What Humans Need.

Family medicine is a champion of human-focused health care in the context of lasting relationships. What do humans need-those who seek care and those who offer it? Respect, understanding, and kindness. Without it, more money, more ancillary personnel, more time-saving technology cannot lift us from the profession's doldrums. The author believes that the deep desire to be of help to others can be rekindled in an office culture where the humanity in all of us is honored.

The Lost Pillar: Does Continuity of Care Still Matter?

Continuity of care has long held a hallowed place in the halls of family medicine. Indeed, it is one of the 4 pillars of an ideal family practice, along with first contact, comprehensive, and coordinated care. But what does it mean to the patient, the doctor, and our sense of identity and purpose? And why, in recent years, has it receded from the discourse of family medicine values? This author suggests that continuity is an expression of the value we place on human relationships, a contract of sorts with the people we care for both inside and outside the office. Such relationships are not lightly discarded, for they serve us best in the long haul when our own sense of identity and purpose is tested and worn.

When It's Time to Retire: Notes From the Afterlife.

At the end of the Second World War, the US birth rate peaked at nearly 27 births per 1,000 population-a rate unparalleled in the previous 3 decades, and one that would not be repeated. That Boomer generation is now retiring. How do those of us caught in the wave feel about stepping back? Who will step in to replace us? And how will we replace the loss of purpose and fulfillment that comes from a career in medicine? A lengthening life expectancy has challenged many of us to consider the "second act" to our adult life. This essay describes the emotional turbulence of ending one career and contemplating the next.

Where We Belong: An Open Letter to My Colleagues in Training.

Although the American health care system seems forever in flux, the young doctors who enter it provide one constant: their desire to help others. How will this desire express itself in an evolving marketplace? This letter is a reassurance that meaning and purpose can still be found in caring for others and investing in their worthy lives.

Caring for the Tribe: From Addiction to Zen.

The culture of medicine is rapidly changing. The majority of primary care physicians are now employed, and the decisions that govern us are made farther and farther from the point of care. Our sense of well-being is threatened less by the demands of clinical practice than it is by the emptiness of our job: we have forgotten who we are working for, or working with, or why we are working at all. The solution lies in creating the kind of practice environment that we advocate for in each of our patients' lives.

Storylines of family medicine VIII: clinical approaches.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VIII: clinical approaches', authors address the following themes: 'Evaluation, diagnosis and management I-toward a working diagnosis', 'Evaluation, diagnosis and management II-process steps', 'Interweaving integrative medicine and family medicine', 'Halfway-the art of clinical judgment', 'Seamless integration in family medicine-team-based care', 'Technology-uncovering stories from noise' and 'Caring for patients with multiple long-term conditions'. May readers recognise in these essays the uniqueness of a family medicine approach to care.

Storylines of family medicine VI: ways of being-in the office with patients.

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'VI: ways of being-in the office with patients', authors address the following themes: 'Patient-centred care-cultivating deep listening skills', 'Doctor as witness', 'Words matter', 'Understanding others-metaphor and its use in medicine', 'Communicating with patients-making good use of time', 'The patient-centred medical home-aspirations for the future', 'Routine, ceremony or drama?' and 'The life course'. May readers better appreciate the nuances of patient care through these essays.

What do you expect from a doctor? Six habits for healthier patient encounters.

Expectations lie at the heart of America's health care crisis. Although doctors cannot control for the unrealistic demands of a consumer-centric society, we might ask what we would want in a physician. Someone who listens longer and lets us express ourselves in our own words? Someone who cares about the outcome-our personal outcome-and not just the "clinical course"? Most patients do not demand perfection. Not cure. Not even relief, no matter what the TV commercials promise or how badly they wish them to be true. What we all desire is a plan that connects us to another human being-our doctor-which is a kind of relief all its own. The author identifies 6 simple habits that will lead to healthier, happier encounters with patients and their illness.

An Exploration of Professionalism in Everyday Practice.

Professionalism is what professionals do to connect, contribute, and give back to their profession. We often picture it on a grand and spot-lit stage: the white coat ceremony, graduation oath, diplomas on the wall, and resumes on file. But it is in the crucible of everyday practice that a different image emerges. The icon of the heroic and duty-bound physician morphs into a kind of family portrait. Here we stand on a stage built by our forebears, lean against our colleagues, and look to the community where our work is fulfilled.

