Searching for the Family Doctor: Primary Care on the Brink

Title: Searching for the Family Doctor: Primary Care on the Brink

Author: Timothy J. Hoff

Publication Details: Baltimore, MD, John Hopkins University Press, 2022, 268 pp., $39.95, hardcover

Searching for the Family Doctor: Primary Care on the Brink by Timothy J. Hoff seeks to interweave the history of family medicine with the personal narratives of 55 individuals to argue that family medicine is a dying specialty that is failing to satisfy its member physicians and that must change in radical ways in order to survive.

Hoff, a nonphysician professor of management, health care systems, and health policy at Northeastern University, presents a well-researched history of family medicine as it was born out of general practice. He effectively highlights the hopes of Nicholas Pisacano and Gayle Stephens, early visionaries in the field, and family medicine’s struggle to realize these visions. Hoff holds up the career of Dr Richard Rutland, a pioneering early family physician and 1981 American Academy of Family Physician Family Doctor of the Year, as the ideal for our specialty then goes on to examine the changes in the US health care system that have transformed family medicine into what it is today.

To support his argument that family medicine is poorly adapted to the current health care environment, Hoff interviewed 55 individuals. He uses their narratives to explore the disillusionment of family doctors, from physicians who lament the viability of remaining in self-employed private practice to those who are experiencing burn out working for health care systems that demand productivity and patient satisfaction over relationships and quality care. While accurately describing the challenges family physicians face to balance self and career, he insinuates that this is unique to family medicine. Physician burnout, however, is seen across specialties and family medicine is not even in the top five according to 2019 and 2020 Medscape surveys. He repeatedly describes the self-imposed limitations of scope of practice into various subsets as “balkanization” but fails to make the case for hostility between the groups and instead accepts it as a given.

Hoff purports that these interviewees are an accurate cross section of the views of family physicians, but his claim is suspect. While varying by stage in career and other demographics, all were working in New York or New England. There were no respondents from the South, Midwest, or West coast, where family medicine may be differently perceived and who might have had a distinctly different opinion. Additionally, interviewees were volunteers who responded to an advertisement in the New York Academy of Family Physicians (NYAFP) newsletter or at a table set up near registration at the biannual NYAFP meeting or were recruited by other interviewees. This sets the stage for volunteer bias, wherein participants who volunteer for a study are known intrinsically to have different characteristics from the general population of interest. ¹

Finally, he finishes with a “top ten” list of the things he believes family medicine needs to do to stay viable in today’s health care environment. It includes embracing virtual care, being the keeper of patient data, partnering with patients, organizing locally for advocacy, creating strategic alliances with other specialties and providers, expanding family medicine creatively and relationally, changing training, downsizing the specialty, renaming and rebranding the specialty, and finally “think[ing] up something radical;” the something he does not specify.

Hoff’s top ten is the strongest part of the book, but Hoff fails to recognize that much of it is already happening. Most family physicians have embraced virtual care, albeit often out of necessity in this era of pandemic. Making patients part of the health care team is taught from early in medical school and reinforced in family medicine residency training. Family physicians are already banding together through specialty societies to advocate for better pay and working conditions, and improvements in primary care reimbursement are a testament to that. Good role models and teachers of family medicine are already emphasizing the importance of ongoing relationships with patients to enhance quality of care and physician satisfaction. Still needed is greater emphasis on care for the patient within the context of the community, greater collaboration with other specialties in a strategic fashion, and changes to medical training in general (not just family medicine training).

In conclusion, while providing a well-written perspective of the history of family medicine and its challenges, this book would have been stronger had it compared physician attitudes by specialty before making assumptions and included a group of physicians practicing in more diverse locations with more diverse viewpoints. Not all of us are burned out. Not all of us regret our choice. Many of us continue to love our specialty and devote time to teaching it. Looking at best practices for physician satisfaction with their career choice would provide hope. While much is controversial, this book will still be a valuable read for those involved in planning the future of family medicine by providing food for thought.