MOUNT SINAI JOURNAL OF MEDICINE 79:603–609, 2012
Family Medicine: A Specialty for All Ages
Neil S. Calman, MD, Diane Hauser, MPA, Francesco Leanza, MD,
and Robert Schiller, MD
The Institute for Family Health, New York, NY and Department of Family Medicine and Community Health,
Mount Sinai School of Medicine
OUTLINE
HISTORY OF FAMILY MEDICINE
FAMILY MEDICINE TODAY
FAMILY MEDICINE AND COMMUNITY HEALTH
ROLE OF SPECIALISTS
PRACTICE ADMINISTRATION
RESEARCH
RURAL AND URBAN FAMILY MEDICINE
CONCLUSION
ABSTRACT
After a diminishing of its ranks following the
post–World War II explosion of growth in medical
discoveries, advanced medical technology, and
the concomitant specialization of the physician
workforce, family medicine is re-establishing itself as
a leading medical specialty that has garnered growing
interest among recent medical-school graduates.
Family physicians provide care for patients of all
ages, from newborns to the elderly. In addition
to its wide scope of practice, family medicine is
characterized by its emphasis on understanding of the
whole person, its partnership approach with patients
over many years, and its command of medical
complexity. Family physicians are trained both to
use community resources to assist individual patients
in meeting medical or social needs and to identify
and address community-wide needs. The specialty
of family medicine is uniquely positioned to provide
a leadership role in health-reform efforts that are
accelerating across the country. Health care models
Address Correspondence to:
Neil Calman
The Institute for Family Health
New York, NY
Email: ncalman@institute2000.org
Published online in Wiley Online Library (wileyonlinelibrary.com).
DOI:10.1002/msj.21333
© 2012 Mount Sinai School of Medicine
603
that are gaining traction, such as the patient-centered
medical home model, health homes, and accountable
care organizations, share the characteristics of
providing comprehensive, coordinated patient care
with an emphasis on disease prevention and health
promotion. This model of care, provided in the
context of family and community, has been the
hallmark of family medicine since its creation as a
distinct medical specialty more than 40 years ago.
In addition, family physicians’ ability to care for
patients of all ages make them particularly cost-
effective as the new models of care move to
improve access to care through expanded hours and
locations. Mt Sinai J Med 79:603–609, 2012. ©
2012 Mount Sinai School of Medicine
Key Words: accountable care organization, family
medicine, health home, health reform, patient-
centered medical home.
There is a widely recognized need to reform the
delivery of health care in the United States, with the
often-stated goals of improving health care outcomes,
increasing the quality and safety of care, improving
patient satisfaction, and decreasing costs. Equally
important is increasing access to care for people
in medically underserved inner-city communities and
rural areas, as well as those who are uninsured and
underinsured.
In addition, it is generally acknowledged that our
technologically advanced hospitals and the specialists
who staff them do not focus on the preventive health
care of community-based populations. This leaves a
void that can be best addressed through the develop-
ment of strong community-based primary health care.
In all but a few areas of the country, that role is played
primarily by physicians trained in family medicine.
HISTORY OF FAMILY MEDICINE
The twentieth century in the United States was
bookended by the predominance of general practice
604
as the preferred model of health care at the start
of the century and again at the end, with a call
to return to a primary and patient-centered care.
In the intervening 100 years, there was explosive
growth in medical discoveries, advanced medical
technology, and the concomitant specialization of
the physician workforce. In 1930, 80% of physicians
were general practitioners. By 2011, only 32% of
physicians were in general practice, a category that
includes family medicine, general internal medicine,
and general pediatrics.1
The trend toward specialization began around
the time of World War II, with new medical
technologies and military exemptions for medical
students who pursued residency training, which
was not available for general practice at the time.2
The American Academy of General Practice was
established in 1947 to support the decreasing number
of generalists.
