Each year we scan the National Resident Matching Program results to see how our community-based family medicine residency program performed in the match. The data over the last five years has told a consistent story: Across the country family medicine has undergone a steady decline in numbers. According to AAFP figures, the 1,132 U.S. medical school graduates who matriculated to family medicine in 2006 represent a 25 percent decline from 2001.¹ Over that same time there has been a concomitant increase in the number of medical students who elect for training in subspecialty programs.

Several theories have attempted to explain the demographic shift. One leading theory is that the growing financial burden associated with physicians' training is pushing more young physicians into the higher-paying subspecialized fields of medicine. The Association of American Medical Colleges estimates that the cost of private medical schools has risen 165 percent and the cost of public medical schools has gone up 312 percent over the last 20 years.² A similar study by the American Medical Association found that medical school costs have increased substantially more than the Consumer Price Index.³ The result is often significant educational debt. In 2006, more than 62 percent of medical school graduates carried $100,000 or more in educational debt.⁴ Given this unprecedented set of financial burdens, it is easy to understand why young physicians would gravitate toward areas of medicine that are more highly remunerated or offer less call and more attractive lifestyles.

While our national leaders in family medicine have tried to reverse this trend and have been vocal in advocating for the importance of generalists with national policy-makers, we in family medicine have engendered own brand of subspecialization – what might be called “specialized generalism.”

Specialized generalism

I have experienced aspects of this trend personally. Over the last year I have counseled several residents concerning their decision not to continue practicing obstetrics. More residents, mere months after electing to become family doctors on the heels of positive experiences during obstetrical rotations in medical school, are abandoning their care of pregnant patients. Recently, a second-year resident told me, “Obstetrics is simply too frightening. There is too much information to manage, and if I make a mistake the consequences are too great.” The anxiety in his voice was apparent as he explained his fears. Sadly, he was not the only member of his class who ultimately concluded to abandon obstetrical care and thereby move away from generalism.

These residents' decisions are mirroring national trends. According to AAFP data, 23.8 percent of family physicians delivered babies in 2003,⁵ down from 46 percent in 1978. For many individuals, this represents a lifestyle choice or an imperative driven by vertiginous increases in medical malpractice premiums. Yet taken as a whole, this trend threatens the very identity of family medicine. It is increasingly difficult for most physicians to identify salient differences between the combination of internal medicine and pediatrics taught in some residencies and the family medicine taught in our residencies. If our own colleagues have such trouble distinguishing what is unique about family doctors, imagine the difficulty our patients must experience.

The fellowship route to specialization

The specialization of family medicine has been further fostered by the expansion of fellowship training programs for family physicians. Graduates of family medicine residency programs can now undergo further training in sports medicine, geriatrics, obstetrics, academic medicine and a number of other fellowship areas⁶ – none of which existed 25 years ago. The number of fellowship positions and the number of residents completing fellowships has increased, likely due to the same lifestyle factors that have driven disproportionate matches in subspecialties.

Many family physicians embark on careers in sports medicine, academic medicine or geriatrics in which they take no overnight call and have no responsibility for caring for hospitalized patients. As “subspecialists,” they typically command higher rates of reimbursement for clinical work – particularly those with certificates of added qualification. In a time when family physicians feel increasing pressure to work longer hours in order to offset flat or declining reimbursements, these financial and lifestyle benefits of fellowship training provide a compelling incentive for today's graduates to abandon traditional generalist medicine.

Some could argue that opting to abandon hospital medicine or obstetrics is very different from augmenting one's skill set by undergoing fellowship training. The first situation represents an attrition of skills. Many would point out that by electing for further training, family physicians are becoming more widely skilled, not less. This is true in theory, and there are many physicians for whom fellowship training is a way to increase the scope of their practice. However, anecdotal and epidemiological evidence suggests that the upswing in subspecialization in the United States across all medical areas does not simply represent an interest among medical students and residents in learning more. Instead, it is commonly acknowledged that this move away from generalist practice, be it in pediatrics, internal medicine or family medicine, results from economic and lifestyle issues that challenge the nature of primary care itself.

The future of generalism

In 2002, seven national family medicine organizations initiated the Future of Family Medicine project in an attempt to address some of the challenges that face our specialty. Independent research firms were tasked with conducting national surveys of diverse groups of stakeholders. The leadership attempted to define a new identity for family medicine that was in concert with the needs of both physicians and consumers. The task force concluded that multidimensional care was one of the five core attributes of a family physician. Yet their work, while comprehensive and visionary, did not answer the most difficult of family medicine's questions: How can we survive when U.S. medical school graduates are spurning our training programs? How can we stem the flow of attrition to “subspecialties” of family medicine when generalism offers longer hours, lower esteem among colleagues and patients, and less pay?

Those on the cutting edge of medical education often advocate an “evolve or die” philosophy. To be sure, our tradition of embracing change has been a significant factor in our leading the way in adopting such innovations as electronic health records, group medical visits and competency-based educational systems. We must continue to adapt to meet market needs and to provide the best possible care for our patients.

Yet there is value in maintaining our identity, as well. In an increasingly cluttered medical marketplace, a unique niche is essential to survival. The family physician's ability to care for an entire family through cycles of birth, childhood, adulthood and death constitutes our unique charge. We in family medicine benefit from our specialty's long and proud history of advocacy for our patients, community involvement and service. These traditions are born of our heritage as generalists, and we should not turn our back on our roots. A good friend of mine has long referred to family physicians as “real doctors.” I have always imagined that he is speaking of a physician out of the Norman Rockwell mold: someone who could be counted on to come to the aid of a patient at home in an emergency, a physician who is equally at home dispensing advice in the office, providing care in the hospital and delivering a baby. These are the things that make us unique, the skills that distinguish us in the medical marketplace. This type of physician has tremendous value in the eyes of those for whom we care. But when I consider the move away from generalism that is afoot in family medicine, I worry that our patients may understand our heritage better than we do.