The Clinical Model of Family Medicine: Debate and Dialogue About Our Future in Alexandria

Historical Context

Family medicine evolves in response to the needs of its patients and society. Born in 1969 out of general practice and a social movement demanding access to care, family practice in the US (as it was then called) promised access to full scope personal physicians³ in solo or small group practices and based in communities. Key parts of this movement were a distinctive training model with a broad scope of practice, a continuity practice for each resident, and novel curricular attention to behavioral health and practice management. As depicted in Figure 1A (Donald Ostergard, email, October 22, 2024), family medicine grew explosively in the 70s and rapidly codified its training program. Uniquely among medical specialties, family medicine residencies are distributed in proportion to the population in urban, suburban, and rural communities.⁴ This wide geographic distribution has been foundational to serving the needs of society.⁴

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Figure 1A. Two Bursts of Growth of Family Medicine Residencies. The Founding Decade

The needs of patients seen by family physicians continue to evolve, as can be seen in Figure 2, which illustrates changes in reasons for office visits^5,6 from the 1950s to the 2000s. Chronic disease has assumed a much greater proportion of a typical family physician’s workday. In the early 2000s, the specialty formally responded to these changes with a specialty-wide initiative to develop a new model of care. The Future of Family Medicine initiative^7,8 highlighted the need for a new care model appropriate for chronic diseases,⁹ including electronic health records (EHRs) that would facilitate the care of chronic disease, and a recommitment to multidimensional access to care.⁹ This led to the Patient-Centered Medical Home (PCMH) movement that emphasized the development of the office systems necessary to provide this new model of care. In the 2020s, while no longer highlighted by insurers, the PCMH model has left its footprints in many current family practices.¹⁰

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Figure 2. Office Visits for Common Diagnoses in North Carolina, 1953 vs. 2002⁵

A generation after the Future of Family Medicine, the specialty is again at an inflection point. There are multiple factors indicating a need for change. Since 2014, well before the COVID pandemic, the life expectancy of Americans began to drop.¹¹ Moreover, despite spending 2–3 times more than in comparably affluent countries, Americans are sicker and die earlier.¹² The population continues to age and multimorbidity is increasing dramatically. Payers, hospitals, and practices have continued to consolidate, accelerating with the pandemic, and family physicians were the first specialty to be heavily employed. In parallel, technology has provided many opportunities for online care, bringing potential for increased access but also potentially fragmenting care and increasing costs. A torrent of new medications offers the possibility of breakthroughs in some cancers and other diseases, but at great cost.

Should the clinical model of family medicine change in response to the changes in our patients and the healthcare environment? In the summer of 2024, the FMLC began to frame the problem in a series of presentations and papers, which are captured in an evergreen website (https://stfm.org/conferences/fmlc/2024_august/overview/). Importantly, the leadership organizations decided to invite a broader audience than the leadership of the national family medicine organization, inviting medical students, residents, members of the public, health system leaders, editors, and others. Presenters used national data from the American Board of Family Medicine to document the changes in the scope of practice of family medicine and reviewed the key drivers of the change; specifically, the hyperconsolidation of payers, hospitals, and physician practices, high-deductible insurance plans, and the fractionation of care driven by the traditional fee-for-service model. At the same time, presenters identified “bright spots”—individual family practices, health systems, and states that were making substantial progress in improving care processes and outcomes.

After the summer 2024 FMLC retreat, the leadership of the national organizations considered how to move forward. While many types of advocacy and action are open to the specialty—for example, payment reform, new approaches to recruiting the workforce, and embracing technology—the group decided that it was important to first critically re-examine the core principles of the family medicine clinical model. For a generation, we have used the Starfield principles of the core functions of primary care—access, continuity, comprehensiveness, and community and related ideas—as a “North Star” for our clinical care. We needed to ask: Are these core functions still relevant for the 2020s? Should our clinical model fundamentally change?