In 1966, 3 commissions released reports
concerning the decline in the number of generalists:
• The Folsom Report concluded that ‘‘every
American should have a personal physician to
ensure the integration and continuity of all medical
services.’’ The report highlighted the need to focus
on preventive medicine, connect patients with
community resources, and care for the patient as a
whole person.3
• The Millis Report focused on residency training
in family medicine and determined that family
medicine needed to become a board-certified
specialty.4
• The Willard Report went further and specified the
establishment of a board to oversee certification,
leading to the establishment of the American Board
of Family Practice in 1969.5
The first family-medicine certifying exam was
offered in 1970, ushering in what some hoped
would be a rebuilding of a health care model in
which every American had a personal physician.
Despite a decade of health care activism, including
the creation of the federal Medicare and Medicaid
programs and the community health center (CHC)
movement, the proportion of physicians in general
practice continued to decline.
Family physicians and other primary-care
providers were positioned at the entry point for
health care, often referred to as ‘‘gatekeepers,’’ during
the growth in managed care of the 1990s. Insufficient
choice and overly restrictive insurance policies
doomed these early manifestations of managed care.
However, there continued to be calls for a stronger
primary-care workforce to serve as the foundation
DOI:10.1002/MSJ
N. S. CALMAN ET AL: FAMILY MEDICINE
of the health care system. Academic departments of
family medicine had been established at virtually all
medical schools in the country, with the exception of
several predominantly East Coast institutions.
Federal funds were made available to support
the training and professional development of fam-
ily physicians and their primary-care colleagues,
particularly those committed to careers in under-
served communities.6 Family medicine, in the mean-
time, pioneered efforts to require ongoing faculty-
development activities and mandatory recertification
to maintain board-certification status.7 These latter
initiatives have since been adopted by many other
specialties and have become standard practice in
primary-care education and certification, respectively.
After a decade of declining numbers of
residency positions offered and relatively stable
numbers of matched residents, family-medicine
residency programs have recently experienced an
upward trend in both the number of positions
offered and matched.8,9 According to preliminary
data from the 2012 National Resident Matching
Program, family-medicine residency programs filled
2611 positions out of 2764 positions offered
(94.5%), representing an increase of 35 matched
positions from the previous year (includes family
medicine–psychiatry, family medicine–emergency
medicine, family medicine–preventive medicine, and
family medicine–internal medicine programs). This
trend includes increases in the proportion of US
medical graduates matching in family medicine. The
widespread acknowledgement of a broken health
care system and the developing vision for reform
may be influencing these decisions.
The central role of family physicians and other
primary-care providers in an effective and efficient
health care system is emphasized by the ecology of
medical care model first conceived by White and
colleagues.10 An update to the model using current
data, presented in Figure 1, has changed very little
in the intervening 40 years. It illustrates that most
health care is provided in the community, whereas
the organization and financing of health care, medical
education, and research continue to be focused in
large medical institutions. Emerging models of care
seek to reverse this model.
FAMILY MEDICINE TODAY
The specialty of family medicine is uniquely
positioned to provide a leadership role in health-
reform efforts that are accelerating across the
country. Health care models that are gaining traction,
such as the patient-centered medical home model,
MOUNT SINAI JOURNAL OF MEDICINE
Fig 1. A typical month of health care in the United States, 2001. Reprinted
from Fryer et al.34
The specialty of family medicine is
uniquely positioned to provide a
leadership role in health-reform
efforts that are accelerating across
the country.
health homes, and accountable care organizations,
share the characteristics of providing comprehensive,
coordinated patient care with an emphasis on disease
prevention, health promotion, and population
management. This model of care, provided in the
context of family and community, has been the
hallmark of family medicine since its creation as a
distinct medical specialty more than 40 years ago. In
addition, family physicians’ ability to care for patients
of all ages make them particularly cost-effective as the
new models of care move to expand access to care
through the addition of evening and weekend hours.
There were an estimated 79,831 family physi-
cians in practice in 2010, making it the largest
primary-care specialty, representing 38% of all
active primary-care physicians.11 Nearly one-quarter
(22.9%) of all physician office visits in the United
States were made to family physicians, as compared
with 14.5% to general internists and 13.2% to general
pediatricians.12
Family physicians differ from their primary-care
colleagues in that they provide care for patients of all
ages, from newborns to the elderly. One in 10 family
physicians delivers babies in uncomplicated pregnan-
cies, with variation between metropolitan and non-
metropolitan areas (8.2% versus 17%, respectively).13
Family physicians perform diagnostic and other pro-
cedures, with the most common being dermatologic
procedures, circumcision, and colposcopy.14 Selected
hospital-based practices of family physicians are pro-
vided in Table 1.
