I’ve taken some time recently to read about some of the earliest thinking about family medicine prior to its creation and into its early years. I find that for the most part, the same unresolved tensions we feel today were present 45 years ago. I’ll spend the next two weeks exploring some of this history.
Just prior to the creation of family medicine, three influential reports on medical education were released in 1966: the Millis Commission Report, the Folsom Report, and the Willis Report.
The Millis Commission focused on the educational needs of physicians broadly. It recognized the difficulties of training and supporting physicians who practice comprehensive medicine: low status, lack of appropriate educational opportunities, and conditions of practice. It also recognized the rapid growth of new skills and technologies, and sought ways for the generalist physician to keep up with the onslaught of new discoveries. The concept of evidence-based medicine would not be created for another 14 years.
The Folsom Report focused more on personal health services and urged a program “to make it possible for the individual and the family to have easy access to health care and to facilitate coordinated, continuing health care in a comprehensive service pattern.” It also concluded:
Every individual should have a personal physician who is the central point for a patient. Such a physician will emphasize the practice of preventive medicine, through his own efforts and in partnership with the health and social resources of the community.
The Willard Report discussed the challenge of family medicine education specifically and defined the family physician as:
A personal physician, oriented to the whole patient, who practices both scientific and humanistic medicine. He may provide care for one member of the family, but more often does so for several or all members. Usually he himself provides medical care in more than one of the traditional specialty fields of medicine, and he coordinates the care obtained by referral to or consultation with other physicians and allied health personnel. He assumes responsibility for the patient’s comprehensive and continuing health care and in effect serves as captain of the health care team.
The Report went on to state that family medicine is truly unique in that it:
(1) The composite body of knowledge utilized by the family practitioner in his regular activities is significantly different from that utilized by other specialists, and
(2) The function of the family practitioner is significantly different from that of other specialists.
An organization called the Family Health Foundation wrote in a 1967 report:
What confronts us in medicine today is a social monstrosity – a profession standing on its head. Its management function—its coordinator—lies at the bottom of the heap and is rapidly being ground out of existence by the pure weight and commotion of the proliferating mass of uncoordinated specialists milling about above it. We must somehow right this pyramid and stand it on its base. To do so, however, we have to create a new primary physician, endow his job with status and authority, support his activity economically on a par with the specialized services he will be expected to correlate, and create the research base and the literature which can give him substantial legitimacy.
Coordinate care or provide comprehensive care? Take care of all a patient’s needs as much as humanly possible or become a medical traffic cop sending patients to a series of ologists. And what about endowing his job with status and authority, and supporting his activity economically on a par with the specialized services?
The early visionaries recognized many important issues, but family medicine and its supporters dropped the ball on several fronts since family medicine was created in 1969. I’ll explore more about why this happened next week.