>October 1, 2020
>Jerry Jebaily, MD

Family Medicine fundamentals have been articulated and residency training stems from these elements. Why are they being questioned now after fifty years? Somehow organization and education leaders have forgotten or never embraced these core concepts or else this recurring "rediscovery" activity would not happen. Reiteration may be necessary. I reference only a few seminal documents these leaders should read or reread.

1. G Gayle Stephens. Intellectual Basis of Family Practice. AAFP Workshop, June 24, 1975.
2. Hiram B. Curry. Family Medicine/Family Practice: Why and How. Graduation address, Harvard Medical School, 1980
3. Beasley, M.D. Ten Central Elements of Family Practice, Journal of Family Practice, 1983; Vol 16, No. 3: pp 551-555
4. Carmichael, Lynn. A Different Way of Doctoring, Family Medicine, 1985; Vol XVII No. 5: pp 185 - 187
5. John P. Guyman. The Family as the Object of Care. Journal of Family Practice, 1977; Vol 5 No. 4: pp 571 - 575
6. John P. Guyman. Family Practice in Evolution: Progress, Problems, and Projections. N. Engl J Med, 1978, Vol 298, No. 11: pp 593 - 601.

>October 1, 2020
>Paul Lazar, MD

Our specialty has always been to some degree defined by others--we do what no one else feels like doing. Care of patients is becoming increasingly fractionated because of both insurance barriers and convenience. While continuity of care remains relevant for patients with chronic illness, it is little valued by relatively healthy patients.

In the urban world, we are finding very little demand for our OB skills in particular. I finally gave up OB at age 60, but had done very little in the five years before that. Now even my fellowship trained colleagues are getting very little practice. Although we have long provided same day access, urgent care has encroached to a great extent on this relatively easy and profitable work... because it is easy and profitable. So our same day access often consists of patients with complex medical and or mental health issues who require lots of time and provide little reimbursement relative to the effort. I don't see ABFM/ACGME having much effect on this, unless a requirement is added for a substantial urgent care rotation so that graduates are prepared for a hybrid practice including some primary care and some urgent care. We have also experienced challenges in volume of care of children. Allowing acute visits in the urgent care setting to be an important part of the learning requirement would be helpful and relevant.

Rural/small town FM's do more stuff because specialists don't feel like living in rural areas and patients don't feel like traveling (or in the case of labor, can't make it there before the baby pops out) to where the specialist is. This is changing due to improved technology/broad acceptance of telemedicine, so rural FM's will find more pressure to have a narrower scope over time. This can and should be ameliorated by changing the training of specialists, not FM's, so that they are trained in providing truly collaborative care. Psychiatry is actively working on this. Perhaps other specialties can be brought along.

Finally, obviously the hospitalist problem is not going away. In fact, many of our graduates are going directly to hospitalist practice. One wonders if training should actually diverge at some point (this may also be true for IM) such that the third year is spent in hospital based rotations (including OB and Peds for people who started out in IM so they can attend to at least emergency care in those specialties) for those going into hospitalist practice and move to almost entirely office based practice for the ambulatorists in the bunch.....It's a tough question.

>October 4, 2020
>Seneca Harberger, MD

As a "young" physician who was strongly attracted to family medicine for the breadth of training and responsibilities, I am particularly interested in discussions of comprehensive care. To me, 2 elements seem most salient in training for comprehensive care in family medicine:

1. The breadth of skills needed (and possible) for a particular family doctor is highly dependent on the community in which they practice. While residencies owe it to their trainees to anticipate needs they may face if they leave the community after graduation, they owe it to the communities they serve to collaborate explicitly to find the scope their population needs. This collaboration should occur on an organizational level, but residents must also be individually trained to develop this skill for their own future practice.

2. The breadth of truly comprehensive care is honestly too wide to effectively train for mastery within a 3-year program, which means that either training should expand to provide more time or the goals of training should focus more on residents’ empowerment to continue to learn and to expand in areas as needed by their patients. I favor the second path as the more practical and efficient approach since individual settings typically do not benefit from having a single doctor who can expertly provide all aspects of their care, but rather, they benefit from having a physician who can adjust into the specific variety of care most needed by their particular community. That means explicit training in the skills of community coordination and responsive, self-directed learning.

Addressing these two elements would entail increasing our focus and direction to provide training in community engagement and collaboration, increasing our explicit training in augmenting or developing new skills after graduation, and introducing more flexibility in our requirements for scope of care.

>October 11, 2020
>Dan McCarter, MD

In the Current Outcomes… Milestones brief—The first point talks about outcomes based GME. I have always told patients, and learners that the only dumb questions are the ones that go un-asked. So, I would love if someone could explain to me what the definition of Outcome(s) in this context is/are?

