Accelerating Momentum Toward Improved Health for Patients and Populations: Family Medicine as a Disruptive Innovation—A Perspective from the Keystone IV Conference

• Doctoring
• Family Medicine
• Family Physician
• Health Care Delivery
• Personal Physician
• Population Health
• Primary Care
• Professionalism
• Social Justice

The Keystone IV conference examined promises personal physicians will make to patients going forward in an evolving health care system.¹ This conference was the fourth in a series to reflect on family medicine, the health professions more broadly, and the needs of people; to discuss core values; and to think creatively about how we collectively continue momentum toward improving the health of all people in America. Gayle Stephens described this goal as a “hope” in 1979: My hope is that we can find leaders who are willing to rethink the priorities of medical education based on the medical needs of the public rather than based on preserving the professional self-interest of organized medicine. We have told ourselves and the public that we are committed to excellence in medicine. I hope we can take an honest look at what that really means … at the very least it means providing enough physicians who are willing to serve all the people for the majority of their medical needs in settings that are as close to the people as possible …. What could be better than that?²

In 1979, Dr. Stephens described “hopes” for family medicine. In 2015, Keystone IV inspired reflection on “promises” personal physicians can make to patients, families, and communities. Keystone IV celebrated the importance of personal physicians making a promise to “be there” for individual patients and also the importance of promising to “be there” to advocate for policies that improve the health of millions of patients and entire communities. Keystone IV sparked passionate dialog and inspired renewed commitment to many of the hopes and promises central to our ideal vision of personal doctoring.

Keystone IV reminded us that family physicians and many others care deeply about the health of Americans and America's health. A similar sentiment sparked the creation of Family Medicine for America's Health (FMAHealth; fmahealth.org), an initiative inspired by the vision of its sponsor organizations to transform family medicine and the health care system to achieve the triple aim.^3,4

The FMAHealth project is sponsored by 8 national family medicine organizations and seeks to build on the work of the original Future of Family Medicine project. Among its objectives are a robust family physician workforce practicing in a continually improving medical home model and supported by a comprehensive payment model sufficient to sustain the medical home. Engagement with patients in this process and in the practice model are key to the project. Although FMAHealth and Keystone conferences are independent activities, their goals are tightly aligned in this aspect. There is substantial congruence between the FMAHealth mission and the ideals put forth at Keystone IV: to enable keeping the promises of personal physicians to “be there” for patients.

FMAHealth provides a communications and strategic planning platform to accelerate momentum toward achieving many of these aspirational goals. As FMAHealth leaders who participated in the Keystone IV conference, we were encouraged to see many synergistic goals between these 2 parallel initiatives aimed at accelerating momentum toward improving health. In this commentary we highlight a few concrete examples of ongoing work from the multifaceted FMAHealth initiative that closely align with key themes from Keystone IV.

To ensure that family physicians can “be there” for individual patients, FMAHealth and its sponsor organizations have reconfirmed the importance of continuing family medicine's broad scope of medical training and practice. With this foundational broad training, family physicians can be personal doctors for their patients in a wide variety of locations and clinical circumstances, meeting the health care services needs of their particular community. In collaboration with all 8 sponsoring organizations, FMAHealth led the recent development of entrustable professional activities for family medicine, which outline the broad training and skills expected of graduates of family medicine residency programs.⁵ FMAHealth will work with the academic family medicine organizations and others to incorporate these entrustable professional activities into residency training and track their impact. FMAHealth is also committed to the continued development of an adequate primary care workforce “willing to serve all the people for the majority of their medical needs in settings that are as close to the people as possible.”⁶

FMAHealth seeks to continue support for and development of the patient-centered medical home (PCMH) and other advanced models of primary care.⁷ At Keystone IV, Kim Griswold asked, “Does the transformative power of the PCMH provide the answer to all the places of care?”⁸ Recognizing the need to build on foundational PCMH work, FMAHealth is advocating for transition to a comprehensive payment model to support continued practice transformation efforts that will sustain and improve the personal doctoring relationship. This work is being designed to expand patients' access to care and to improve continuity with primary health care teams who can “be there” and provide tailored care based on individual patient needs, matched with the expertise of many different health care professionals. Heeding Will Miller's charge at Keystone IV to “use technology to share power” with patients, FMAHealth is also focusing on making improvements in health information technology to expand and strengthen the patient–physician relationship and to enable a personal physician to “be there” virtually when it is not possible to be there in person.^9,10

