Do you find your scope of practice yielding to outside pressure? Certainly, the combined weight of outrageous malpractice premiums, decreasing reimbursement, hospitalist programs, privileging problems and competition from limited specialists (to name a few of the pressures) can be a potent force. Such pressures can squeeze out deliveries, inpatient care, surgical assisting, nursing home care, house calls – anything that increases your liability exposure or interrupts the rapid flow of patients from waiting room to exam room to check-out desk.

In fact, if you don’t see at least some disconnect between the way you practice in today’s world and the traditional ideals of what family practice should include, you’re quite lucky –although chances are that you’re working long hours and taking home relatively little. And speaking of long hours, one of the pressures that has been growing over the past two or three decades is the radical idea, held by family physicians and their families alike, that a family physician should actually be able to have a life. That in itself has been enough to squeeze deliveries out of many a practice.

Rethinking the practice

One ingenious idea for regaining at least some of the lost ground is advanced in this issue (see page 29). Michael J. Worzniak, MD, and Margit Chadwell, MD, suggest a model for shared practice that allows individual physicians to practice in a variety of settings while maintaining a reasonable life outside of medicine and, remarkably enough, improving the bottom line of the practice. The financial magic comes from the authors’ recognition that two physicians who rotate times in and out of the office need less office space and a smaller staff than they would in a conventional practice. While one is seeing patients in the office, the other can be out making house calls, rounding on hospitalized patients, seeing patients in a nursing home, etc.

It’s an intriguing idea, and it may work well for compatible family physicians with a flexible staff. Of course, the concept suggests that it can take two of today’s family physicians, albeit perhaps working part time, to live up to the ideal of what one family physician ought to be able to accomplish. That says something about the ideal or today’s world or both.

Rethinking the specialty

In raising this issue, however incidentally, the article by Worzniak and Chadwell is certainly in tune with the times. Apparently we’ve traveled far enough from the founding of the specialty that many thoughtful family physicians are wondering what family medicine really should be today, how it connects with the world of the 21st century, and what relationship it has to its roots. The most obvious manifestation of this self-analytical mind-set is the “Future of Family Medicine Project” (FFM). The fact that the FFM project is sponsored by all of the national family practice organizations is an indication of the breadth of concern with the issue.

And indeed, at least a couple of the questions the FFM project is setting out to answer underlie the article in this issue: “What are the core attributes of family practice?” and “How can we ensure that family physicians continue to deliver the core attributes of family practice and the services the system expects throughout their careers?”¹

Of course, the FFM project has a much broader scope than the Worzniak/Chadwell article, and it operates on the societal level. Still, the two share some of the same spirit. Both show a dissatisfaction with how the world has shaped family practice over the past three decades and a desire to make it new again. While the dissatisfaction is old news, the idea that we can “transform and renew the specialty of family practice,” as the FFM charge has it, is new and refreshing. At the very least, it’s good to have an occasion for optimism. And a recent article by Larry A. Green, MD, and George E. Fryer, PhD, argues that “this is possibly the first time in history that the ambitious aspirations of family practice are actually achievable.”² I, for one, am willing to hope they’re right.