A change will do you good.

The primary care physician is described as many things-generalist, information manager, chronic care coordinator, and specialist in disease prevention. But midlevel clinicians, the Internet, and self-motivated patients can provide most of these services quite ably on their own. Why, then, are we here? One indispensable role for the family doctor is to be an agent of change for our patients and our communities. Through the groundbreaking work of Michael Balint, William Miller, and Stephen Rollnick, we have a solid framework for understanding our role in the change process. It is through working with patients, however, that we learn of their extraordinary capacity for change-and by extension, ours.

The dream of home ownership.

Part of the American Dream involves home ownership and its claim to a stronger investment in one's family, neighborhood, and community. The medical version of that dream is called private practice. Almost overnight, it seems, we have awakened to the reality that most primary care physicians are now employed by large corporations or hospital networks. What does this mean for our patients and the practice of medicine? Did patients lose a sense of ownership when insurance companies began to speak on their behalf? Have boutique practices, Internet sales, and online information banks restored their control? This essay explores the fundamental question, "Does ownership matter?" and suggests what we all can do to retrieve paradise lost.

Doctors' work: eulogy for my vocation.

I, like so many of those who filled the first ranks of family practice, often described my career choice as a calling, a vocation, something more than a meal ticket. It was a source not only of pride and conviction but also resentment and resistance to change. By mid career I was largely out of step with new movements in family medicine that veered from the generalist approach toward focused fellowships, added qualifications, and office practices that opted out of obstetrics and hospital work. As often happens, it was a patient of mine who brought the issue into focus and showed me the potential that lay in each encounter. We long for connection-doctor and patient alike-and for the skill and compassion to express it without judgment or self-denial. There is no higher calling.

The Old Duffers' Club.

As baby boomers move toward retirement and nursing home care, medicine can no longer ignore the daunting task of caring for the aged. The physical and emotional challenges are enormous-and shocking-especially for a culture that prefers to jump rather than wade into the experience of old age. A new book by Dennis McCullough, My Mother, Your Mother, offers "slow medicine" as a corrective to the quick, curative methods in which we were trained. A large part of the answer-as I was taught by the members of the Old Duffers' Club-lies simply in self-support, conversation and friendship, accepting our physical decay, and finding the inner gift of ourselves that never grows old.

Five easy answers: where the ABFM cognitive exam has gone wrong.

The American Board of Family Medicine Maintenance of Certification (MOC) Exam of Cognitive Expertise is a rite of passage for the board-certified family physician. This year is the author's turn, and he looks at what the test includes, omits, and says about our professional posture. He questions the reader for five easy answers to the quagmires of everyday practice.

Whither Family Medicine? Our Past, Future, and Enduring Scope of Practice.

After 3 decades in private practice, I joined the faculty of a nearby residency program. Like most family medicine residencies, it follows a curriculum that my physician father would have recognized: heavy emphasis on inpatient medicine; short shrift to continuity care. Despite a changing marketplace, there is still a disconnect between how we train graduates (for full spectrum care) and where they end up (in ambulatory practices). Is our identity disappearing? I contend that the primary and indispensable duty of a residency program is to model professional values and prepare residents to live and work in sustainable communities. Though the scope of practice will vary, family physicians still pride themselves in putting the needs of their patients at its center.

Changing horses midstream: the promise and prudence of practice redesign.

An emerging vision for primary care calls for the adoption of information technology and a strong business model to save a dying health care system. The authors are participants in the National Demonstration Project (NDP), a study sponsored by leading organizations in family medicine and directed by a for-profit subsidiary of the American Academy of Family Physicians, TransforMED. The NDP embraces the Future of Family Medicine Report and seeks to test the ability of existing practices to implement its basic tenets. The NDP will conclude in June 2008, but its findings and observations will likely ripple out for years. Our report is a personal reflection that looks beyond the question of whether busy practices and practitioners can change horses midstream. We ask, "Is this primary care, and is this what it needs?"