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Learning From the Mistakes of the Past

October 30, 2011

I confess that I feel slightly guilty for writing this post. As a general rule, I don’t like overly critical people who create an ideal past world in their head, compare their forefathers (and mothers) to that world, then complain that the previous generation’s leaders did not live up to the expectations of the perfect world.

I have no doubt that many battles had to be fought and won over many years simply to create family medicine in America. The field has grown from a few converted general practitioners in the 1960s to over 100,000 members of the AAFP today. However, as we continue to struggle to make American healthcare more affordable by promoting the growth of family medicine, it is fair and appropriate to take a critical look at the decisions of the past that might guide us toward a more efficient American healthcare system founded on family medicine in the future. In no particular order:

The 1966 Folsom report thought that a key feature of family medicine would be preventive care. While preventive care helps extend some lives, it is often hugely expensive. The science of cost-effectiveness in medicine would not start in earnest until 1975, so the early leaders can’t be blamed for their optimistic assumptions about the benefits of prevention.

Another source of self-reflection on the misplaced priorities of early family medicine came from one of its pioneers, G Gayle Stephens, MD. In an article published in 1989 he commented “Our debates about the family as a unit of care, the role of behavioral sciences in medical practice, and the meaning of community medicine led us down some blind alleys that have not stood the test of time.” Some families want everyone to see the same doctor, others don’t. Whether or not a family physician actually cares for the whole family has little impact on the decisions that need to be made on the behalf of the individual patient in the exam room. Behavioral science is an important, but small part of family medicine and should not be the principal defining feature. Community involvement is common to many family physicians, but it is a trait shared by other physicians and also shouldn’t define who we are or why we’re important to the healthcare system.

Some people have commented that the creation of family medicine did not accidentally coincide with other reform movements of the 1960s, including utopianism, humanism, consumerism, and feminism. Like the well-meaning but unsustainable communal movements of the same era, the altruistic dreams of early family medicine proved to be stymied by human nature and left the movement limping along ever since.

The passivity of family medicine was born of a society of physicians who wanted to change the world, but didn’t spend the time and energy to aggressively stake their rightful place in American medicine. When icons such as Dr. Tinsley Harrison (of the medicine textbook fame) said, “Never! Never! Never! allow yourself to be treated by a general practitioner,” they didn’t fight back, but assumed love and understanding would ultimately turn the public in their favor. When the managed care companies tagged family medicine with the epithet “gatekeeper,” family medicine gladly accepted the label while sheepishly trusting the for-profit insurance companies to promote family medicine’s place in the healthcare system, without first making sure the American people understood family medicine’s role separate from the insurance companies. It was no surprise when the American people justly tossed out most of the managed care companies in the early 2000s, family medicine was tossed with it.

The idealistic branch of family medicine wanted to remain pure and not let the field be sullied with politics and money. Therefore the interests of family medicine were never presented effectively to many legislatures for much of its existence. Family medicine did not have a national PAC until 2005 (a glimmer of hope).

Physicians are commonly accused of taking care of their patients, but not themselves or their families. This is exactly what happened to the field of family medicine. We were so busy worrying about our patients and our communities, we forgot to take care of ourselves and our place in the healthcare system. We were so committed to the greater cause of compassionate but efficient first-contact patient care, we forgot to explain to the American people why our approach to patient care was better in many cases than the standard ologist approaches. We were so busy building excellent residencies away from the tertiary medical centers, we forgot that medical students would not understand our unique positive qualities if they rarely see us and are barraged by a constant stream of anti-family medicine bigotry during most of their education. When the RUC cheated us year after year, we did not stand up from the table and leave, we chose to stay in an abusive relationship.

We have been resistant to the idea that we deserve to thrive in all professional ways including financial, because when we do well the American people and the greater healthcare system does well. In the past, this kind of self-promotion self-sustaining was felt to be materialistic, inappropriate, and counter to our values of equity and justice. The irony is that in the end, family medicine’s lack of self-promotion has contributed to a profound lack of family physicians that will persist for decades, and America has been left with exactly the kind of inefficient and inequitable healthcare system the founders of family medicine tried to tear down.

Family medicine, heal thyself. When you do, the American people will be better off as well.

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3 Responses to Learning From the Mistakes of the Past

  1. Christopher Gregory on October 31, 2011 at 12:08 pm

    Well, you just never saw Marcus Welby, MD portrayed as a rip-roaring activist. As one of my family practice physician friends explains it, “family docs are lovers, not fighters”.

    So maybe we could change that, because the stakes sure are high enough to get things right about how we are wasting so much on the disoriented, disjointed spending spree we call our health care system.

  2. Robert Watkins on November 1, 2011 at 9:54 am

    So true. And so sad.

    The AAFP made the disastrous mistake of spending the last decade promoting EMRs, PCMH, and the ACA. If all the time, effort, and money spent there had been directed towards the root problem, inadequate payment, rather than these peripheral issues, family physicians might be in better shape today.

    I don’t know if anything can be done to reverse the death spiral our specialty finds itself in.

    Any suggestions?

  3. Richard Young MD on November 1, 2011 at 8:33 pm

    All I know to do is keep up the good fight. Maybe the AAFP payment reform commission might do something good. Whatever they come up with, I think it would still be helpful to have other people propose payment reform ideas also.

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