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What's a Family Physician to do?


A doctor finds her scope of care narrowing considerably as the healthcare landscape changes, leaving her contemplating her future as a physician.

I find myself in a peculiar conundrum. As a former full-scope family physician, I have watched my skills and scope narrow considerably since I graduated residency fifteen years ago. As readers of this blog may remember, I recently stopped seeing newborns in the hospital, becoming something I swore I would never be – an outpatient-only family physician. Every time I give a skill up, there's a good reason. I stopped hospital medicine when I could no longer juggle hospital rounds and middle-of-the-day admissions with a busy outpatient clinic. Maternity care – one of the great joys of my practice – was abandoned when my call group became markedly anemic.

Procedures that used to be commonly performed by family physicians are now only done in interventional radiology suites. Nursing home care has become highly specialized and demanding, as patients who would previously be found in the hospital are now discharged to long-term care facilities. Home visits are no longer practical in an era where every RVU still counts.

At the same time, I see other health care professionals' practices expanding. In Wisconsin, there is a bill before the assembly which would authorize chiropractors to do sports physicals. I recently became aware of a university that has its entire nurse practitioner program online with only four months of clinical rotations before a new NP is launched into practice. It is odd that my own practice has narrowed in scope because of a greater emphasis on specialization and expertise while at the same time, medical practice is expanding to include health care professionals who have far less training doing pretty much the same thing I am doing. What's a family physician to do?

I frequently reflect on what the value of my medical training is for things I no longer do like, inpatient medicine, obstetrics, thoracentesis and paracentesis, circumcisions and the newborn nursery. Are these just dusty rooms I once visited that I now need to close the door on? Or, was this training an integral part of my medical education, offering skills and knowledge I need even in my outpatient-only practice? If it is the latter (which I certainly hope is the case), how do we understand whether a chiropractor is able to competently perform a sports physical or how four months of clinical training compares with seven years of medical education and residency?

I currently practice with truly exceptional advanced practice clinicians. They are an integral and important part of my healthcare team. I would not want to artificially limit someone's capabilities. However, I also do respect the rigorous and extensive training I experienced as a physician. I believe that training equips me to practice family medicine better even if I do not do everything I was once trained to do.

The questions I face are questions that will continue to confront many healthcare professionals as the lines blur between physicians, chiropractors, and advanced practice clinicians. 

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