The 2025 Family Medicine Leadership Council (FMLC) retreat meeting addressed these questions. Like the 2024 meeting, the major national family medicine organizations and a broad array of guests were invited. Starting before the meeting, a draft set of foundational principles for the clinical model for the future were identified through an iterative process involving all participants. To advance the dialogue, a series of formal debates were framed with sharply defined propositions with pro and con speakers identified in advance, and formal votes before and after. Several topics did not lend themselves to simple pro and con discussions; instead, contrasting propositions were presented. The meeting agenda provided optional background papers and included purposefully provocative papers, such as papers against a role for family medicine in prevention and performance improvement. The evergreen website includes the PowerPoints and discussion papers (https://stfm.org/conferences/fmlc/2025_august/overview/).

Table 1 lists the propositions and the pre and post votes. Those assigned to difficult positions—who wants to argue against prevention or performance improvement?—took their roles seriously. This JABFM theme issue provides the authors a joint presentation on their assigned topics, whether they were pre-designated as the pro or con speaker. The papers in this issue were provided by the speakers after the topics were discussed in small groups. Their synthesis is designed to capture interesting pro and con discussions about what should be the Future of Family Medicine as of 2026.

While the papers convey the nuances of the discussions, the top line pre and post votes are also informative. Not surprisingly, there was unanimous support for promotion of access and continuity; what is distinctive, however, is the synthesis—that the goal should be promotion of access to continuity. Similarly, there was wide support for team-based care, but discussion focused on implementation—how to spread and pay for it. Regarding prevention, despite examples and a paper from the United Kingdom, the group supported continuation of prevention in family physician practice because of the impact of the pandemic on vaccination rates in primary care offices and the frequent lack of formal connection of local public health offices to primary care offices typical in the US. With regard to addressing the social drivers of health, the group pulled back from taking “responsibility” for them, voting instead to emphasize awareness and allying with efforts to address the issue. Finally, with respect to professionalism, after debate, the proposition that professionalism is foundational to our clinical and education efforts gained almost unanimous support over the proposition that professionalism is “nice to have” but we need to focus on other pressing issues. The more we talk about professionalism, the more salient it becomes.

The debates directly addressed the principles of the clinical model of care for family medicine in the future. At the end of the conference, and one more time, all participants were given another chance to review, comment on, and edit the principles. This version was then finalized by a small set of leaders of the AAFP, ABFM, ADFM, AFMRD, NAPCRG, and STFM. What follows is their final draft—the sixth draft over the last year.

Principles for a Clinical Model of Care for Family Medicine of the Future

In a time of worsening life expectancy, disappointing outcomes of health care, and deep social division, family medicine recommits to supporting far-reaching sustained reform, and the transformation and reorganization of the healthcare system. For the best healthcare results, the foundation of this healthcare system must be robust primary care based in communities and delivered by family physicians and their colleagues in other specialties and professions.

Such a sweeping change will require new models of care adapted to all communities and settings. We believe stated principles should serve as the foundation of any new model of primary care. The principles should be generalizable and provide implementation flexibility to meet the needs across communities and across the country.

Family medicine commits to the following principles to maximize patient care outcomes:

1. Expanding access to continuous, relationship-centered care delivered person by person, family by family, and community by community. The longitudinal doctor-patient relationship is the foundation of what we do and key to the best outcomes. Continuity will seamlessly integrate synchronous and asynchronous encounters. Patients will have reliable access to a trusted personal physician and healthcare team.

2. Caring for the whole person, embedding behavioral health in everyday practice, and referring patients when clinically appropriate. Comprehensive care remains the cornerstone of primary care, driving improved outcomes, patient experience, cost effectiveness, and joy in practice.

3. Integrating preventive care into daily practice. In collaboration with partners, we will strengthen clinical and public health systems to assure evidence-based prevention and screening for all patients. Increase the vaccination rate by rebuilding vaccination in primary care is a priority.

4. Bringing evidence to shared decision-making. We seek best evidence and embrace shared decision-making to leverage our knowledge of the totality of our patients’ health conditions and goals.

