Residents & New Physicians

RESIDENTS & NEW PHYSICIANS

By Ryan Paulus, DO, PGY-2 UNC Family Medicine Residency, NCAFP Board Resident Director-Elect

~ FULL SPECTRUM~

Holistic Care is at the Core of Continuity in Family Medicine

“Thank you for taking care of my grandma, she was my best friend,” said a tearful young girl in the hospital lobby. Her grandma was one of my first patients in residency. I was taking care of her in the hospital and was going to meet with her family after we decided to pursue comfort care. As I was approaching the family, I thought about the first time I met her and everything she has taught me as a young resident physician. The son, who accompanied her at clinic visits, emerged from the group in tears and met me with a big hug. The rest of the family proceeded with thanking me for taking care of their loved one. It was a moment I will never forget.

I grew up in a rural community where continuity of care was practiced and valued. Family physicians cared for their patients in the office, hospital, labor and delivery, nursing home, and even the emergency department. By doing so, they practiced traditional full spectrum Family Medicine. When it came time for choosing a residency, it was important for me to choose a program that focused on a full spectrum of training. During residency, I have been trained to provide the traditional full spectrum of care, but I have also been able to expand the outpatient scope to meet the changing needs of our patient population. Point of care ultrasound, telemedicine, population management, addiction medicine, hepatitis C treatment as well as more advanced therapies for patients living longer with chronic diseases, are some examples of this extended scope.

The AAFP states that, “continuity of care is a hallmark and primary objective of Family Medicine.” By providing continuity of care, we form trusting bonds with our patients that leads to lower healthcare costs, reduced ED visits and hospitalization rates, shorter hospital stays, and an improved physician-patient experience.1-3

As I interviewed applicants this year for our residency program, I listened to medical students express their interest in our program because they too want to practice full spectrum Family Medicine. However, I was surprised by the diversity of responses describing full spectrum care and it has caused me to reflect on my definition of the term. I started to look at the data and found that it is apparent that our traditional scope is changing. Only 7% of family physicians practice obstetrics and only 46% of recent Family Medicine graduates practice inpatient medicine, a decline from 78% prior to 2010.4,5 Ironically, this is occurring despite residents’ intention to have a broader scope of care than the actual care provided by current practicing family physicians.6 Constraints imposed by employers, insurers, and market forces, as well as individual lifestyle and general changes in medicine, have contributed to this change in scope.

While the settings where we provide care maybe narrowing, the comprehensiveness of care we provide is expanding. With the expansion of medical education and access to readily available information, family physicians are more equipped to care for and treat conditions than they were in the past. We may not be caring for our patients as much in the hospital, but

we are now placing an ultrasound probe on their chest in clinic looking for a pneumonia or providing more complex services to keep our patients out of the hospital. Advances in telemedicine will lead to more co-management with specialist rather than absorption of the patient by the specialist.

As I continued to reflect on the definition of full spectrum and what it actually means to practice full spectrum care, I continued to think about the quote from the AAFP stating, “continuity of care is a hallmark and primary objective of Family Medicine.” I came to realize full spectrum care can be practiced in many forms but what lies at its core is continuity of care and the ability to provide holistic care for our patients. Therefore, I would like to end with a question to create conversation and thought. As the scope of the family physician continues to change, how do we continue to ensure that continuity of care remains at the heart of our profession?

REFERENCES: Bazemore A, Petterson S, Peterson LE, Bruno R, Chung Y, Phillips RL Jr. Higher Primary Care Physician Continuity is Associated With Lower Costs and Hospitalizations. Ann Fam Med. 2018 Nov;16(6):492-497. doi: 10.1370/afm.2308. PMID: 30420363; PMCID: PMC6231930.

Irwin KA, Agius M. How does continuity of care affect quality of care in primary healthcare? Psychiatr Danub. 2017 Sep;29(Suppl 3):452-456. PMID: 28953807.

Pandhi N, Saultz JW. Patients’ perceptions of interpersonal continuity of care. J Am Board Fam Med. 2006 JulAug;19(4):390-7. doi: 10.3122/jabfm.19.4.390. PMID: 16809654.

Tyler W. Barreto, Aimee R. Eden, Stephen Petterson, Andrew W. Bazemore and Lars E. Peterson. Intention Versus Reality: Family Medicine Residency Graduates’ Intention to Practice Obstetrics. J Am Board Fam Med. July 2017, 30 (4) 405-406; DOI:

Weidner AKH, Chen FM. Changes in Preparation and Practice Patterns Among New Family Physicians. Ann Fam Med. 2019 Jan;17(1):46-48. doi: 10.1370/afm.2337. PMID: 30670395; PMCID: PMC6342592.

Coutinho AJ, Cochrane A, Stelter K, Phillips RL Jr., Peterson LE. Comparison of intended scope of practice for family medicine residents with reported scope of practice among practicing family physicians. JAMA. 2015; 314(22): 2364–2372.

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