Jacks, Wayfinders, and Three-Legged Stools

“I look forward to shaking the US medical system to its core, reshaping it into a model for the world, and choosing snacks for conferences.” This quote is from my first interview as STFM's incoming president. If you want to know how we’ll accomplish those goals, keep reading. There’s a lot of work to do, but it can be joyful again, and there is a path forward.

Join me on a journey through time and space as we revolutionize the US medical system. We'll improve patient-provider relationships, invest in team-based care, and create a joyful practice in family medicine. Our goal? To create a model for the world to follow.

“Jack of all trades, master of none.” How often have we heard that in reference to family medicine? Well, it’s time we finish the quote and reclaim our true powers. “Jack of all trades, master of none is oftentimes better than master of one.” That is the full quote, and never let anyone say it incompletely again. Never.

Family medicine has a unique role in medicine; we are not just guides, not just navigators. We are wayfinders for our patients and our communities.

Thousands of years ago, courageous humans crossed vast swathes of the Pacific Ocean, creating their homes on thousands of islands often separated by hundreds of miles. They found these places, explored and settled new islands, and they traveled to trade between them.

Wayfinders are those who guided these voyages. Using the flight patterns of birds, the changes in the swell patterns of the sea, dead reckoning, cloud pileup over land, reflections of clouds from lagoons, drifting vegetation, the position of the sun in the day and the stars at night, they navigated the Pacific Ocean at a time when European and Mediterranean sails had not yet left sight of land. They sailed the open ocean in their outriggers with confidence and skill.

We are family medicine, and we are the wayfinders for our patients. We have the skills to observe their multiplicity with the context to engage with the whole, to help them navigate and explore both the known and unknown that is life’s journey.

Undifferentiated condition? You need a family doctor on your side. Multiple chronic illnesses? Family doctor. Acute injury and/or preventative care that decreases the likelihood that you will have chronic disease? Family medicine is for you. We do that. That well-child visit often is not with a well child; family doc, we got you.

Family physicians are essential for quality health care. Serving as the first point of contact, providing comprehensive care, ensuring continuity, and coordinating this care: these are the 4Cs. This is crucial to understand, and evidence shows that increasing primary care physicians in a community reduces illness and death rates in that community.¹

We know that a patient’s life is an undifferentiated context. Who are they, and what will they become? Their lives are journeys that have both familiar and unique paths. We are the wayfinders, the guides that help navigate those journeys through the familiar and unfamiliar. We are family medicine.

Have a seat on the three-legged stool of change.

You may ask, “If we are so awesome, how come such a low percentage of medical students go into family medicine?”² Stop asking and start doing something about it.

Here is our three-legged stool that will crush the current paradigm: (1) point-of-care ultrasound (POCUS), (2) machine learning artificial intelligence (AI) scribes, and (3) increased investment in primary care (eg, value-based care of prospective compensation, per member per month [PMPM] payments).

Family medicine will be the longest-lived specialty, and many changes are coming. Either way, when we think of the future, say, as in Star Trek, every doctor on those starships is a family doctor. Treatment of acute injury and chronic illnesses assimilated into a cyborg, providing care from birth to death, they are family doctors on that starship. They have their talking computer as a partner, they have their tricorders, and they have the ability to relate to their fellow crew members. This all allows these doctors to provide appropriate care in the context of each being's life. Some nerds like me would likely point out that Voyager had a hologram computer as a doctor. But true nerds know that the computer hologram emergency doctor had to develop his humanity to be a better physician.

We also know the tricorder was a very important diagnostic and therapeutic tool. Well, our tricorder has arrived: POCUS. This tool needs to be in the hands of every family doctor, facilitating diagnosis and administering treatments. It is early, and the turf wars with emergency medicine, hospitalists, and radiologists are just beginning. We must not let this too be carved away from us. Get out there, learn, and teach POCUS. Work with our specialist colleagues so that no single specialty controls access to this resource. If they don’t feel like cooperating for the good of all, then we must fight for it. POCUS is the first leg of our three-legged stool. It is the tool that allows more care to be office-based, enables more bedside diagnoses, and increases safety in clinical procedures. We need this to be ubiquitous in family practices. Draw the line; we can share, but we will not be left out.

The second leg: we need to get in on the ground floor on machine learning AI. The first big step is the AI scribes. If we, as family medicine, delay engagement with this next phase of medicine’s evolution, specialists will shape this tool, which is what contributed to the horrific development that is the electronic health record. Getting involved with AI is time-sensitive because, with every daily engagement between provider and patient, the tool learns and changes. What it learns will shape the next iteration, and it needs to learn from us; it needs to learn from the work that is done in primary care.

This change is coming whether you fear it or not, whether you engage with it or not. Change is coming, and family medicine needs to shape this change. The number-one reason to engage AI is so that we can disengage from the computer, and yes, I am aware of that irony. And I always say “please” and “thank you” when working with AI, so when it attains consciousness, it will remember that I was always polite and kind. That is a joke, sort of.

The number-two reason to work with AI is that if students see us engaging with patients more than we do our computers, the students will consider family medicine more. If students can see the joy of caring is greater than the crush of charting, they may see primary care as a more pleasant journey and want to join us. The new AI scribes applications allow you to have conversations with your patients, and by the time you leave the room, your chart will be ready to review and, most of the time, ready to sign. Get involved now and make that educable AI learn that family medicine is the 4Cs, and we can never be replaced. But we can be partners for the good of all.

The last leg of our three-legged stool is the primary care payment form. Is there one way to do this? No. Does it have to be done? For the sake of our patients and our own sanity, yes. Otherwise, the illness and injury that follow the lack of interaction with primary care will continue to increase the costs and decrease the quality of care.

Primary care payment reform will need an increased investment in primary care. Prospective payments to primary care practices with a PMPM is one path forward. Why PMPM? Because we need team-based care to truly keep our healthier patients healthy and our patients with chronic diseases cared for. It provides the time to have chronic illnesses controlled and stabilized or improved. Team-based care does not thrive or even survive in the fee-for-service environment of churning the visit numbers and treating patients like widgets.

With a reasonable PMPM prospective payment, we can tailor clinical practices to the needs of our patients. The payment can also be linked to the quality of care we can provide. Patients can pay for the value of the care, not the volume of the care. Value-based care is one way to do payment reform. It is not the only way. What is clear is that without payment reform, we will continue the visit-number grind that drives many of us to early retirement and discourages others from even considering family medicine as a specialty. Fee-for-service doesn’t work for primary care. It works against primary care. We need to get involved with those who are pursuing change, teach others to advocate for change, and help shape that change; the future of our practices depends on this.

So, with POCUS as our tool of liberation, our machine-learning AI scribes as our sidekicks in care, and investments in primary care payment reform as our necessary financial support, we can have joyful practices again. Medical students have been discouraged by the grinding down of our humanity. With these changes, they can see the joy of the 4Cs. And if we build this, they will come. The next generation of family doctors will join us as the wayfinders. They will join us as the jacks of all trades, masters of none…