A Specialty for Generalists (cont'd.)
Thus, medicine's post-war mandate was further refined. In the words of one influential study, "medicine needs a new kind of specialist, the family physician who is educated to provide comprehensive, personal health care, because of the complexity of modern medicine and the health care system … the preparation of large numbers of such physicians is essential if the public is to receive maximal benefits from American medicine." In short, it was not enough to produce more physicians; they must be family physicians.(8)
Two major reports advocating a shift in medical manpower objectives, the "Millis" and the "Willard" Reports, were published in 1966
with support from, and endorsement by, the American Medical Association. Although no consensus was yet evident about what to call the
new specialty, the reports clearly agreed about its social purpose and medical goals. The Millis Report, The Graduate Education of
Physicians, spoke of the "primary physician" who would deliver "continuing, comprehensive care." The Willard Report,
Meeting the Challenge of Family Practice, advocated changes in undergraduate medical education, also for the purpose of
increasing the number of primary care doctors. In the Willard Report, such physicians were termed "a new kind of specialist, the
family physician who is educated to provide comprehensive, personal
health care." Willard et al envisioned the family physician as the "captain of the health team." The
Millis report, similarly, envisioned "him" as a "quarterback who will diagnose the constantly changing situation, coordinate the whole
team." Interestingly, while there appeared to be wide agreement that "general practice" was no longer an adequate model of care, the
terms we now use, primary care and family medicine, had not yet achieved general acceptance in the 1960s. The Willard
Report acknowledged that they were working under the assumption that "family physician," "primary physician," and "personal physician"
were synonymous. And indeed, the two Reports held a shared conception of primary care medicine.(9)
Dr. G. Gayle Stephens, a pioneering physician of the family practice movement and author of one of the specialty's seminal texts, told
an interviewer recently,
… I think we used "family" [practice] as a synonym for general [practice] … And this is still an issue because the name has recently been changed to family "medicine" … I think this has to do with the professionalization of the specialty more than its ideology. We meant that all members of a family could be seen in the same medical facility, either independently or together, for their ordinary medical care. That's what we meant.(10)
The Millis and Willard reports had been in the works for several years. Their main sponsor, the AMA, as well as countless family doctors across the country, eagerly awaited their findings. For nearly twenty years, ever since a concerned group of general practitioners had formed the American Academy of General Practice to try and address a crisis of legitimacy for general practitioners, many older doctors had begun to anticipate a movement to consolidate and professionalize general medicine.(11) Stephens remembered that when the two reports appeared, "We devoured them word by word in shaping the new residencies…"(12) As one leading analyst of the Family Practice movement, Dr. John Geyman, has written, general practice suffered from its "lack of definition as a specialty whereby the … research elements of the field could be developed." Medical school curricula increasingly deemphasized general practice over the course of the twentieth century; by the late 1960s, when Family Practice began its serious push for recognition as a board certified specialty, fewer than twenty percent of practicing physicians were still GPs. Fewer and fewer GPs, especially on the east coast, held hospital privileges to perform obstetrics; by the same period, only about one-third performed "major surgery" anywhere in the country.(13)
General Practitioners fought back. In 1947 they formed the American Academy of General Practice which by 1970, still retained about 30,000 members. They even attempted to start their own licensure process by launching the American Board of General Practice in 1960. But this battle could not be won. Not only did general practice no longer seem intellectually challenging to many medical students, on a practical basis its long hours, relatively low pay, and geographic isolation appeared positively burdensome to many younger doctors. Between 1931 and 1965, the number of GPs in practice had dropped from 112,000 to 66,000.(14) Thus, from the end of World War II until the creation of the American Board of Family Practice in 1969, the fate of the GP became increasingly doubtful. But not until the 1970s was it clear to the majority of medical educators what distinguished Family Practice from General Practice.
Certainly they held in common the ancient tradition of the physician as healer. Moreover, both types of physician—family physician and general practitioner—were committed to practicing in their communities among the widest possible range of patients, and, ideally, to providing such care over a span of many years: comprehensive, continuous care. Yet there existed a key difference between the two. Unlike most general practitioners, especially those who had graduated from medical school before World War II, leading family practitioners insisted on the need for academic credentialing including Board Certification, and a meaningful presence among the departments of American medical schools. In its academic incarnation, family practice was known as Family Medicine by the early 1970s when the first future residency classes would have been graduating from medical school. Even an early edition of Our Bodies, Ourselves, a volume intended for the layperson, could make a fine-gauged comparison between the two approaches based on Family Medicine's status as an academic specialty.(15)
Yet, precise definitions of Family "Medicine," took longer to agree upon than did a common understanding of family "practice," a clinical approach which prepares the physician for a "'unique role in patient management, problem solving, counseling and as a personal physician who coordinates total health care delivery.'" The definition of that portion of family practice comprising its academic disciplinary profile took longer to crystallize. What were the salient features of Family Medicine as an intellectual discipline? Some early commentaries stressed its unique dependence on behavioral science and stressed this feature as the discipline's core academic feature. By the end of the specialty's first decade, however, Family Medicine was presented to residents in its fullest proportions, as
… that body of knowledge and skills applied by the family physician as he/she provides primary, continuing, comprehensive health care to patients and their families regardless of their age, sex, or presenting complaint. It is a horizontal discipline, sharing portions of all other clinical and related disciplines from which it is derived but applying these derivative portions in a unique way to families. In addition, family medicine includes new, incompletely developed elements, such as family dynamics in health and disease and its own areas of developing research.(16)