605
The centerpiece of family-medicine training is
the continuity experience in ambulatory settings in
which residents provide a minimum of 1650 visits
over 3 years for a panel of pediatric, adult, and
geriatric patients, which includes the continuous
involvement in the prenatal care, delivery, and post-
partum care of ≥10 women and the performance of
40 deliveries overall.15 Residents coordinate referrals,
consultations, and psychosocial needs with a mul-
tidisciplinary care team; manage inpatient care for
patients requiring hospitalization; and conduct group
and home visits. Family physicians’ broad scope of
training is highlighted in the sample residency rota-
tion schedule provided in Table 2. There is some
recent concern about family physicians voluntarily
limiting their scope of care, particularly maternity
care and pediatrics, that bears monitoring.16,17
In addition to its wide scope of practice,
family medicine is characterized by its emphasis on
understanding of the whole person, its partnership
approach with patients over many years, and its
command of complexity.18 Its holistic approach to
care is based on an understanding that health and
disease are functions of mind, body, and spirit, as well
as life context that includes family and community.19
Table 1. Percentage of Family Physicians Engaged in
Selected Hospital Services and Procedures.
Pediatric care 62.3%
Newborn care 57.1%
Formal interpretation of EKGs 44.4%
Minor surgical procedures 34.0%
Psychiatry 29.2%
Care in CCU 28.7%
Care in ICU 34.2%
Care in hospital ER 35.8%
Abbreviations: CCU, critical care unit; EKG, electrocardio-
gram; ER, emergency room; ICU, intensive care unit.
Source: American Academy of Family Physicians, Practice
Profile I Survey, April 2011.13
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606 N. S. CALMAN ET AL: FAMILY MEDICINE

Table 2. Sample Family Medicine Residency Rotation populations. Family physicians often play an integral
Schedule. role in community-based health outreach programs
Rotation Months Setting such as school-based health centers, a natural exten-
sion of the community-centered model of health
First year
Family medicine service 4 Inpatient care. There are >1700 school-based health centers
Pediatric and adolescent care 2 Inpatient in the United States providing patient-centered care
Maternity care 1 Inpatient to underserved children.25 Family physicians are also
Newborn care 1 Inpatient involved in caring for people who are homeless, often
Emergency medicine 1 Inpatient in collaboration with other service providers who
General surgery 1 Inpatient
Practice of family medicine I 1 Ambulatory offer meals, showers, and beds. Homeless patients
Second year often have chronic medical conditions, dual diag-
Family medicine service 2 Inpatient noses of mental illness and substance abuse, and
Pediatric ER 1 Inpatient developmental delay or low literacy levels. These
Practice of family medicine II 1 Ambulatory challenges, coupled with inconsistent access to basic
Gynecology 1 Ambulatory
Orthopedics 1 Ambulatory
needs such as shelter and regular meals, make it
General surgery 1 Ambulatory difficult to manage chronic medical and psychiatric
Cardiology 1 Ambulatory conditions by traditional means. Family physicians’
Nephrology 1 Ambulatory ability to provide a broad range of services and
Pulmonary 1 Ambulatory their use of the harm-reduction model and a patient-
Track selection/electives 2
Third year
centered approach, coupled with their knowledge
Family medicine service 2 Inpatient of community resources, are crucial when caring for
Orthopedics/sports medicine 1 Ambulatory homeless patients.
