Responses to Questions About the Specialty of Family Practice as a Career



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JULEA G. GARNER, M.D. American Academy of Family Physicians Kansas City, Missouri JOSEPH E. SCHERGER, M.D., M.P.H. University of California, Irvine, College of Medicine Irvine, California JOHN W. BEASLEY, M.D. University of Wisconsin Medical School Madison, Wisconsin WM. MACMILLAN RODNEY, M.D. University of Tennessee, Memphis, College of Medicine Memphis, Tennessee DAVID E. SWEE, M.D. University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School New Brunswick, New Jersey ELIZABETH A. GARRETT, M.D., M.S.P.H. University of Missouri-Columbia School of Medicine Columbia, Missouri NORMAN B. KAHN, JR., M.D. American Academy of Family Physicians Kansas City, Missouri

This article provides answers to many of the questions medical students ask about the specialty of family practice. It is the fourth update of a previous article and was developed in response to feedback from medical students at the 1997 National Congress of Student Members held by the American Academy of Family Physicians. Students at the 1998 Congress also identified areas of interest and concern. This article discusses the hours and income of the family physician, the scope of medical practice in the specialty, required continuing medical education and board certification, family practice residency training and combined-specialty training.

Am Fam Physician 1999;60:167-74.


Medical students frequently have questions about the specialty of family practice and what a family physician does. As defined by the American Academy of Family Physicians (AAFP), the family physician is one who has been educated and trained to provide continuing and comprehensive medical care, health maintenance and preventive services to all members of the family regardless of sex, age and type of problem (i.e., biologic, behavioral or social).1

This article is the fourth update of an earlier article and provides the most current information about family practice. It was developed after feedback on the previous article was obtained from students who attended the AAFP's 1997 National Congress of Student Members (NCSM). Medical students at the 1998 NCSM also identified the areas they considered to be of most interest and concern.

Much of the core information about the specialty of family practice and the values of the family physician remains unchanged. The family physician continues to be trained to care for patients of all ages in the family practice center, the emergency department, the hospital, the nursing home, the sports field and the family home. The family physician can manage 90 percent of patients' health problems, accessing consultants as necessary.2 Although the face of health care as a whole has changed dramatically in the past few years, the need and demand for family physicians by the U.S. population and health care delivery system remain great.3

What is life like for a family physician? Is there enough time for a good personal life?

Balancing a busy professional career with a satisfying personal life is a challenge for all physicians. Being family- and community-oriented, family physicians strive to achieve this balance. The work schedules of family physicians vary considerably, depending on the practice setting and type of medical group. With greater numbers of women entering family practice and the increased prevalence of two-career families, flexible models of practice, including part-time and shared arrangements, have become more common.

Family physicians work an average of 53 hours per week, with about 43 of these hours spent in direct patient care. On average, they work 48 weeks per year, which leaves four weeks for vacation and continuing education.4 These numbers are in the middle range for all physician specialties.5

In the past, solo family physicians were on call for their patients after office hours. Currently, most family physicians share responsibility for after-hour emergency calls with a group. This arrangement greatly reduces interruptions of their personal time.

What is the average income of a family physician? As a family physician, will I be able to repay my student loans and live a comfortable lifestyle?

The income of family physicians has risen rapidly during the 1990s. According to Medical Economics, family physicians led the list for advances in income among all primary care disciplines, with a 24.8 percent increase between 1990 and 1995.6 As of 1997, the average net income for family physicians not doing obstetrics was $136,002 (compared with $139,879 for internists and $131,803 for pediatricians).7 The average net income for all specialties in 1997 was $220,476.7 Although dramatic increases in financial compensation probably will not be sustained, the need and demand for family physicians will provide continued income support. Moreover, the current surplus of subspecialists has placed downward pressure on their income.

Along with higher initial earnings, starting family physicians are gaining a greater amount of income compared with more established physicians.8 Most newly graduated family physicians have used this higher income to pay off their student loans more rapidly. Furthermore, many underserved communities offer loan forgiveness programs to attract family physicians. Given the multitude of practice arrangements available, family physicians can expect to achieve a comfortable lifestyle and pay off student loans.

What is the scope of practice for family physicians?

Family physicians engage in a broad range of clinical activities. A family physician may choose the most comprehensive style of family practice, in which he or she is the only local source of health care for a community. This type of practice includes providing care for patients in the office, the hospital critical care unit and local nursing homes, providing support for local sports teams, managing trauma patients, performing surgical procedures and delivering infants (including cesarean sections). At the other end of the spectrum is the family physician who limits his or her practice to outpatient care, often in the setting of a multispecialty group.9 In either extreme, the family physician may be a practice owner or an employee.

Most family physicians have a practice that is somewhere between the two extremes. These family physicians have a comprehensive office practice with or without low-risk maternity care. They assist with cesarean sections and minor surgeries, care for their hospitalized patients with consultants as necessary, perform a wide range of office procedures, make nursing home and home visits, and may serve as team physician for the local high school. This type of practice is found in a variety of locations in all parts of the United States.