5. Implementing team-based care models that include a diversity of health professionals, administrative staff, patients, and patients’ families. Team-based care must spread. Family physicians will lead and participate in the teams of the future. We will organize teams around patient panels and focus on implementing best practices of population-health management and accountable care.

6. Embracing a clinical presence across the continuum of care, collaboratively leading efforts to improve hospital-based care and transitions across the continuum of care.

7. Embracing innovation and technology when it elevates the continuity relationship and improves the health of populations. We will work with partners who share our values to implement technology into the primary-care model that serves the Quintuple Aim (ie, improving patient experience, improving population health, reducing costs, improving the work-life of the healthcare workforce, advancing health equity).

8. Involving ourselves in, and being accountable to, communities. We recognize the interconnectedness of individual and community health. We will strive to improve health equity through cultural humility, shared decision-making, advocacy, and bringing about structural changes in access and care provision.

9. Strengthening the formal linkages between clinical practice and public health. For too long, practices and public health have worked separately. We will build bridges across systems and create incentives to work together towards improvement of health.

10. Developing systems of care that address the social drivers of health and support improvement of the health of populations. This will include new kinds of health professions or personnel, new systems for practical, real-time collaborations among personal physicians and their teams, local public health departments, and subspecialist colleagues.

11. Dedicating ourselves to continuous improvement in health and health care. The US confronts crises of access, burnout, cost, and health disparities that threaten public trust in our profession and the US healthcare system. We recognize that sustained effort is required across individual, practice, and system levels. We will focus on preventing chronic disease, managing multimorbidity, and altering the trajectory of progressive chronic disease and aging.

12. Recentering professionalism in the care we provide every day to patients and in communities. How family physicians conduct themselves in everyday practice and in public is critical to the future of the specialty and the profession.

Further, it was agreed that family medicine embraces the following key enablers:

• Metrics aligned with holistic patient-centered goals;

• Technology that enhances and supports enduring continuity in doctor-patient relationships;

• Payment reform that supports both personal doctors and team-based care;

• Efforts to make primary care affordable for our patients and to society;

• Commitment to developing and using evidence to guide practice;

• Embracing new models of care; and

• Ongoing progress towards health equity.

Next Steps: From Principles to Action

As in the 1960s and the early 2000s, the specialty is acting again to shape its own future. All family medicine organizations came together to rethink residency training in family medicine and to restore residency faculty time for teaching.¹ As incorporated into the Family Medicine Review Committee requirements in 2023 and the implementation of ABFM competency-based board eligibility in 2024, the major changes include emphasis on the organization and quality of care of the residency clinical practice, the commitment to work in communities to address disparities, competency-based assessment, flexibility for residents and residencies, and restoration of faculty teaching-time requirement. Overall, they represent the most significant changes in family medicine residency education since 1969; the transition will take a decade but is well on its way. Importantly, these changes are happening at the time of another era of dramatic growth in family medicine residencies, as depicted in Figure 1B. A major challenge is that the growth of interest in family medicine among medical students stalled with the pandemic, and the specialty is now addressing that issue.

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Figure 1B. 2014–2026 Growth of Family Medicine Residencies¹²

In addition to residency redesign, NAPCRG and ADFM have led the specialty to develop and implement a national plan for building advocacy, mentorship, and training pathways for family medicine research.² Without substantial development of specialty-wide research infrastructure and culture, the future of the practice of family medicine and patient-care quality will be impoverished. This process will also take many years, but initial achievements include a new significant line of NIH funding and new programs to support mentorship and research development—despite a very challenging social and political environment.

The upcoming FMLC 2026 summer retreat continues the focus on the clinical model. We will begin by prioritizing the principles. Given a timeframe of the next 3–5 years, what should the specialty focus on? What commitments should the specialty and the organizations that lead the specialty make?

We now seek broad input and participation from our community. This is a time of existential significance for our specialty and for health care in the United States. As we have done in residency redesign and research, what we do, we need to do together—and, as always, we need to be guided by the needs of our patients and society. And the need is now.