Jim Collins in his book talks about the importance of a business understanding their denominator. I think we have all been whipsawed by the many denominators in medicine-- whether it be the many different quality metrics. (I recently heard a faculty member in the southeast talking about the over 400 quality metrics they were responsible for.) In my mind, this over complicates things, when in fact the outcome we are looking for is how well we can give our patients more healthy days now and in the future.

I think it is worth having a discussion if FM education was knocked out of the park, what is the equivalent of more healthy days. Or in information mastery terms, how do we help the future family physicians have more fulfilling careers that allow them to help more people, without suffering burnout or undo economic harm to themselves or their family.

>November 9, 2020
>Drew Keister, MD

In response to clinical and social needs FM needs to address. I agree with many of the suggestions contained herein, and yet I think that it fails to capture the largest issues at hand. Our society is growing into junk food and sedentary lifestyles. We are killing ourselves, and there is no end in sight. Family Physicians have little way to impact this patient by patient. We are spitting into the wind through that approach. We need to find larger solutions to encourage change in our communities. I do not have the answer of how to do it, but we need to make sure that our residents see this (and other large societal problems) as a necessary calling. The Family Physician can no longer be just the doc in the office. We need to be active and working in our communities to make the change the public needs.

>September 17, 2020
>Ron Stout, MD

Family physicians must be empowered with the knowledge to guide their patients in preventing, treating and reversing chronic disease. COVID has demonstrated that pills, potions and procedures don't address the underlying challenges of a damaged physiology. The emerging field of Lifestyle Medicine deserves significant attention and engagement from educators.

>October 14, 2020
>Patrick Couchot, MD

Thank you all for opening up this dialogue among family medicine providers. I would offer two suggestions to add or at least have a discussion about.

1. I would like to see a stronger emphasis of preventative medicine. Many of the systemic disease that affect and plague our country are preventable disease (ie heart disease, obesity, diabetes, etc). I am happy to provide research material supporting this claim. Family medicine providers are uniquely positioned to have a dramatic impact on this expanding field of medicine. I would place an emphasis on diet and exercise as lifestyle modifications which can be used as treatment modalities. Medical schools and residency programs are not fully preparing our physicians for these tasks and additional requirements would be paramount, especially as we move into quality based payments. I also have additional research to back this claim.

2. I would also like to see some involvement of training with mid level providers, as many large primary care groups are moving toward this model. I think exposure to these other specialties will allow for a more seamless transition when moving into different practices. Understanding the role of the mid level provider, and the role of the physician leader, can be crucial in providing care to an increasing amount of patients.

>November 23, 2020
>Alberto Alzate, MD

Perhaps is time to start thinking of having some subspecialties in Family Medicine. other specialties like EM that is a new specialty compere with

Family Medicine is advancing a lot because they are not asking other specialties for approval to embrace procedures that were not part of that specialty some time ago like ultrasound, echocardiogram, critical care, sport medicine, palliative medicine. Family Medicine need to give the chance to us to pursue different avenues and we need as specialty to get the recognition the we deserve.

>January 16, 2021
>Cara Horrop, MD

Although I haven't had a chance to deeply delve into the website, I was pleased to see topics like leadership, advocacy and team based care as part of a proposed curriculum. I also think it is critically important to teach residents about the business of medicine so that they can be conversant in leadership roles with members of administration and be advocates for their own practices. It is time for family physicians to not graduate from residency and believe that the only way they can make a living is to be employed by someone else. Thank you for your time.

>March 10, 2021
>Mary Callis MD, MPH

As a clinician dualy residency training in both family and emergency medicine I feel that family medicine residencies should increase the amount of emergency medicine and critical care training given that many emergency rooms nationwide particularly in more rural areas are staffed by family medicine physicians who may not be adequately trained to treat trauma or critical illness.

>October 1, 2020
>Paul Lazar, MD

In family medicine residency settings, we have not been able to do much team based care because of resource limitations, and the fact that if we have other learners see patients without residents the residents can't get their 1650. So we end up treating the few PA and NP students we get the same as medical students, and the residents don't really learn anything different than how they were taught.

In the world of practice, when you look at the masthead of a letter from a primary care group (single specialty or mixed) there are almost always both physicians and NP/PA's on the letterhead.

Here's a radical idea. Since so much of primary care is actulaly being provided by NP's and PA's, why don't we actually train them to do it by admitting them to Family Medicine Residency alongside the resident physicians? We have a good model for training ambulatory based practitioners, and we could start to better define team roles--including having the resident extenders maintain chronic illness registries and do the outreach and follow up-- and teach team leadership if the residents had a team that didn't just consist of other residents. 1650 would obviously have to be adjusted to allow the resident physician to count some visits by NP/PA for which they provided medical supervision.