Some family physicians develop an area of special interest and expertise, such as sports medicine, geriatrics, preventive care, international health, women's health, adolescent health or research. Others choose career paths in public health, administration, emergency medicine, part-time urgent care or teaching.9 Fellowships after residency are available to further develop a particular area of interest10 (Table 1).4

The types of procedures performed by family physicians are as varied as the scope of practice (Table 2).4 The range of procedures includes, but is not limited to, assisting in major surgeries and performing cesarean sections, vasectomies, flexible sigmoidoscopy, colposcopy, skin biopsy and lesion removal, cryotherapy of skin lesions and the cervix, cervical biopsy, endometrial biopsy, spirometry, exercise treadmill testing, splinting and casting, obstetric ultrasound and endoscopy of the nasopharynx, larynx and gastrointestinal tract.9,11-27

The AAFP's philosophical statement on the scope of family practice notes that "the specialty is three-dimensional, combining knowledge and skill with a unique process. The patient-physician relationship is central to this process. ... Knowledge and skills vary among family physicians according to their patients' needs and the ability to incorporate new information into their practices. Above all, the scope of family practice is dynamic, expanding, and evolutionary."28

How can I possibly keep current with medical advances in the care of children, adolescents, adults, older adults, men, women and pregnant women?

Family practice was the first specialty to require continuing medical education (CME) and the first specialty board to require periodic recertification. As part of the seven-year recertification process, each family physician must complete 50 hours of CME for each subsequent year after residency completion.29 This education enables family physicians to keep their knowledge base current.

CME credits can be obtained from a variety of sources, including journals, courses, national, regional and local lectures, teaching, audio and video programs, telemedicine, CD-ROMs and Internet services. Many family physicians access information from computer-based medical programs and Internet services on a regular basis. Physician-to-physician communication and focused consultations are other excellent ways to learn and stay current.

In addition, a teacher learns twice. Many family physicians precept and teach. These physicians continually add to and reinforce their own knowledge base. Their participation in the instructional process keeps them current and intellectually refreshed.

What is involved in family practice residency training?

The number of family practice residency programs has continued to grow. As of 1998, a total of 475 accredited programs provided more than 10,500 residency positions.30 Graduates of U.S. medical schools fill 85 percent of these residency positions. Family practice residencies are based in academic medical centers, community hospitals, community health centers, health maintenance organizations and U.S. military installations.

Residency training provides future family physicians with integrated inpatient and outpatient learning over a period of three years. Family practice residencies give extensive in-hospital training in the care of adults and children, maternity care, emergency and critical care, and other inpatient situations. Equally important, family practice residencies have a strong focus on learning in the outpatient setting. Thus, residents have an opportunity to learn by providing continuous care to a population of families.

Family practice residents learn how to comprehensively manage the multiple problems of patients and their families, including health risks and psychosocial problems. They develop meaningful relations with their patients over time, and they also engage in community health experiences. Most programs provide opportunities for family practice residents to do research and to teach medical students and more junior residents. Different residencies provide varying opportunities to develop specific procedural skills, but all provide enough training for residents to develop a high level of technical skill in a broad range of common procedures.

Newer training models, including rural training tracks, provide exceptionally rich clinical experiences with a wide variety of populations of all economic strata and levels of medical need. Learning to address the needs of ethnically and racially diverse patients is considered an important aspect of family medicine training, as is learning to care for the medically underserved.

Although good stewardship of health care resources and cost containment are part of the curriculum of most programs, family practice residency training focuses on providing the skills needed to be the patient's advocate. In addition, newer curricula in managed care are directed at going beyond a strictly clinical role within managed care settings to a role in shaping the future of health care organizations.

Satisfaction with family practice residency training tends to be high. Graduates indicate that their residency did an "excellent" or "good" job of preparing them for practice, especially with regard to coordinating care with community resources, providing preventive care and providing cost-effective care.31

What is the difference between a family practice residency and combined residencies in internal medicine and pediatrics, family practice and psychiatry, and family practice and internal medicine?

During the past several years, modest growth has occurred in the development of residency education programs that use other models for generalist training, such as combined residencies in internal medicine and pediatrics or family practice and another specialty.

Combined specialty programs must be approved by each respective board in order for graduates to be eligible for certification. In dual certification, each board makes an independent ruling on the eligibility of every candidate for board certification.

The American Board of Family Practice and the American Board of Internal Medicine each offer certification to graduates of a handful of programs that provide for completion of four years of combined training. Currently, fewer than five such programs are available in the United States. The certifying boards of family practice and psychiatry and neurology each offer certification for the completion of at least five years of training in a combined residency. At present, fewer than 15 of these programs are available in this country. The American Board of Internal Medicine and the American Board of Pediatrics offer certification for the completion of a combined residency that includes two years in each specialty, for a total of at least four years. In 1998, there were approximately 100 such programs.32

Compared with family practice residencies, dual certification programs tend to emphasize inpatient medicine. They also tend to offer broader exposure to the "specialist aspects" of each specialty. They tend to place less emphasis on continuity of care in the outpatient setting.