Urology 1 Ambulatory Mental health care is well-integrated into family
ENT and ophthalmology 1 Ambulatory medicine. Twenty percent of all office-based visits
Practice of family medicine III 1 Ambulatory
Dermatology 1 Ambulatory
to physicians for mental-health issues are made
Ambulatory pediatrics 1 Ambulatory to family physicians.26 Training in family medicine
Open electives 2 Ambulatory incorporates robust experience in human behavior
Track selection/electives 2 and mental health. Competencies in the diagnosis and
Abbreviations: ENT, ear, nose, and throat; ER, emergency
room. Training in family medicine
incorporates robust experience in
Family physicians are trained both to use community
resources to assist individual patients in meeting human behavior and mental
medical or social needs and to identify and address health.
community-wide needs.20
management of psychiatric disorders in children and
adults, emotional aspects of nonpsychiatric disor-
FAMILY MEDICINE AND ders, psychopharmacology, alcoholism and other
COMMUNITY HEALTH substance abuse, and counseling skills are established
under the direction of interdisciplinary teams that
With this community orientation, family physicians include family physicians, psychiatrists, and behav-
are drawn to practice in CHCs. They comprise ioral scientists. The behavioral change model is taught
almost half of the physician workforce in federally through motivational interviewing and harm reduc-
funded CHCs, which provide community-oriented, tion in an integrated model of care. These skills
patient-directed services to >20 million Americans in are used in the management of increasing numbers
high-need areas.21 Almost one-quarter of all family- of patients with both chronic medical and mental
medicine residency programs provide some training illnesses.
experience in CHCs, which is associated with their The prevention and management of illness and
eventual practice in underserved areas.22,23 Starting injury is fundamental to the practice of family
in 2011, the federal government began further pro- medicine. In nearly 20% of all office visits in the
moting CHCs as training sites by offering Teaching United States, preventive care is the primary reason
Health Center awards to CHCs that sponsor residency for the visit.12 Family physicians are primed for this
training programs.24 role, as they are taught to serve as partners with
In addition to working in CHCs, family physi- patients to maintain well-being, empower them with
cians are well-prepared to work with special information and guidance needed to self-manage,

DOI:10.1002/MSJ
MOUNT SINAI JOURNAL OF MEDICINE
provide care that promotes behavioral change that
leads to better health, and develop ongoing commu-
nication with patients.
In addition to patient-specific preventive ser-
vices, family medicine has partnered with public-
health professionals and preventive-health specialists
to train physicians focused on population-based
health. A number of academic departments of fam-
ily medicine include preventive medicine training,
In addition to patient-specific
preventive services, family
medicine has partnered with
public-health professionals and
preventive-health specialists to
train physicians focused on
population-based health.
practice, and research, and there are several com-
bined family medicine–preventive medicine resi-
dency programs. Population-based approaches to
health, whether within a patient panel or a commu-
nity, may increasingly become part of the primary-
care physician’s training and practice as emerging
models of care call for these approaches and elec-
tronic health records facilitate their implementation.27
Core training in family medicine typically incor-
porates other health professionals, such as physician
assistants, advanced-practice nurses, social workers,
pharmacists, nutritionists, health educators, and nurse
midwives. Interdisciplinary primary-care teams prac-
tice in family medicine training sites, CHCs, and
other settings with evidence of improved care and
lower costs. Family physicians refer patients to other
specialists or caregivers when indicated, but they
are guided by professional philosophy and train-
ing to remain the coordinators of patients’ care,28
minimizing the fragmentation of care often cited as
a fundamental flaw in the US health care system.
The family-medicine model is designed to prevent
Family physicians refer patients to
other specialists or caregivers
when indicated, but they are
guided by professional philosophy
and training to remain the
coordinators of patients’ care,
minimizing the fragmentation of
care often cited as a fundamental
flaw in the US health care system.
607
fragmentation among care providers and care
settings, which has become a priority in national
health care-reform efforts. The expanding capacity
to exchange electronic health record data provides
opportunities for improved coordination of care.
ROLE OF SPECIALISTS
Family physicians collaborate with specialists in the
care of patients who require complex diagnostic and
therapeutic interventions beyond the scope of the
family physicians’ practice. The relationship between
referring family physicians and their specialty
colleagues is complex, influenced by multiple
considerations. Once built solely upon a collegial
relationship between the 2 providers, increasingly the
referral patterns of family physicians are determined
by the diversity of managed-care plans in which
they participate and the specialists who participate in
those plans. Specialists, especially in urban areas, are
often highly competitive with one another, fostering
relationships with neighborhood family physicians
to ensure an ongoing stream of patient referrals.