>January 14, 2021
>Patrick Sweet, MD

Training tracks in family medicine similar to what is seen in Canada would be great for our future. Otherwise future graduates will just become inbox managers whose main goal is to connect patients to other doctors (or midlevels many times) to definitively manage medical issues. Although this supports the 9-5 lifestyle that many who chose family medicine crave, it undercuts the roots of our profession. There should be OB track, Procedures track, EM track to represent areas many of us practice. There should als be a primary care manager track. This should only be a 2 year residency as is the case for Canada. Everyone is happy, the 9-5ers, the adrenaline junkies and the procedurally inclined.

Alas this will never happen here. Too many benefit from the current referral geared system and ABMS designed way to manage the various guilds into staying in their predetermined lanes.

>January 15, 2021
>Michael NIziol

There is absolutely no need for 12 years of education to produce a competent Family Doc. I was a dual Chemistry and BIo major. I did the Krebs cycle 35 times - never used it once - Schrodinger Wave equation was fascinating – but doesnt get much use in front line medicine. Here is the issue – you encumber people with loans and loss of time unnecessarily. A competent Family Doc can be produced in 6-8 years. Now you have an individual with fewer loans and 4-6 extra years to work ( or possibly retire) MY two neighbors just retired at age 55 after teaching Health – between them they bring home 170 K per year in retirement benefits. They had every weekend every summer every holiday off worked about 6 hours per day never worked an evening or night I am 65 – still working – worked every summer many holidays many weekends many nights and will be lucky if I bring home 40 K per year in retirement benefits at age 70. I use to teach students but stopped – one asked me if I would do it again. I had to say honestly – no – you can have a much easier more enjoyable life teaching etc. and oh by the way – Docs strolling around with an instrument made in the 17th century as their main tool (stethoscope) is an utter embarrassment to the profession – everyone should be well trained in sonography – thats where time should be spent anatomy meds etc... Forget College feeder programs – develop your own system grabbing students right out of high school tons of other ideas but have to go – good luck

>December 3, 2020
>Laurie McLemore, MD

Introduction: You should take into account who is responding, and what they bring to table of discussion.  I have 20 plus years of experience in rural medicine as a family practice physician in Oklahoma.  I have worked in a federally qualified health clinic the majority of the time. I support the mission of the FQHC to see everyone including those with Medicaid, Medicare, private insurance and those without insurance, are still being seen with a sliding scale, (not a free clinic).  I also am a full-blood Native American female. The majority of my patients are elderly and have complex chronic conditions. Also I am certified to provide MAT (medication assisted treatment). Our FQHC has a pharmacy and behavioral health providers integrated as part of the MAT program.

1. What does society need from the personal physicians of the future?

In this current time we seem to have barriers to progress for many physicians. Physician face a variety of societal issues like Black lives matter and a pandemic with the unprecedented negative influence on physician practices. Even with universal health insurance coverage, we still have poor health care outcomes. COVID 19 is affecting elderly and those with poor health as seen in minorities.

The physician of the future needs resilience and flexibility.  Many physicians have responded with incredible speed by barely using telemedicine at the beginning of this year to actively using telemedicine in order to keep giving healthcare. We have added telemedicine as a valuable tool. Elderly need not only access to healthcare but access to technology to do so. Our elderly patients were shown by nurses how to use an ipad in the parking lot of the clinic during the COVID 19 shutdown.

2. What should we teach?

To take care of the elderly and those with complex chronic conditions, this should represent the core concepts.  To be able to address the opioid problem, residents should be trained and required to be certified to provide MAT upon graduation.

3. How should we teach?

Focusing on clinical case presentations on elderly and complex chronic conditions.  The Board could certify webinars for physicians that meet guidelines for their level of education. Zoom and other platforms have opened accessibility to experts and outstanding programs without going to a conference. This format should continue post pandemic for both residents and practicing physicians.

4. How will we prepare graduates for practice over their lifetimes?

Teaching a graduate to self-educate to keep up to date on increasing medical information.  Providing mentors who can guide new graduates. Ask retired physicians to assist with this role.

The Board could consider adding fast track residencies for physicians wanting to expand their knowledge. For example since there is a shortage of behavior health and addiction specialists by providing fast track opportunities in these areas to board certified physicians would help meet the shortage needs.

5. What is the right balance between innovation and regulation?

Technology should be seen as a necessary tool to facilitate the physician’s progress. As physicians we often spend more time charting than with the patient trying to meet measures. Regulation needs to keep up with innovation, not be another barrier to innovation.

6. How can we improve the accountability of residency education?

Accountability begins in medical school with who should we teach? I remember a time of affirmative action.  We are fast approaching a time where the minorities will be the majority.  We do not see this ratio in our medical school classes. This requires commitment from medical schools to provide support to minority students who are in need.  Medical school needs to remove barriers to be successful in graduating minority medical students. Then residency education needs to continue to prepare these minority residents in positions of leadership. That will result in future minority physician leaders who can help guide further effective healthcare change.

In conclusion, change will require funding, which will require effective lobbying.