The family in family medicine revisited, again
In this issue of The Journal of Family Practice, a well-written paper describes an instrument that evaluates the level of physician involvement (LPI) with patients and their families. Marvel and Schilling, in collaboration with Doherty and Baird, the seminal authors of a model of physician involvement with patients' family issues, report on the LPI of 10 faculty family physicians who were videotaped during 200 office visits.(1)(2)
I agree with the authors that "This model may be a useful tool for education and research..." as it relates to the medical interview that examines family content. My concern is that in this study of residency-trained family medicine faculty, the videotape evaluators found a biomedical focus (ie, levels 1 and 2) in individual and family assessment in 76.5% of the 200 interviews. Physicians reached level 3 of the LPI 23% of the time. Although level 3 recognizes a physician's sensitivity to patient and family stresses, physicians in this category were not considered to have an approach that represented "...a systematic assessment of the patient's or family's context...."
Although the study of Marvel et al(1) does not reveal the level of family training or interest of the videotaped physicians, empirical evidence suggests that the physicians in the study were probably representative of the family physicians of the United States. As family medicine faculty, however, they might have been even more psychosocially oriented than are most family physicians. Such information suggests to me that family medicine should be concerned about whether its graduates are capable of an organized approach to the psychosocial problems of patients in the context of family.
Have educators and practitioners of family medicine relegated the family to a display piece that is trotted out for ceremonies and holidays? This question must be asked, for it seems to me that family in family medicine is fast becoming an anachronism not unlike the royal family in the United Kingdom. Family has retained its noble position, because, as in most sovereignties, it had functional importance in the establishment of the parent organization.
There is more to family, however, than historical significance. Whether royal or plebeian, family has the power of rallying the emotional energy of believers. This is certainly evident in the United Kingdom, where even though some members of the royal family are much maligned, any recommendation to dissociate the royal family from the government results in a national outcry of "God save the Queen." This same kind of devotion to family exists among members of the various family medicine organizations in the United States.
Although it is true that the founding members of the American Academy of Family Physicians recognized the political and social benefits to be gained from the cosmetic surgery that replaced "general" with "family," both teachers and practitioners in the discipline had hoped for more.(3) In the early years of the growth and development of this discipline, family medicine's publications proclaimed the family as a worthy subject for study and integration into practice. The drive to focus on family,...