To ensure that family physicians can “be there” for populations, the work of FMAHealth is also focused on improving health, not just health care. Personal physicians need to be there in the community to provide leadership and collaborate with other important health professionals in crucial areas of community, public, and behavioral health. FMAHealth is committed to expanding interprofessional collaboration toward this goal. Keystone IV focused on how relationships between personal physicians, patients, and communities can be strengthened by and can thrive in “the evolving health care system in the United States.” In the evolution that is underway, FMAHealth recognizes the central place for primary care in leading transformation to ensure the American health care system is reconstructed on a primary care foundation that enables an advanced care delivery model that is supported by payment structures that prioritize population health.¹¹ FMAHealth seeks to engage patients, employers, policymakers, payers, and other primary care professionals, strengthening key relationships and partnerships that will amplify our collective voice to affect change.

FMAHealth is creating strategies for how America can make evidence-based investments in primary care and study whether these investments improve our nation's health.¹² As has been demonstrated in many other countries, investing a significant proportion of total health care expenditures in primary care infrastructure is essential for improving population health, sustaining an advanced primary care delivery model, and building and maintaining an adequate primary care workforce.¹³ In addition, FMAHealth is committed to strengthening primary care research infrastructure and ensuring that our scientific enterprise can continually contribute new evidence that informs our future direction.¹⁴

Personal doctoring is about relationships that can also lead to partnerships to affect change. Although the term personal physician usually inspires visions of a healing relationship between a patient and his or her primary care physician, Keystone IV challenged us to think about how this vitally important relationship between patient and physician could transcend the walls of the office and be a force in health care system transformation. In many ways the health care system is our most important “patient.”

FMAHealth has recognized the critical importance of engaging patients and patient advocates as partners in our efforts. At the practice level, FMAHealth is encouraging all primary care practices to have a patient advisory group or similar mechanism to receive and respond to patient input in improving primary care delivery and to amplify our collective voices to call for change in the overall health care system. FMAHealth also seeks to partner with patients and communities to create a grassroots public movement advocating for system change.

Toward this goal, FMAHealth has launched the Health is Primary communication effort, which aims to improve understanding among the public about the importance of health and the central role of primary care in ensuring better health for individuals, families, and communities.³ Health is Primary ads highlight aspects of advanced primary care practice, including the use of technology, that allow personal physicians to “be there” for patients virtually when it is not possible to be there in person. This campaign also aims to increase the general public's awareness and understanding of how a stronger primary care system can help the American health care system achieve the not just the triple aim (better health care, improved health, lower health care costs) but also he quadruple aim to include improved professional satisfaction of clinicians.^15,16

In the early days of the specialty, Gayle Stevens promoted the concept of “family medicine as counterculture.” There was discussion at the Keystone IV conference regarding whether there is an equivalent phrase today. “Family medicine as innovation” was identified as a fitting phrase for this new era. Change in the world today is less about opposition to the status quo and more about advancing better models and forging new paths through innovation. Family medicine has much to offer in innovating, and FMAHealth was launched to be a catalyst and driving force for this change and innovation.

At Keystone IV, David Loxterkamp reminded us that “effective primary care management hinges on a sense of timing based on trust.”¹⁷ Now is the time to be innovative in defining a truly patient-centered health care system that aligns with achieving the quadruple aim and nurtures strong relationships between patients and their personal doctors. These are not new goals for family medicine, but a new era has dawned that calls for revisiting past ideals and inventing (or in some cases reinventing) new approaches to achieve our most important goals. Family physicians must also renew promises: the promise to maintain a broad scope of training and practice for family physicians to meet patient and community needs, the promise to collaborate with other primary care professionals and stakeholders outside of medicine, the promise to embrace patients and patient advocates as partners in our work at the patient/organizational/systems levels, and the promise to be leaders in our communities with regard to bridging public and behavioral health.

FMAHealth will capitalize on the work of the Health is Primary campaign to inspire patients and other stakeholders to join forces with the family medicine community to successfully transform our health care system to a system that improves health, and to Make Health Primary.

FMAHealth leaders returned from mountains of Colorado and Keystone IV with a renewed energy and commitment to continue the important work of FMAHealth, working toward the vision of realizing family medicine's full potential to be a discipline that improves health for all Americans. As Rosemary Stevens said, we were called to “recharge family medicine.”¹⁸ With renewed inspiration from Keystone IV, we believe we can leverage the foundational work of the FMAHealth initiative and the Health is Primary campaign to accelerate momentum toward transforming our health care system into a system that truly makes health primary.

• Received for publication April 29, 2016.
• Revision received April 29, 2016.
• Accepted for publication April 29, 2016.