Although I appreciated the article “The State of Family Medicine” [January/February 2012], I cannot agree with the conclusion that the ability to manage the “dynamic tension” between the challenges and rewards of family medicine signals a “first-rate intelligence.” Someone with a first-rate intelligence would look at the state of family medicine today and choose another specialty. It's not just about the money. Family medicine today is rudderless with regard to its scope of practice. What defines us as a specialty today? On the one hand, clinical services commonly offered by family physicians are also offered by doctors better trained to deliver them. For example, 80 percent of survey respondents practice adolescent medicine, according to the article, but adolescent medicine is its own subspecialty, requiring a three-year fellowship and boards, a career path most commonly embarked on by pediatricians. We offer these services because our medical licenses allow us to, not because we are necessarily trained in them.

On the other hand, common services we all provide – chronic disease management and urgent care – are rapidly becoming the province of NPs and PAs because they can provide most of these competently and at less expense, although not as efficiently as we do. Still, cost considerations rule, and there is no future in primary care for physicians who have gone through four years of medical school and three or more years of residency to see the same kinds of problems as providers with a mere two years of training beyond the baccalaureate degree who are allowed to bill Medicare and other insurances at 85 percent of the physician rate. Medical students realize this, and that is why the numbers of students matching with family medicine has been largely in decline since 1997. Although there was a slight upward blip these past three years, I believe the downward trend will continue as medical school graduates look for more remunerative ways to pay back their loans while choosing specialties where they don't have to fight for privileges.

Family medicine physicians, who are still viewed as general practitioners by most people despite the specialty's having been in existence for almost 40 years, will have to use their imaginations to carve out areas of expertise distinct from midlevels and specialists in order to make family medicine economically viable, professionally satisfying, and distinct from what other health care providers do in their workplace. For more thoughts on this issue, read “Reinventing Family Medicine” [April 2006].