No evidence shows that the graduates of any of these combined programs are more effective in practice or obtain more privileges than those who graduate from a family practice residency program.33 In fact, evaluations of these programs often use family practice as the benchmark. Only about 68 percent of physicians trained in internal medicine and pediatrics, for example, actually practice primary care medicine, and only about 55 percent practice both internal medicine and pediatrics.34 In contrast, family medicine is practiced by more than 91 percent of the physicians who received training in a family practice residency during the first 25 years that the training was offered, and family medicine is practiced by more than 93 percent of current graduates of family practice residency programs.35,36

Graduates of dual certification programs face some special challenges. Some have complained about difficulties in being listed by managed care organizations under both specialties at the same time. They must maintain certification with two boards and membership in two national organizations. They also must obtain coverage for patients during off hours. Unless another physician with the same dual certification is available, coverage must be obtained from two physicians at the same time. However, family physicians are able to provide coverage for patients of almost all dual-certified physicians who are practicing primary care medicine.

What is the future of family practice?

The AAFP has analyzed the physician work force and called for U.S. family practice residency programs to graduate 3,700 to 4,100 family physicians each year to meet the need for these physicians in the United States (i.e., a goal of 35.1 family physicians per 100,000 people).37 A total of 3,380 family physicians graduated in 1998, and 3,570 to 3,580 family physicians are projected to graduate this year and in 2000.37 These projections take into consideration the number of general internists and general pediatricians, as well as the growing number of physician assistants and nurse practitioners.37 Family physicians have been (and are still) the most recruited physicians for managed care systems, as well as for rural and inner-city practices.38,39

Opportunities and challenges for family physicians persist, more than for any other specialty. Family physicians are suited for practice in the smallest and largest communities, in partnerships, in single specialty or multispecialty group practices, and in fee-for-service or managed care systems. The challenge is to continue to distribute family physicians in the same percentages as the U.S. population so that every American has access to cost-effective, comprehensive, continuous primary care services.

The family practice specialty has gone a long way toward meeting the nation's health care needs. Indeed, family practice is the only medical specialty in which physicians distribute themselves in the same geographic proportions as the American people.40 Family physicians will continue to work with other health care providers to ensure that all Americans have access to primary care.

What career opportunities will be available to me as a family physician?

Family physicians continue to have great career flexibility, with documented needs in a variety of areas. Most family physicians care for patients in group and private practices. Another option is academic medicine. A 1994 survey of family practice residencies and academic departments revealed a short-term need of nearly 1,200 faculty positions.41,42 In addition, there is a critical need for more investment in and support for primary care research.43 The major research initiative launched by the AAFP in 1997 has underscored the need for more family physician researchers.

Important contributions in teaching and research are not limited to full-time faculty positions. As many as 30 percent of community-based family physicians teach medical students in their offices, and an increasing number are participating in practice-based research networks.44,45

In addition, 51 percent of U.S. family physicians include some emergency room care in their practices, with as many as 88 percent providing this type of care in some states.4 A full-time career in emergency medicine was chosen by 4 percent of physicians who completed family practice residencies in 1969 through 1993.35 Many managed care organizations consider family physicians to be the specialist of choice because of their breadth of skills, the quality of care provided and their skills in preventive care.46,47

Family physicians with interest and expertise in public policy and administration can find challenging careers at all levels of influence, from the local community to state and federal agencies. For example, family physicians are directors of state health departments, legislators, administrators in managed care organizations and heads of federal bureaus. A family physician, David Satcher, M.D., became Surgeon General of the United States in 1998.

International opportunities are especially exciting at this time, with many initiatives in progress to develop family medicine training programs and models of care in countries around the world. These opportunities are in addition to the more traditional roles of practicing physicians in a multitude of settings in developing countries.48

How satisfied are family physicians with their career choice?

Family physicians are as satisfied and in some cases more satisfied with their participation in managed care organizations than consulting subspecialists.49 As more physicians have moved into the status of employees rather than business owners, no change in physician satisfaction has become apparent. A nonsignificant loss of perceived physician control among employed physicians is compensated for by significantly more satisfaction with leisure and family time.50

The results of a recent survey published in Medical Economics suggest that generalists are more satisfied with their freedom to make treatment decisions than are subspecialists.51 A survey of younger physicians in California found that 92 percent of family physicians were satisfied with their practice choices.52

With the profession of medicine changing so rapidly, perhaps a more important question is "How satisfied will family physicians be in the future?" It appears that family physicians are faring better than most physicians in the evolving medical environment. Certainly the demand for family physicians has increased dramatically because of the cost-effective care they deliver.53 Their ability to coordinate care, to take responsibility for patient care, to use resources wisely and to be efficient and comprehensive bodes well for the future.

Finally, it should be noted that family physicians have great control over their level of satisfaction in their professional lives. Family physicians who include maternity care in their practice and who are in small group practices are generally more satisfied.54 Physicians whose main value is benevolence (e.g., as contrasted to power) are the most satisfied.55 As a whole, family physicians report being extremely satisfied with their general professional life, intellectual stimulation, status within the community, clinical competence and long-term relationships with their patients.56

The authors thank Diana Swafford for assistance in the preparation of the manuscript.