Over the past few years, managed care and the integration frenzy have swept over family practice like a mast-high wave. Now, poorly managed integrated systems are coming apart, managed care is subsiding, and the specialty is sliding down the back of the wave, trailing a tangle of spars and rigging, to wallow in the trough. The old problems are still present – an inefficient system, spiraling costs and the like – while new questions abound: Is there any way for integrated systems to survive? How can practices growing from the ashes of disintegrated systems function? Is there any way to get back the intimacy, the established relationships and other lost virtues of the old system? How can physicians cope with the disjunction between patients who feel entitled to the moon and payers who demand bargains? Above all, how can you protect patients, and the joy of good patient-physician relationships, from the general chaos?

Wallowing

The bad part about being stuck in the trough behind the wave is that you’re not going anywhere. Such sails as are left can catch no wind, and it’s all you can do to cut away the wreckage. The time is characterized more by hard-won knowledge of what didn’t work than by the excitement of new possibilities. The good part is that we do know more than we did before the wave hit, and we know we have to do something.

What that something is, nobody is quite sure. What we’ve had doesn’t work, what works is not clear, and whether anything will work is by no means certain. A bad state of affairs, true, but a great impetus to experimentation. And everywhere you look experiments are in progress. Here, a large system is reorganizing to create what are in effect small practices where there had been one huge bureaucracy. There, a family physician is developing a boutique practice designed to thrive on direct payments from patients. Over there, a group is building an all-house-calls practice, and right next door, a family practice is attempting to incorporate alternative providers. In various places, managed care organizations are developing hybrid and mutant managed care plans. Scattered physicians are working to build e-mail into their patient management. All over the map, physician groups are working to develop paperless work flow. We seem to be leaving behind a time that was frustrating and disastrous. We’re entering a time that is equally frustrating and potentially full of small and large disasters – but also a bit exciting.

Into the next wave

One of the large-scale efforts to climb the next wave is the Future of Family Medicine Project that’s described in this issue’s cover story. Since this is a combined effort of several family practice organizations, including the AAFP and the American Board of Family Practice, it may seem to play out on some plane that has little to do with you personally. After all, how can you be expected to worry about something as abstract as the future of family practice when you’re worried by such a concrete problem as the future of your family practice? But given the players, the project merits watching. It’s not outside the bounds of possibility that the project will eventually produce changes in what you need to do to maintain certification, what constitutes CME credit and how you need to practice to call yourself a family physician. The project is a specialty-wide manifestation of the sense you probably have that things aren’t working the way they should – that we need to try something else.

There’s at least a decent chance that the decade we’ve just entered will be exciting and positive for family practice. I grant you that the chance and the upside potential may be limited by our culture’s almost certain refusal to confront our fundamentally irrational expectations of the health care system. But look at it this way: When you’re in the trough between waves, you’ve got nowhere to go but up – assuming you can stay afloat.