Saturday, April 13, 2019

Whence, and whither, family medicine: will it have role in improving our nation’s health?: Part 1


This was the 25th J. Jerry Rodos Lecture, presented at the 30th Annual Conference of Primary Care Access, Kauai, April 8, 2019:

Part I: Whence family medicine, and me

The history of family medicine is familiar to those of us attending this conference. Although most of us were not there “at the beginning” in the 1960s, we have heard, frequently at this conference, about the seminal reports, people, and events that led to the founding of our discipline.

The Willard Report, issued in 1966, was commissioned in 1964 by the American Medical Association’s Council on Medical Education and found that medicine needed a new kind of specialist, the family physician, educated to provide comprehensive personal health care within the nation’s complex healthcare system. It defined a family physician as one who “accepts responsibility for the patient’s total health care within the context of his or her environment, including the community.”[1] The COME also commissioned a report on graduate medical education to achieve this goal, and the Millis Report was also issued in 1966. It contained one of the earlier modern definitions of a primary physician, one who “...will serve as the primary medical resource and counselor to an individual or a family”.[2] The 1967 Folsom Report, developed by the private National Commission on Community Health Services and sponsored by the American Public Health Association and the National Health Council, called for “communities of solution”.[3]
 
Following these reports, the AMA hired two early leaders in our field, Drs. Leland Blanchard and Lynn Carmichael to “develop family practice”, and they crossed the country doing just that; Carmichael established the first FP residency at the University of Miami in 1965.[4] By 1969 there were 16 residencies. These early residencies were led by major figures in the history of the discipline, including Gayle Stephens in Wichita and Gene Farley at the University of Rochester, and grew to nearly 500 by 2016.[5]

The choice of the term “family doctor” to replace “general practitioner” was not incidental. The ABFM was founded in 1969, but the AAGP did not change its name to the AAFP until 1971, after at least 3 failed efforts. Obviously, people had always referred to their primary physician as their “family doctor” and for marketing purposes the term “family doctor” evoked positive feelings among the American people.

Like everyone here, I am sure, I can tie this to my personal story. Entering medical school in 1973, I did not come from a medical family, and think my parents had only one physician among their friends. I knew what kind of doctor I wanted to be, but not the right word for it. I didn’t even register GP; I wanted to be a “regular doctor”. You know, the kind you can go to with whatever is wrong and not have to diagnosis yourself first, and they can take care of it. As far as specialties were concerned, I guess I had an idea that pediatricians took care of children and obstetricians delivered babies. And maybe from high school friends who had money as well as acne, I knew that dermatologists took care of skin, but that was probably it. Of internal medicine, which played such a huge part in medical school, I had no concept; if anything I would have probably guessed it had something to do with gynecology, as I remember my mother having gone for annual “internal” exams.

My medical school, Loyola, had no family medicine at that time, but as I approached my scheduling for clerkships I found out that there was a physician, Werner Cryns, who ran a family practice clinic at the school. Trained as a pediatrician, Dr. Cryns had gotten private outside funds to establish this small clinic in a corner of the medical school, and I chose it for my elective. It was also my first clerkship, and from then on, I knew that was what I wanted to do. I did my residency at Cook County Hospital in Chicago, under Dr. Jorge Prieto, only the fourth full class to start in 1976. (Little side story: the hospital had always given out an “intern of the year” award, and in the first full class of FP residents, in 1973, it was won by one of them. Everyone else freaked out because “they rotate with everyone; they’ll always win it”, so there went the hospital-wide award. It became departmental.) I wanted very much to work at this public hospital with all of my socially and politically conscious friends from many of the Chicago medical schools, and was thrilled that they had a program in family medicine.

I had interviewed around the country, though, and found out about different programs, including two others that consciously saw themselves as training doctors for the urban inner city populations, Montefiore and San Francisco General. If I had gone to Montefiore, back in New York where I had lived my entire life before medical school, I likely would have had me a different life, but that cannot be known. I wanted to love SF General, as I loved San Francisco and had been unsuccessfully trying to get to California at least since applying to college, but was actually turned off by its emphasis on family dynamics and behavioral science. As someone who loved his own family but saw very much the negative impact that many families had on their children, I wanted to “keep the family out of family medicine”! Suffice it to say, I was wrong, and long since have understood the importance of the interaction of people, families, and communities, on an individual’s health.

At the 1989 Denver STFM meeting, I heard Gayle Stephens talk about “Family medicine as counterculture” (the talk was later published in Family Medicine[6]), and I admit that I was pretty surprised. I felt I had been part of the counterculture, but that doctors, even family doctors, even Dr. Stephens, were a bunch of old white guys in suits representing the establishment. I have to admit that, even though I have long since become an old white guy, and have been frequently known to wear a suit, the faces of those stern corporate-type authority figures from the 1950s and 1960s still make me anxious and a little bit hostile. (Full family disclosure, my father was a worker, not a suit.) But 1989 was a seminal STFM meeting.

I had already been attending STFM for some years, first in 1982 as a fellow at the University of Arizona, and then starting in 1985, when Dr. Prieto shared the educator award, every year since. If I make it to Toronto that will be 35 in a row. Actually, maybe it was 1988, in Baltimore, that was the seminal year, because that was the year Sen. Orrin Hatch received the Leland Blanchard award from the Foundation, orchestrated by Utah department chair and STFM matriarch F. Marian Bishop. I am sure Dr. Bishop did not anticipate, and surely did not appreciate, the antipathy of much of the younger cohort of STFM members to Sen. Hatch. From her point of the senator had been a big supporter of Title VII and family medicine. From our perspective, he was a virulent opponent of not only abortion rights, but ERA and other key issues affecting women. The only organized group within STFM opposing this was the Group on Women, which gathered signatures on a petition that was presented at the business meeting.

So, the next year, 1989, in Denver, there was a conscious effort to make a change. David Schmidt welcomed us with an upbeat and progressive speech. The Blanchard lecturer was Christine Cassel, then a professor of geriatrics at the University of Chicago and later a lot of other things, including head of the ACP Foundation and seminal in developing the “Choosing Wisely” program, speaking on medical ethics. In addition to Dr. Stephens’ talk on counterculture, Dr. Roger Rosenthal spoke about the need to care for underserved people. Several new groups were organized that year, including the Group on Minority Health, which still exists, and the Group on Universal Health Care, which had a shorter life. I felt really good about STFM and Family Medicine – and still do.

I met lots of people through family medicine – at STFM and the Program Directors’ meeting (later AFMRD), and this meeting, who were inspirational, like Frank Dornfest, the South African who was at the time program director in Santa Rosa -- the program our own Rick Flinders has written a history of -- and Gene Farley, who I met when I was a fellow at Arizona and he was chair at Colorado – an inspiration for his whole life. And some who were not old white men – Jorge Prieto, Denise Rodgers, and Carlos Moreno, and Janet Townsend, and others like David Swee and John Frey, white men who were not yet old! And the folks I worked with at Cook County – Pat Dowling, Janice Benson, and Crystal Cash, and many others. And, of course, many of those I have met or gotten to know better at this conference.

Part II: Whither family medicine, and American medicine, will be forthcoming

[1] https://cchs.ua.edu/the-willard-report-2/
[2] https://www.nap.edu/read/9153/chapter/4#10
[3] http://www.annfammed.org/content/10/3/250.full
[4] https://www.aafpfoundation.org/foundation/chfm/collections/exhibits/carmichael.html
[5] https://www.stfm.org/FamilyMedicine/Vol49Issue4/Carek275
[6] “Family medicine as counterculture”, Family Medicine, 21(2):103-109, Mar-Apr 1989

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