The Family Physician as Coordinator

Francis Peabody (1930), Professor of Medicine at Harvard Medical School from 1921 to 1927, was ahead of his time. His comments remain appropriate today:

Never was the public in need of wise, broadly trained advisors so much as it needs them today to guide them through the complicated maze of modern medicine. The extraordinary development of medical science, with its consequent diversity of medical specialism and the increasing limitations in the extent of special fields—the very factors that are creating specialists—in themselves create a new demand, not for men who are experts along narrow lines, but for men who are in touch with many lines (p. 20).

The family physician, by virtue of her or his breadth of training in a wide variety of medical disciplines, has unique insights into the skills possessed by physicians in the more limited specialties. The family physician is best prepared to select specialists whose skills can be applied most appropriately to a given case, as well as to coordinate the activities of each, so that they are not counterproductive.

As medicine becomes more specialized and complex, the family physician's role as the integrator of health services becomes increasingly important. The family physician facilitates the patient's access to the whole health care system and interprets the activities of this system to the patient, explaining the nature of the illness, the implication of the treatment, and the effect of both on the patient's way of life. The following statement from the Millis Commission Report (Citizens' Commission, 1966) concerning expectations of the patient is especially appropriate:

The patient wants, and should have, someone of high competence and good judgment to take charge of the total situation, someone who can serve as coordinator of all the medical resources that can help solve his problem. He wants a company president who will make proper use of his skills and knowledge of more specialized members of the firm. He wants a quarterback who will diagnose the constantly changing situation, coordinate the whole team, and call on each member for the particular contributions that he is best able to make to the team effort (p. 39).

Such breadth of vision is important for a coordinating physician. She or he must have a realistic overview of the problem and an awareness of the many alternative routes to select the one that is most appropriate. As Pellegrino (1966) stated:

It should be clear, too, that no simple addition of specialties can equal the generalist function. To build a wall, one needs more than the aimless piling up of bricks, one needs an architect. Every operation which analyzes some part of the human mechanism requires it to be balanced by another which synthesizes and coordinates (p. 542).

The complexity of modern medicine frequently involves a variety of health professionals, each with highly developed skills in a particular area. In planning the patient's care, the family physician, having established rapport with a patient and family and having knowledge of the patient's background, personality, fears, and expectations, is best able to select and coordinate the activities of appropriate individuals from the large variety of medical disciplines. He or she can maintain effective communication among those involved, as well as function as the patient's advocate and interpret to the patient and family the many unfamiliar and complicated procedures being used. This prevents any one consulting physician, unfamiliar with the concepts or actions of all others involved, from ordering a test or medication that would conflict with other treatment. Dunphy (1964) described the value of the surgeon and the family physician working closely as a team:

It is impossible to provide high quality surgical care without that knowledge of the whole patient, which only a family physician can supply. When their mutual decisions . . . bring hope, comfort and ultimately, health to a gravely ill human being, the total experience is the essence and the joy of medicine (p. 12).

The ability to orchestrate the knowledge and skills of diverse professionals is a skill to be learned during training and cultivated in practice. It is not an automatic attribute of all physicians or merely the result of exposure to a large number of professionals. These coordinator skills extend beyond the traditional medical disciplines into the many community agencies and allied health professions as well. Because of his or her close involvement with the community, the family physician is ideally suited to be the integrator of the patient's care, coordinating the skills of consultants when appropriate and involving community nurses, social agencies, the clergy, or other family members when needed. Knowledge of community health resources and a personal involvement with the community can be used to maximum benefit for diagnostic and therapeutic purposes and to achieve the best possible level of rehabilitation.

Only 5% of visits to family physicians lead to a referral, and more than 50% are for consultation rather than direct intervention. Surgical specialists are sent the largest share of referrals at 45.4%, followed by medical specialists at 31% and obstetrician-gynecologists at 4.6%. Physicians consulted most frequently are orthopedic surgeons, followed by general surgeons, otolar-yngologists, and gastroenterologists. Psychiatrists are consulted the least (Forrest et al., 2002; Starfield et al., 2002).

Figure 1-4 Number of persons experiencing an illness during an average month per 1000 people. (From Green LA, Fryer GE Jr, Yawn BP, et al. The ecology of medical care revisited. N Engl J Med 2001;344:2021-2025.)

Figure 1-4 Number of persons experiencing an illness during an average month per 1000 people. (From Green LA, Fryer GE Jr, Yawn BP, et al. The ecology of medical care revisited. N Engl J Med 2001;344:2021-2025.)

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