Over the past decade, specialists have supported
family doctors in obtaining hospital privileges and in
playing important roles in their multispecialty groups.
The ongoing relationship between primary-care
physicians and specialists will be facilitated by better
flow of information due to the increasing capabilities
of electronic health information exchange.
PRACTICE ADMINISTRATION
In 2004, in an uncertain health care environment,
7 leading family-medicine organizations reported on
their vision for family medicine as a specialty and
change agent in the Future of Family Medicine, a doc-
ument that has guided practice transformation over
the past several years.18 Consistent with this vision,
the American Academy of Family Physicians (AAFP)
was a founding member of the Patient-Centered
Primary Care Collaborative, along with the Amer-
ican Academy of Pediatrics, the American College
of Physicians, and the American Osteopathic Asso-
ciation, which presented the Joint Principles of the
Patient-Centered Medical Home in 2007.29 The core
principles of this model require a personal physi-
cian providing comprehensive care to each patient,
interdisciplinary team-based care, whole-person ori-
entation, care coordination across the health sys-
tem, improved quality and safety, enhanced access
and extended patient-care hours, and appropriate
payment.
DOI:10.1002/MSJ
608
The AAFP founded a subsidiary known as Trans-
forMED to operationalize practice transformation
aligned with these goals, which it has accomplished
in >500 practices to date. A demonstration project
report from TransforMED notes the complexity of this
transformation and the need for upfront resources.30
The Agency for Healthcare Research and Quality has
funded 14 investigator teams to assess the impact of
the patient-centered medical home model on health
care use, quality, and cost in a variety of settings,
with findings forthcoming.
RESEARCH
Research in family medicine is predominantly focused
on translational studies in practice-based settings. The
AAFP National Research Network was established in
1999 to facilitate practice-based primary-care research
and currently includes 2200 primary-care clinicians
in 600 offices.31 With a growing federal emphasis on
translational research and patient-centered outcome
research,32,33 family physicians have unprecedented
opportunities to engage in research to establish
evidence for effective clinical models that address
national health care priorities. Its substantial clinical
With a growing federal emphasis
on translational research and
patient-centered outcome
research, family physicians have
unprecedented opportunities to
engage in research to establish
evidence for effective clinical
models that address national
health care priorities.
presence places family medicine in a position to lead
and participate in research that will reduce the gap
between medical knowledge and clinical care that
improves health. Patient-centered outcome research
is particularly well-suited for family medicine–based
research in that it incorporates outcomes that are
important to patients and their families, involves
longitudinal follow-up of patients, and engages
diverse stakeholders, from insurers to policymakers,
in the entire research process.
RURAL AND URBAN FAMILY MEDICINE
The goal of training a family physician for every type
of practice environment is challenging. In urban areas
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N. S. CALMAN ET AL: FAMILY MEDICINE
there is generally easy access to specialists and, thus,
training family physicians to engage in a broad scope
of practice that includes specialized procedures, for
example, may be unnecessary. Family physicians
who choose to practice in communities with a high
prevalence of uninsured individuals, however, are
often called upon to engage in a larger scope of
practice because of the difficulties arranging specialty
care for patients without insurance coverage. In
rural areas, family physicians have become the
mainstay of the health care system, often delivering
babies, resuscitating neonates when needed, staffing
emergency rooms, assisting at surgery, and setting
uncomplicated fractures. When there is only one
doctor in a community, a broadly trained family
physician can provide care for all of its residents.
CONCLUSION
Family physicians are uniquely positioned to help
reach the goals of health care reform to create a
more effective and efficient delivery system in the
United States, resulting in improved health outcomes,
lower costs, and greater patient satisfaction. These
goals will be undoubtedly be achieved through
more coordinated, continuous, patient-centered care.
Family physicians have long been in the forefront
of public-health efforts, as well as efforts to care
for the medically underserved in both rural and
urban communities. As providers who can see all
comers, they offer an especially efficient addition
to the health-reform goals of increasing access to
care. With its broad scope of training, emphasis on
preventive care and care coordination, and use of
community-based resources, family medicine is well-
positioned to lead the way toward change.
DISCLOSURES
Potential conflict of interest: Nothing to report.
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