to identify the values most dear to us. What is the core of who you want to be — as a doctor, as a spouse, as a parent, as a member of the community, as an individual? Once we know who we really want to be, we can do a better job of making the choices of what to do and when to say “no” that strike the balance between our professional and personal lives.

Our once and future practice

These are not suggestions for doctors who think they have no control over the future. They are for doctors who realize that their futures are largely their own to make. If we embrace the knowledge and skills we will need for practice in the new century, we'll be in a far better position to shape that practice and choose what we want to be.

Although taking these steps will help bring us into the new century, they will simultaneously help take us back to our roots. If we treat our patients as we'd like to be treated, give them the best care we can, mind the cost of what we recommend, provide a broad scope of care, coordinate our patients' care, manage their health information effectively and find harmony and peace-of-mind in our own lives, we can become who every family doctor really wants to be: a joyful, caring, compassionate, effective physician. Finding those roots is a fundamental part of preparing for practice in the new century. Despite the many changes taking place in health care and the need to learn knowledge and skills to help us adapt in that evolving environment, each of us will be successful if we find within ourselves what makes us who we are and who we aspire to be.