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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